What is the recommended treatment for panic disorder in pregnancy?

Treatment of Panic Disorder in Pregnancy

Cognitive Behavioral Therapy (CBT) should be the first-line treatment for panic disorder during pregnancy, with medication reserved for moderate to severe cases or when psychotherapy is ineffective. 1

Non-Pharmacological Approaches

First-Line Treatment: Psychotherapy

• Cognitive Behavioral Therapy (CBT) has the strongest evidence for treating anxiety disorders in adults, including during pregnancy 2, 1
  • Focuses on modifying maladaptive thoughts and behaviors related to panic
  • Shown to improve symptoms and decrease relapse rates compared to waitlist controls
  • No reported harms in systematic reviews of psychological therapies 2
  • Safe during pregnancy with no evidence of fetal harm 3

Additional Non-Pharmacological Options

• Mindfulness-Based Interventions can help with emotional regulation and executive functioning 2
• Psychoeducation about panic disorder, symptoms, and management strategies 2, 1
• Stress reduction techniques and sleep hygiene to minimize triggers 2

Pharmacological Approaches

When to Consider Medication

• For moderate to severe panic disorder that:
  • Significantly impairs functioning
  • Does not respond adequately to psychotherapy
  • Poses risks to maternal or fetal health if left untreated 1

Medication Options

1. SSRIs (First-line pharmacological option)

   • Sertraline is preferred (starting at 25-50mg daily) 1
   • Fluoxetine (starting at 10mg daily) may be considered, with careful dose titration 4
   • Potential risks: Slightly increased risk of hypertensive disease of pregnancy, minor respiratory interventions in newborns, and shortened gestation by approximately 1.8 days 5

2. Low-dose Imipramine (Second-line option)

   • 10-40mg daily has shown effectiveness in pregnant women with panic disorder 6
   • 75% response rate in a retrospective study 6
   • Lower plasma concentrations may be effective during pregnancy 7

3. Avoid Benzodiazepines if possible

   • Associated with increased risk of cesarean delivery, low birth weight, and need for ventilatory support in newborns 5
   • If needed for severe, treatment-resistant cases, use lowest effective dose for shortest duration

Treatment Algorithm

1. Initial Assessment

   • Screen for panic disorder using validated tools like GAD-7 or Edinburgh Postnatal Depression Scale 2, 1
   • Assess severity, functional impairment, and comorbidities

2. Mild to Moderate Panic Disorder

   • Begin with CBT (8-12 sessions)
   • Add psychoeducation and stress management techniques
   • Reassess at 4-8 weeks 1

3. Moderate to Severe Panic Disorder

   • Begin CBT while simultaneously considering medication
   • If medication needed, start with sertraline 25-50mg daily
   • Alternative: low-dose imipramine 10-20mg daily, titrating as needed
   • Monitor closely for treatment response and side effects
   • Reassess every 4 weeks 1

Important Considerations

• Natural course during pregnancy: Approximately 78% of women with pre-existing panic disorder experience either improvement or no change in symptoms during pregnancy, while 20% may experience worsening 8

• Risk of untreated panic disorder: Associated with increased maternal distress and potential complications, making treatment important 1

• Medication discontinuation: If a patient was stable on medication before pregnancy, abrupt discontinuation may lead to relapse and should be avoided 1

• Monitoring: Regular assessment of both symptoms and potential side effects is essential, particularly when using medications 1

Common Pitfalls to Avoid

• Undertreating due to medication concerns: Untreated severe panic disorder may pose greater risks than carefully selected medication 1

• Overreliance on benzodiazepines: These should be avoided when possible due to associated adverse birth outcomes 5

• Failure to screen regularly: Symptoms may change throughout pregnancy, requiring ongoing assessment 1

• Not considering individual factors: Previous response to treatment, severity of symptoms, and patient preferences should guide treatment decisions 1