What are the recommended adjunct treatments for panic disorder?

Recommended Adjunct Treatments for Panic Disorder

For panic disorder, the recommended adjunct treatments include cognitive behavioral therapy (CBT) as the first-line psychological intervention, with selective serotonin reuptake inhibitors (SSRIs) as the first-line pharmacological treatment. 1

First-Line Treatments

Cognitive Behavioral Therapy (CBT)

• CBT is the psychological treatment of first choice for panic disorder 1, 2
• Individual CBT is preferred over group therapy due to superior clinical effectiveness 3, 1
• Key CBT elements include:
  • Education about anxiety
  • Behavioral goal setting with contingent rewards
  • Self-monitoring for connections between worries/fears, thoughts, and behaviors
  • Relaxation techniques (deep breathing, progressive muscle relaxation, guided imagery)
  • Cognitive restructuring to challenge distortions
  • Graduated exposure to feared stimuli
  • Problem-solving and social skills training 3

Pharmacotherapy

• SSRIs are recommended as first-line pharmacological treatment 1, 2
  • Options include fluoxetine, fluvoxamine, paroxetine, escitalopram, citalopram, and sertraline
  • Sertraline is particularly recommended for patients with both anxiety and depression due to its well-established safety profile 1
  • Starting dose of sertraline: 25-50 mg daily; target dose up to 200 mg daily 4
• SNRIs such as venlafaxine are suggested as alternatives 3, 1
  • Starting dose: 37.5 mg daily; target dose up to 225 mg daily 1
  • Requires blood pressure monitoring 1

Combination Approach

• Combined treatment of SSRI plus CBT is recommended over monotherapy for anxiety disorders 1
• For mild to moderate anxiety, consider starting with CBT alone and adding an SSRI if there is inadequate response after 8 weeks 1
• For moderate to severe anxiety, begin with a combination of CBT and an SSRI 1

Short-Term Adjuncts

• Benzodiazepines (e.g., alprazolam) may be used as short-term adjuncts in specific situations 1, 2, 5:
  • During the initial weeks of SSRI treatment before onset of response
  • For treatment-resistant patients without history of dependency
  • Alprazolam has been shown effective in placebo-controlled studies for panic disorder 6
  • Caution: Benzodiazepines should not be used as first-line treatments due to risk of dependence and potential for abuse 1, 2

Lifestyle Interventions

• Regular exercise
• Sleep hygiene practices
• Stress management techniques:
  • Deep breathing
  • Progressive muscle relaxation
  • Meditation 1

Treatment Duration and Monitoring

• Continue SSRI treatment for at least 12-24 months after achieving remission 1
• Regular monitoring at 2,4,6, and 12 weeks using standardized rating scales 1
• Monitor for side effects, particularly during the first few weeks of treatment 1
• For patients on SSRIs, assess response at 4 and 8 weeks using standardized instruments 1
• Monitor for suicidal ideation, especially in patients under 24 years 1

Special Considerations

• SSRIs vary in their potential for drug-drug interactions, with citalopram/escitalopram having the least effect on CYP450 isoenzymes 1
• Paroxetine, fluvoxamine, and sertraline have been associated with discontinuation syndrome 1
• Citalopram may cause QT prolongation at doses exceeding 40 mg/day 1
• Avoid combining SSRIs with MAOIs due to risk of serotonin syndrome 1

The evidence strongly supports a combined approach using both psychological and pharmacological interventions for optimal management of panic disorder, with CBT and SSRIs forming the cornerstone of treatment 1, 2, 7.