What medications help with panic attacks and Generalized Anxiety Disorder (GAD)?

Medications for Panic Attacks and Generalized Anxiety Disorder

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are the first-line medications for treating both panic attacks and generalized anxiety disorder due to their proven efficacy and favorable safety profile. 1

First-Line Medications

SSRIs

• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Paroxetine
• Escitalopram
• Citalopram
• Fluvoxamine

SSRIs work by inhibiting the presynaptic reuptake of serotonin in the brain, increasing serotonin availability at the synaptic cleft 1. They have shown consistent efficacy in reducing anxiety symptoms, improving global functioning, and achieving remission of anxiety disorders 1.

SNRIs

• Duloxetine (Cymbalta) - FDA approved for GAD in children and adolescents 7+ years
• Venlafaxine (Effexor)
• Desvenlafaxine (Pristiq)

SNRIs inhibit the reuptake of both serotonin and norepinephrine, which helps modulate stress responses including alertness, arousal, and vigilance 1.

Medication Selection Algorithm

1. Start with an SSRI (particularly sertraline or escitalopram) due to:

   • High efficacy for both panic disorder and GAD 1, 2
   • Better tolerability profile compared to other options 3
   • Lower risk of drug interactions (especially escitalopram) 1

2. If inadequate response or intolerance to first SSRI:

   • Try a different SSRI
   • OR switch to an SNRI (venlafaxine or duloxetine) 1

3. For severe, acute panic attacks requiring immediate relief:

   • Consider short-term benzodiazepine (like clonazepam) as adjunctive therapy 4, 5
   • Note: Benzodiazepines should be limited to short-term use due to risk of dependence 6

Dosing and Administration

• SSRIs:

  • Start at low doses (e.g., sertraline 25-50mg daily)
  • Titrate gradually over 1-2 weeks to minimize initial anxiety/agitation
  • Therapeutic effects may take 4-6 weeks to fully manifest
  • Continue treatment for at least 6-12 months after symptom remission

• SNRIs:

  • Start at low doses (e.g., venlafaxine 37.5mg daily, duloxetine 30mg daily)
  • Titrate gradually to minimize side effects
  • Monitor blood pressure with venlafaxine due to potential hypertensive effects 1

Important Considerations and Precautions

• Initial worsening of anxiety: SSRIs and SNRIs may temporarily increase anxiety during the first 1-2 weeks of treatment 7

  • Consider starting at lower doses to minimize this effect
  • In severe cases, short-term benzodiazepine coverage may help during this period

• Discontinuation syndrome: Particularly with paroxetine, fluvoxamine, and venlafaxine 1

  • Taper medications slowly when discontinuing
  • Symptoms include dizziness, nausea, headache, and sensory disturbances

• Suicidality risk: Monitor for increased suicidal thoughts, especially in the first few weeks of treatment and with dose changes 7

• Serotonin syndrome: Risk increases when combining multiple serotonergic agents 7

• Cardiac considerations: Citalopram may cause QT prolongation at doses exceeding 40mg/day 1

Benzodiazepines

While effective for short-term management of panic attacks, benzodiazepines (like clonazepam) are not recommended for first-line or long-term treatment due to:

• Risk of dependence and tolerance
• Cognitive impairment
• Higher mortality with long-term use 6
• Withdrawal symptoms upon discontinuation

Clonazepam is FDA-approved for panic disorder 4 but should be reserved for:

• Short-term use during initiation of SSRIs/SNRIs
• Treatment-resistant cases
• Acute management of severe panic attacks

Combination Therapy

For patients with inadequate response to medication alone, combining pharmacotherapy with cognitive behavioral therapy (CBT) has shown superior outcomes compared to either treatment alone 1, 5.

The combination of an SSRI with CBT is particularly effective for both panic disorder and GAD, with higher rates of symptom remission and improved quality of life 1.