What is the recommended treatment for panic disorder?

Recommended Treatment for Panic Disorder

For panic disorder, the first-line treatment is a selective serotonin reuptake inhibitor (SSRI) such as paroxetine or sertraline, combined with cognitive behavioral therapy (CBT). 1, 2, 3

Pharmacological Treatment

First-line medications:

• SSRIs:
  • Paroxetine: FDA-approved for panic disorder 2
    • Starting dose: 10-20 mg daily
    • Target dose: 40-60 mg daily
  • Sertraline: FDA-approved for panic disorder 3
    • Starting dose: 25-50 mg daily
    • Target dose: 50-200 mg daily
    • Demonstrated efficacy in reducing severity and frequency of panic attacks 4

Treatment duration and monitoring:

• Continue medication for several months beyond initial response
• Maintenance treatment for 12-24 months after achieving remission is recommended to prevent relapse 1
• Systematic evaluation has shown that sertraline's efficacy in panic disorder is maintained for up to 28 weeks following 24-52 weeks of initial treatment 3
• Monitor for:
  • Serotonin syndrome (mental status changes, neuromuscular hyperactivity, autonomic hyperactivity)
  • Behavioral activation/agitation (more common in younger patients)
  • Suicidal ideation (especially in patients under 24 years)
  • Common side effects: anxiety, insomnia, nervousness, gastrointestinal effects, sexual dysfunction 1

Non-Pharmacological Treatment

Cognitive Behavioral Therapy (CBT):

• Has the strongest evidence for treatment of panic disorder, either alone or as augmentation to medication 1, 5
• Addresses underlying cognitive patterns and avoidance behaviors
• Comparable efficacy to medication in some studies 4
• Components include:
  • Education about panic and anxiety
  • Cognitive restructuring
  • Exposure to feared sensations and situations
  • Breathing and relaxation techniques

Combination Approach

• Combined medication and CBT is the most successful treatment strategy for panic disorder 6
• Medication provides rapid symptom relief while CBT addresses underlying cognitive and behavioral patterns
• This approach shows better long-term outcomes and lower relapse rates

Treatment-Resistant Cases

For patients with inadequate response to first-line treatment:

• Optimize current SSRI dose before considering alternatives
• Consider augmentation strategies rather than switching medications 1
• Alternative options:
  • Switch to another SSRI or SNRI
  • Add benzodiazepines (e.g., alprazolam) for short-term use when no history of dependency 6
  • Consider tricyclic antidepressants (equally effective but less well tolerated) 6, 5

Special Considerations

• Comorbidities: Panic disorder frequently co-occurs with depression, other anxiety disorders, and substance use disorders 7
• Agoraphobia: Often develops as a complication of panic disorder; requires specific attention to avoidance behaviors 8
• Benzodiazepines: While effective for short-term symptom relief, they are not first-choice medications for medium and long-term treatment due to tolerance and dependence issues 8

Treatment Algorithm

1. Start with SSRI (paroxetine or sertraline) at low dose and titrate up as needed
2. Refer for CBT concurrently if available
3. Continue treatment for at least 12-24 months after symptom remission
4. For partial response, optimize SSRI dose before considering augmentation
5. For non-response, consider switching to another SSRI/SNRI or adding short-term benzodiazepine

The goal of treatment is not only to reduce panic attacks but also to improve anticipatory anxiety, avoidance behaviors, and overall quality of life 4, 7.