What is the best medication for treating panic attacks?

Best Medications for Panic Attacks

Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for panic attacks, with benzodiazepines reserved for short-term or treatment-resistant cases. 1

First-Line Treatment: SSRIs

Why SSRIs are First-Line

• SSRIs effectively reduce panic attack frequency, severity, and associated anxiety symptoms 2
• Provide long-term efficacy with better safety profile than other options 3
• Recommended by clinical guidelines for anxiety disorders including panic disorder 4

SSRI Options and Dosing

1. Sertraline (Zoloft)

   • FDA-approved for panic disorder 5
   • Starting dose: 25-50 mg daily
   • Target dose: Up to 200 mg daily
   • Common side effects: Nausea, diarrhea, headache, insomnia, sexual dysfunction 6

2. Other Effective SSRIs

   • Fluoxetine: 10-20 mg daily
   • Escitalopram: 10-20 mg daily
   • Paroxetine (note: higher risk of discontinuation symptoms)

Important SSRI Considerations

• Start with a subtherapeutic "test" dose to minimize initial anxiety/agitation 4
• For shorter half-life SSRIs (like sertraline), increase dose at 1-2 week intervals 4
• Full therapeutic effect may take 4-6 weeks 6
• Monitor for increased anxiety in first few weeks of treatment 7

Short-Term/Adjunctive Treatment: Benzodiazepines

When to Consider Benzodiazepines

• For immediate symptom relief while waiting for SSRIs to take effect 1
• For treatment-resistant cases 8
• For short-term management of severe panic symptoms 7

Benzodiazepine Options

1. Alprazolam
   • FDA-approved for panic disorder 9
   • Demonstrated efficacy in placebo-controlled studies 9
   • Rapid onset of action (minutes to hours)

Important Benzodiazepine Cautions

• Risk of tolerance and dependence 7
• Should be avoided in patients with history of substance abuse 8
• Not recommended for long-term use 1
• Requires gradual tapering when discontinuing (25% dose reduction every 1-2 weeks) 6

Treatment Algorithm

1. Initial Treatment:

   • Start with an SSRI (sertraline preferred due to strong evidence base) 2, 3
   • Begin with low dose (25-50 mg/day for sertraline)
   • Gradually increase dose every 1-2 weeks as tolerated

2. If immediate symptom control needed:

   • Consider short-term benzodiazepine (alprazolam) for 2-4 weeks while waiting for SSRI effect 1
   • Discontinue benzodiazepine gradually once SSRI takes effect

3. If inadequate response after 8-12 weeks:

   • Optimize SSRI dose
   • If still inadequate, switch to another SSRI
   • Consider adding cognitive behavioral therapy (CBT) 4, 6

4. Treatment-resistant cases:

   • Consider SNRI (venlafaxine) 6
   • Consider benzodiazepines for carefully selected patients without history of substance abuse 8

Combination Therapy

• Adding cognitive behavioral therapy (CBT) to medication significantly improves outcomes 4, 6
• Combination of CBT plus SSRI shows superior efficacy compared to either treatment alone 4
• Never combine two SSRIs due to increased risk of serotonin syndrome 6

Monitoring and Duration

• Evaluate response after 2-3 weeks initially, then at 4-6 weeks for full effect 6
• Use standardized assessment tools to track progress 6
• Continue effective treatment for at least 6-12 months after symptom resolution 3
• When discontinuing, taper gradually over 10-14 days to minimize withdrawal symptoms 6

Common Pitfalls to Avoid

1. Starting SSRIs at too high a dose, which can temporarily worsen anxiety
2. Prescribing benzodiazepines for too long, leading to dependence
3. Discontinuing medications too quickly
4. Failing to combine medication with CBT when available
5. Combining multiple serotonergic medications, increasing risk of serotonin syndrome 6