What is the initial treatment for panic attacks in an outpatient setting?

From the Guidelines

The initial treatment for panic attacks in an outpatient setting should involve a combination of cognitive behavioral therapy (CBT) and medication, with selective serotonin reuptake inhibitors (SSRIs) being the first-line pharmacological treatment, as recommended by the American Academy of Child and Adolescent Psychiatry 1. The goal of this treatment approach is to achieve meaningful symptomatic and functional improvement, addressing both the immediate symptoms and underlying causes of panic attacks. CBT typically involves 12-20 sessions, including education about anxiety, behavioral goal setting, self-monitoring, relaxation techniques, cognitive restructuring, and graduated exposure 1. Key elements of CBT for panic attacks include:

• Education about anxiety and panic attacks
• Behavioral goal setting with contingent rewards
• Self-monitoring for connections between worries/fears, thoughts, and behaviors
• Relaxation techniques, such as deep breathing, progressive muscle relaxation, and guided imagery
• Cognitive restructuring to challenge distortions and negative thinking patterns
• Graduated exposure to help patients gradually become comfortable with situations that trigger panic attacks In terms of medication, SSRIs such as sertraline or escitalopram are commonly used, with dosages starting at 25-50mg daily for sertraline and 5-10mg daily for escitalopram, gradually increasing as needed and tolerated 1. It is essential to note that while benzodiazepines like lorazepam can provide immediate relief during acute attacks, their use should be limited due to the risk of dependency. Lifestyle modifications, including regular exercise, adequate sleep, stress management techniques, and avoiding caffeine, alcohol, and recreational drugs, can also significantly reduce attack frequency and improve overall quality of life. By prioritizing a multimodal approach that combines CBT, medication, and lifestyle modifications, patients with panic attacks can achieve long-term remission and improved quality of life.

From the FDA Drug Label

The effectiveness of sertraline in the treatment of panic disorder was demonstrated in three double-blind, placebo-controlled studies (Studies 1-3) of adult outpatients who had a primary diagnosis of panic disorder (DSM-III-R), with or without agoraphobia. Studies 1 and 2 were 10-week flexible dose studies. Sertraline was initiated at 25 mg/day for the first week, and then patients were dosed in a range of 50 to 200 mg/day on the basis of clinical response and toleration.

The initial treatment for panic attacks in an outpatient setting with sertraline is to start with a dose of 25 mg/day for the first week, and then adjust the dose based on clinical response and toleration, in a range of 50 to 200 mg/day 2.

From the Research

Initial Treatment for Panic Attacks in Outpatient Setting

• The initial treatment for panic attacks in an outpatient setting can include pharmacological and psychological interventions 3, 4, 5, 6, 7.
• Antidepressant medications, such as selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants, have been shown to be effective in reducing the severity of panic symptoms and eliminating panic attacks 3, 4, 7.
• Benzodiazepines are also effective in treating panic disorder symptoms, but they are less effective than antidepressants and cognitive behavior therapy 3, 5, 6.
• Cognitive behavior therapy (CBT) is a strongly supported treatment for panic disorder, and it can be used alone or in combination with antidepressants 3, 6, 7.
• The choice of medication is based on side effect profiles and patient preferences, and SSRIs such as sertraline, paroxetine, and fluoxetine are commonly used 4, 7.

Medication Options

• SSRIs, such as sertraline, paroxetine, and fluoxetine, are effective in treating panic disorder and are often used as first-line treatments 4, 7.
• Tricyclic antidepressants, such as clomipramine and imipramine, are also effective, but may have more side effects than SSRIs 3, 5.
• Benzodiazepines, such as alprazolam and clonazepam, can be used for short-term treatment of panic disorder, but they can be habit-forming and are generally not recommended for long-term use 3, 5, 6.

Psychological Interventions

• CBT is a highly effective treatment for panic disorder, and it can be used alone or in combination with medication 3, 6, 7.
• Exposure therapy, which involves gradually exposing the patient to the feared situation or object, can be an effective component of CBT for panic disorder 7.