What is the first-line treatment for panic disorder?

First-Line Treatment for Panic Disorder

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line pharmacological treatment for panic disorder due to their established efficacy, favorable side effect profile, and long-term safety. 1, 2, 3

Treatment Algorithm

1. Initial Pharmacotherapy

   • Start with an SSRI (sertraline, fluoxetine, escitalopram, or paroxetine)
   • Sertraline is often preferred due to:
     • Proven efficacy in reducing panic attack frequency (approximately 2 attacks per week compared to placebo) 4
     • Favorable tolerability profile
     • Evidence for long-term maintenance and relapse prevention 5

2. Dosing Strategy

   • Begin with lower doses than used for depression to minimize initial activation/anxiety:
     • Sertraline: Start at 25 mg/day for first week, then titrate to 50-200 mg/day based on response 4
     • Fluoxetine: Start at 10 mg/day for one week, then increase to 20 mg/day 6
   • Allow 4-6 weeks for full therapeutic effect
   • Target doses:
     • Sertraline: 50-200 mg/day (mean effective dose in trials: 131-144 mg/day) 4
     • Fluoxetine: 20-60 mg/day (though doses above 60 mg/day not systematically studied) 6

3. Short-term Adjunctive Therapy

   • Consider temporary benzodiazepine co-administration during initial 2-4 weeks while waiting for SSRI effect 2, 3
   • Only use in patients without history of substance dependence
   • Plan for gradual taper once SSRI becomes effective

Monitoring and Maintenance

• Evaluate initial response after 2-3 weeks
• Assess full effect at 4-6 weeks using standardized anxiety assessment tools
• For responders, continue treatment for at least 6-12 months
• Long-term maintenance reduces relapse rates 4, 5
• When discontinuing, taper gradually to minimize withdrawal symptoms

Alternative First-Line Options

• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) like venlafaxine are acceptable first-line alternatives 1, 3
• Cognitive-Behavioral Therapy (CBT) is as effective as medication and should be considered either as monotherapy or in combination with pharmacotherapy 2, 7
• Combined SSRI + CBT may provide superior outcomes to either treatment alone 1

Treatment-Resistant Cases

For patients not responding to first-line SSRIs:

• Switch to another SSRI or SNRI
• Consider tricyclic antidepressants (effective but less well-tolerated) 2
• Consider benzodiazepines for short-term use in non-responsive cases 2
• Evaluate for comorbid conditions that may complicate treatment

Common Pitfalls to Avoid

• Starting with full antidepressant doses can increase anxiety and activation symptoms
• Abrupt discontinuation of SSRIs can lead to withdrawal symptoms
• Inadequate duration of treatment increases relapse risk
• Overlooking comorbid conditions (depression, substance use, other anxiety disorders)
• Failing to monitor systematically using standardized assessment tools

SSRIs have demonstrated consistent efficacy in reducing panic attack frequency, anticipatory anxiety, and improving quality of life in patients with panic disorder 5, 8. Their favorable side effect profile and long-term safety make them the preferred first-line pharmacological intervention for this chronic condition.