Recommended Medications for Panic Attacks
Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line pharmacological treatment for panic attacks, with benzodiazepines reserved for short-term use in acute situations or as adjunctive therapy during SSRI initiation. 1
First-Line Treatment: SSRIs
SSRIs are recommended as the primary pharmacological intervention for panic disorder due to their effectiveness and favorable safety profile:
- Specific SSRIs with evidence for panic disorder:
Mechanism and Considerations
- SSRIs increase serotonin availability at the synaptic cleft, which helps modulate fear, worry, and stress responses 3
- Therapeutic effect typically takes 4-6 weeks to fully develop 1
- May cause initial anxiety exacerbation in the first 1-2 weeks of treatment 4
- Common side effects include nausea, headache, insomnia, sexual dysfunction, and dry mouth 3
Alternative First-Line Option: SNRIs
- Venlafaxine is suggested as an alternative first-line medication with efficacy comparable to SSRIs 3, 1
- May have more noradrenergic side effects such as increased blood pressure and sweating 1
Short-Term/Adjunctive Treatment: Benzodiazepines
Benzodiazepines can be used in specific circumstances:
- For short-term treatment (1-4 weeks) during SSRI initiation to manage breakthrough anxiety 1
- In treatment-resistant cases when the patient has no history of substance dependence 5
- For acute panic attacks requiring immediate symptom relief 6
Specific Benzodiazepines:
- Alprazolam has demonstrated efficacy for panic disorder 7, 6
- Clonazepam shows strong reduction in frequency of panic attacks 6
- Diazepam ranked highly for effectiveness in recent meta-analyses 6
Cautions with Benzodiazepines:
- Risk of dependence and tolerance with prolonged use 7
- Not recommended for long-term management 8
- Should be gradually tapered when discontinuing to prevent withdrawal symptoms 1
Treatment Algorithm
Initial Treatment:
- Start with an SSRI (sertraline or escitalopram) at standard dosing
- Consider short-term benzodiazepine (2-4 weeks) if immediate symptom relief is needed
Monitoring and Adjustment:
- Assess response after 4-6 weeks of SSRI treatment
- If partial response, continue and optimize SSRI dose
- If no response after 8 weeks at optimal dose, switch to another SSRI or SNRI
Treatment-Resistant Cases:
- Consider switching to another class (SSRI to SNRI or vice versa)
- Consider adding cognitive behavioral therapy (CBT) if not already implemented
- For severe cases not responding to above measures, consider tricyclic antidepressants (TCAs) like clomipramine, though these have more side effects 6
Maintenance and Discontinuation:
Common Pitfalls to Avoid
- Premature discontinuation of medication increases relapse risk 1
- Abrupt discontinuation can cause withdrawal symptoms, especially with SSRIs and benzodiazepines 1
- Overlooking comorbidities such as depression or substance use disorders can lead to inadequate treatment 1
- Prolonged benzodiazepine use can lead to dependence and tolerance 7, 8
- Inadequate SSRI trial duration - effectiveness may take 6-12 weeks for maximum benefit 1
Special Populations
- Children and adolescents: SSRIs are recommended for ages 6-18 with anxiety disorders including panic disorder 3, 1
- Elderly patients: Use lower starting doses and slower titration 1
- Patients with hepatic or renal impairment: Use caution with medication selection and dosing 1
The most recent evidence from comprehensive meta-analyses confirms that while both SSRIs and benzodiazepines are effective for panic disorder, SSRIs should be preferred for long-term management due to their favorable safety profile and lower risk of dependence 6.