What medication should be prescribed for a 23-year-old female with panic disorder?

Medication Management for Panic Disorder in a 23-Year-Old Female

For a 23-year-old female with panic disorder, a Selective Serotonin Reuptake Inhibitor (SSRI) such as sertraline (starting at 50 mg daily) should be prescribed as first-line pharmacotherapy. 1

First-Line Medication Options

SSRIs (Preferred First-Line)

• Sertraline:

  • Initial dose: 50 mg once daily
  • Titration range: 50-200 mg daily
  • Mean effective dose in clinical trials: 131-144 mg/day 2
  • Demonstrated significant reduction in panic attack frequency (approximately 2 attacks per week) compared to placebo 2

• Escitalopram:

  • Initial dose: 20 mg once daily
  • Titration range: 20-50 mg daily 1

Advantages of SSRIs

• Effective for both panic symptoms and comorbid depression (common in panic disorder)
• Better tolerated than tricyclic antidepressants
• No dependency risk (unlike benzodiazepines)
• Suitable for long-term management 1, 3

Alternative First-Line Options

SNRIs

• Can be considered as alternative first-line agents
• Venlafaxine specifically recommended with efficacy comparable to SSRIs 1
• May have more noradrenergic side effects (increased blood pressure, sweating) 1

Short-Term Adjunctive Options

Benzodiazepines

• Alprazolam:
  • May be used for short periods (1-4 weeks) during SSRI initiation for breakthrough anxiety 1
  • FDA-approved for panic disorder 4
  • Not recommended for long-term management due to dependence risk 1, 5
  • Should be avoided in patients with history of substance dependence 5

Treatment Implementation

Initiation Phase

1. Start with sertraline 50 mg once daily
2. Assess response after 4-6 weeks
3. If needed, gradually titrate dose up to maximum of 200 mg daily based on clinical response and tolerability 1, 2
4. Consider short-term (1-4 weeks) benzodiazepine use only if severe breakthrough anxiety occurs during initial SSRI treatment 1

Maintenance Phase

• Continue effective treatment for at least 24-28 weeks after initial response 1
• Monitor for side effects regularly
• If discontinuation is planned, taper gradually over several weeks to avoid withdrawal symptoms 1

Non-Pharmacological Treatment

Cognitive Behavioral Therapy (CBT)

• Highly effective either alone or in combination with medication 1, 3
• Individual CBT superior to group therapy in both clinical and economic effectiveness 1
• Typically consists of 14 individual sessions over 4 months (60-90 minutes each) 1
• Key components: psychoeducation, cognitive restructuring, graduated exposure, relaxation techniques 1

Important Considerations

Potential Pitfalls

• Abrupt discontinuation of SSRIs can cause withdrawal symptoms - always taper gradually 1
• Overlooking comorbid conditions (especially depression) may lead to inadequate treatment 1
• Initial SSRI side effects may include increased anxiety - warn patient this is temporary

Monitoring

• Assess therapeutic response and side effects after 4-6 weeks of starting medication 1
• Regular follow-up every 2-4 weeks during medication transitions 1

Treatment Duration

• Premature discontinuation increases relapse risk 1
• Maintenance treatment for at least 24-28 weeks after response is recommended 1

By following this evidence-based approach with an SSRI as first-line treatment, potentially augmented with short-term benzodiazepines if needed and CBT when available, this 23-year-old female with panic disorder has an excellent chance of achieving symptom control and improved quality of life.