From the Guidelines
The most effective treatment for panic disorder is a combination of cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitor (SSRI) medication, as this approach has been shown to be more effective than either treatment alone 1.
Treatment Approach
The treatment of panic disorder should prioritize a combination of psychotherapy and medication, with CBT being the most effective psychotherapy approach. CBT helps patients identify and change thought patterns that lead to panic attacks. For medication, SSRIs like sertraline, escitalopram, or paroxetine are usually first-line treatments, taken continuously for at least 6-12 months after symptom improvement.
Medication Options
- SSRIs: sertraline (50-200 mg daily), escitalopram (10-20 mg daily), or paroxetine (20-60 mg daily) are recommended as first-line treatments 1.
- Benzodiazepines: such as clonazepam (0.5-2 mg daily) or alprazolam (0.5-4 mg daily) can provide rapid relief for acute symptoms but should be used short-term due to dependency risks.
Lifestyle Modifications
Lifestyle modifications including:
- Regular exercise
- Adequate sleep
- Stress management techniques
- Avoiding caffeine and alcohol can significantly complement formal treatment by addressing both the psychological factors that maintain panic (through CBT) and the neurochemical imbalances (through medication) that contribute to the disorder.
Cultural Considerations
While there is evidence that exposure and CBT are effective treatment approaches with African Americans, it is essential to consider cultural sensitivity and tailor treatment to individual needs 1. However, the most recent and highest quality study 1 prioritizes CBT and SSRI medication as the most effective treatment approach, regardless of cultural background.
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. In these studies, sertraline was shown to be significantly more effective than placebo on change from baseline in panic attack frequency and on the Clinical Global Impression Severity of Illness and Global Improvement scores. The difference between sertraline and placebo in reduction from baseline in the number of full panic attacks was approximately 2 panic attacks per week in both studies The effectiveness of PAXIL in the treatment of panic disorder was demonstrated in three 10- to 12-week multicenter, placebo-controlled studies of adult outpatients (Studies 1-3) In these studies, PAXIL was shown to be significantly more effective than placebo in treating panic disorder by at least 2 out of 3 measures of panic attack frequency and on the Clinical Global Impression Severity of Illness score Support for the effectiveness of alprazolam tablets in the treatment of panic disorder came from three short-term, placebo-controlled studies (up to 10 weeks) in patients with diagnoses closely corresponding to DSM-III-R criteria for panic disorder
The best treatment for panic disorder is sertraline or paroxetine, as they have been shown to be significantly more effective than placebo in reducing panic attack frequency and improving clinical global impression scores 2 3. Alprazolam has also been found to be effective in the treatment of panic disorder, but the studies were shorter in duration and had a smaller sample size compared to the studies on sertraline and paroxetine 4.
- Sertraline and paroxetine are preferred due to their longer-term efficacy and safety data.
- Alprazolam may be considered for short-term treatment, but its use should be carefully monitored due to the risk of dependence and withdrawal.
From the Research
Treatment Options for Panic Disorder
- Cognitive-behavioral therapy (CBT) is considered a first-line treatment for panic disorder, offering benefits after short-term intervention 5, 6, 7, 8
- CBT focuses on eliminating patterns that underlie and perpetuate the disorder, and patients learn strategies to counter fears of panic attacks and break the cycle of anticipatory anxiety, panic, and agoraphobic avoidance 5
- Pharmacotherapy, including selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors, is also an effective first-line treatment for panic disorder 6, 7, 9
- Combination treatment strategies, such as CBT and pharmacotherapy, may be effective for some patients, and predictors of non-response and mechanisms of action are being considered 6, 7, 9
Efficacy of Treatment Options
- CBT has been shown to be effective in reducing symptoms of panic disorder, with a relatively quick onset of action and long-term maintenance of treatment benefits 5, 6, 8
- SSRIs have been proven to be superior to pill-placebo in the treatment of panic disorder, agoraphobia, and associated symptoms such as depression 9
- Meta-analyses have suggested that combining an antidepressant with exposure in vivo produces the greatest treatment gains 9
Recommendations for Treatment
- CBT is recommended as a first-line treatment for panic disorder, either alone or in combination with pharmacotherapy 5, 6, 7, 8
- Pharmacotherapy, including SSRIs, is also recommended as a first-line treatment for panic disorder, either alone or in combination with CBT 6, 7, 9
- Optimal long-term treatment of panic disorder involves adequate medication and duration of treatment, since relapse is frequent 7