What is the recommended treatment for panic disorder?

Treatment of Panic Disorder

For patients with panic disorder, cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are strongly recommended as first-line treatments, with combination therapy often providing superior outcomes compared to either treatment alone. 1

First-Line Treatment Options

Cognitive Behavioral Therapy (CBT)

• Recommended as first-line psychological treatment for panic disorder
• Should be delivered by a skilled therapist following structured protocols
• Self-help CBT with support is an alternative if the patient declines face-to-face therapy

Medication Options

• SSRIs are the first-line pharmacological treatment 1, 2
  • Sertraline: Starting dose 25-50 mg daily, target dose up to 200 mg daily 3, 4
  • Other SSRIs: Fluoxetine, fluvoxamine, paroxetine, escitalopram, citalopram 5
• SNRIs (e.g., venlafaxine, duloxetine) are also effective options 1, 2

Treatment Algorithm

1. For mild to moderate panic disorder:

   • Start with CBT alone
   • If inadequate response after 8 weeks, add an SSRI

2. For moderate to severe panic disorder:

   • Begin with combination of CBT and SSRI
   • Sertraline is a preferred SSRI due to its established efficacy, safety profile, and positive effects on quality of life 6, 4

3. Medication initiation and monitoring:

   • Start with low doses and titrate gradually
   • Assess response at 4 and 8 weeks using standardized instruments
   • Weekly face-to-face contacts for the first 4 weeks to monitor for side effects
   • Continue effective treatment for at least 12-24 months after achieving remission

Special Considerations

Short-term Use of Benzodiazepines

• Benzodiazepines (e.g., clonazepam) may be used for short-term treatment 7, 2, 8
• Consider only when:
  • Patient does not have history of dependency
  • Used for short duration (typically first few weeks while waiting for SSRI effect)
  • Used in treatment-resistant cases not responding to first-line options
• Caution: Risk of physical dependence with continued therapy 7
• Withdrawal symptoms can be severe if discontinued abruptly

Treatment-Resistant Cases

• Options for patients with inadequate response to initial treatment:
  1. Switch to a different SSRI or SNRI
  2. Augment with another agent
  3. Consider referral to a specialist for more intensive treatment

Monitoring and Maintenance

• Regular assessment using standardized instruments
• Monitor for side effects, particularly during first few weeks of treatment
• For SSRIs: watch for increased anxiety/agitation, suicidal ideation, sleep disturbances
• Treatment should continue for 12-24 months after achieving remission to prevent relapse

Common Pitfalls to Avoid

1. Inadequate dosing: Ensure appropriate dose titration if insufficient response after 4-6 weeks
2. Premature discontinuation: Continue medication after symptom improvement
3. Ignoring comorbidities: Address concurrent conditions like depression
4. Neglecting non-pharmacological interventions: Always consider CBT alongside medication
5. Abrupt discontinuation of benzodiazepines: Use gradual tapering to avoid withdrawal symptoms

Lifestyle Modifications

• Regular exercise, sleep hygiene practices, and stress management techniques should be implemented alongside medication and CBT
• Techniques include deep breathing, progressive muscle relaxation, and meditation

The evidence strongly supports that combination treatment (SSRI plus CBT) provides superior outcomes compared to either treatment alone for most patients with panic disorder 1.