What is the recommended treatment for panic disorder?

Treatment of Panic Disorder

Cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are the first-line treatments for panic disorder, with SSRIs being the preferred pharmacological option. 1

First-Line Treatments

Pharmacotherapy

• SSRIs are the first-line pharmacological treatment due to their efficacy and favorable side effect profile:
  • Sertraline (50-200 mg/day) is particularly effective and well-studied 2, 3
  • Start at low doses (25-50 mg daily) and titrate up as needed 4
  • Other effective SSRIs include paroxetine, which is FDA-approved for panic disorder 5
  • Fluoxetine is another viable option with a long half-life allowing once-daily dosing 4

Psychological Interventions

• CBT specifically developed for panic disorder is highly effective 6
  • Should include exposure techniques to feared sensations and situations
  • Typically consists of 10-20 sessions 4
  • Can be delivered individually or in groups, in-person or via remote/internet protocols 4

Monitoring and Treatment Response

• Assess response at 2,4,6, and 12 weeks using standardized anxiety rating scales 4
• Initial improvement may begin within 2 weeks, with clinically significant improvement typically by week 6 4
• Maximal improvement may take 12 weeks or longer 4
• Monitor closely for:
  • Suicidal ideation (especially in patients under 24)
  • Behavioral activation/agitation
  • Serotonin syndrome when combined with other serotonergic medications 4

Treatment-Resistant Cases

• For patients who don't respond adequately to initial treatment:
  • Consider combination of CBT and medication, which is superior to either treatment alone 4, 7
  • Patients unsuccessfully treated with CBT alone may benefit from adding an SSRI 7
  • Effect sizes for combined therapy (CBT plus paroxetine) range from 1.0 to 1.8, compared to 0.4 to 1.0 for CBT plus placebo 7

Benzodiazepines in Panic Disorder

• Clonazepam has demonstrated efficacy in panic disorder in controlled trials 8
• However, benzodiazepines should be reserved for:
  • Short-term use
  • Treatment-resistant patients without history of dependence
  • Combination with SSRIs in the first weeks of treatment before SSRI response begins 1

Duration of Treatment and Discontinuation

• Long-term maintenance of efficacy has been demonstrated in relapse prevention trials 5, 2
• Continue treatment for at least 12-24 months after achieving remission 4
• When discontinuing:
  • Taper gradually to avoid discontinuation syndrome, especially with shorter-acting SSRIs 4
  • Consider monthly booster sessions of CBT for 3-6 months after completion 4

Common Pitfalls to Avoid

1. Premature discontinuation: Panic disorder is often chronic and requires extended treatment
2. Inadequate dosing: SSRIs may require higher doses for panic disorder than for depression
3. Overlooking comorbidities: Panic disorder frequently co-occurs with depression, other anxiety disorders, and substance abuse 9
4. Failure to combine treatments: For treatment-resistant cases, combining CBT and medication is more effective than continuing with a single modality 7
5. Overreliance on benzodiazepines: While effective for short-term relief, they carry risks of dependence and should not be first-line long-term treatment 1

By following this treatment approach, patients with panic disorder can experience significant reduction in panic attacks, anticipatory anxiety, and phobic avoidance, leading to improved quality of life and functioning.