What is the recommended medication for treating panic disorder?

Medication Treatment for Panic Disorder

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line medication treatment for panic disorder, with sertraline being a preferred option due to its established efficacy and favorable side effect profile. 1

First-Line Medication Options

SSRIs

• Sertraline: Start at 25-50 mg daily, with target dose up to 200 mg daily 1, 2

  • Demonstrated efficacy in numerous short and long-term studies 3
  • For panic disorder specifically, treatment should be initiated at 10 mg/day, increased to 20 mg/day after 1 week 2
  • Dose increases may be considered after several weeks if clinical improvement is not observed
  • Maximum studied dose is 60 mg/day for panic disorder

• Fluoxetine: Start at 10 mg daily, with target dose of 20-30 mg/day 4

  • For panic disorder, initiate at 10 mg/day, increase to 20 mg/day after 1 week
  • Experience with daily doses greater than 20 mg is minimal
  • Maximum studied dose is 60 mg/day

• Other SSRIs: Paroxetine, escitalopram, citalopram, and fluvoxamine are also effective 1

SNRIs (Alternative First-Line)

• Venlafaxine (start 37.5 mg daily, target 225 mg daily)
• Duloxetine (start 30 mg daily, target 60 mg daily) 1

Treatment Algorithm

1. Initial Treatment:

   • Begin with an SSRI (sertraline preferred) at low dose
   • Start sertraline at 25 mg daily or fluoxetine at 10 mg daily
   • Gradually increase dose at 3-4 day intervals to minimize side effects 1

2. Dose Adjustment:

   • Assess response after 4 and 8 weeks using standardized instruments 1
   • If inadequate response after 6-8 weeks, consider dose increase
   • For sertraline, most patients respond to 20 mg/day, but doses up to 60 mg/day may be needed 2

3. Maintenance Treatment:

   • Continue successful treatment for at least 12-24 months after achieving remission 1
   • Periodically reassess to determine need for continued treatment
   • When discontinuing, taper gradually to avoid withdrawal symptoms 1, 4

Special Considerations

Combining with Psychotherapy

• Combination of SSRI plus Cognitive Behavioral Therapy (CBT) is superior to either treatment alone for moderate to severe panic disorder 1
• For mild to moderate cases, consider starting with CBT alone and adding an SSRI if inadequate response after 8 weeks 1

Short-Term Adjunctive Treatment

• Benzodiazepines (e.g., clonazepam) may be used short-term in patients without history of dependency 1, 5
• Can be combined with SSRIs in the first weeks to provide relief before SSRI onset of action 6
• Not recommended as first-line or long-term treatment due to risk of dependence 1, 7

Common Pitfalls and Caveats

1. Starting with too high a dose:

   • Begin with low doses of SSRIs to minimize side effects 1
   • For sertraline in panic disorder, start at 10 mg/day 2
   • For fluoxetine in panic disorder, start at 10 mg/day 4

2. Inadequate duration of treatment:

   • SSRIs may take 2-4 weeks to show initial effect
   • Full therapeutic effect may require 8-12 weeks
   • Premature discontinuation can lead to relapse 1

3. Abrupt discontinuation:

   • Always taper gradually to avoid withdrawal symptoms 1, 4
   • Withdrawal symptoms can include rebound anxiety 1

4. Overlooking comorbidities:

   • Depression, substance use disorders, and other anxiety disorders commonly co-occur with panic disorder 1
   • These may require additional treatment approaches

5. Monitoring issues:

   • Monitor for suicidal ideation, especially in patients under 24 years, particularly during first 1-2 weeks of treatment 1
   • Watch for common side effects: nausea, sexual dysfunction, insomnia, headache 1

Special Populations

• Elderly patients: Use lower or less frequent dosing 1, 4
• Hepatic impairment: Lower or less frequent dosing recommended 4, 2
• Pregnant women: Special consideration needed in third trimester; consider tapering SSRIs 4

SSRIs have demonstrated superior tolerability compared to tricyclic antidepressants while maintaining equivalent efficacy 5, 6, making them the preferred first-line pharmacological treatment for panic disorder.