What is the recommended treatment for panic attacks?

Treatment for Panic Attacks

The first-line treatment for panic attacks should be a combination of cognitive-behavioral therapy (CBT) and a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI), particularly for moderate to severe cases. 1

Recommended Treatment Approach

Psychotherapy

• Cognitive-behavioral therapy (CBT) is the psychological treatment of first choice for panic attacks 1, 2
• For individuals concerned about prior panic attacks, psychological treatment based on CBT principles is strongly recommended 3
• Individual therapy is preferred over group therapy due to superior clinical and economic effectiveness 1

Pharmacotherapy

First-line medications:

• SSRIs (e.g., paroxetine, sertraline) are the first-line pharmacological treatment 1, 4, 2
  • Start with 20 mg once daily of paroxetine, with titration range of 20-50 mg daily 1
  • Sertraline has proven effective in the range of 50-175 mg per day 5
• SNRIs are also effective first-line options:
  • Venlafaxine is preferred for generalized anxiety disorder 1, 6
  • Duloxetine is preferred when comorbid pain conditions exist 1

Short-term/adjunctive medications:

• Benzodiazepines (e.g., alprazolam) may be used for short-term treatment or in treatment-resistant cases 4, 2
  • Initial dose of alprazolam may be 0.5 mg three times daily, with careful titration up to a maximum of 4 mg daily in divided doses 7
  • For panic disorder specifically, doses of 1-10 mg daily have been used in clinical trials, with mean dosage of approximately 5-6 mg daily 7
  • Benzodiazepines should be reserved for patients without history of dependency and tolerance 4, 8
  • They can be combined with SSRIs in the first weeks of treatment before the onset of SSRI response 2

Treatment Algorithm

1. For mild panic attacks with minimal functional impairment:

   • Begin with CBT alone 1
   • If inadequate response after 4-6 weeks, add an SSRI

2. For moderate to severe panic attacks:

   • Begin with both CBT and an SSRI/SNRI simultaneously 1
   • Consider short-term benzodiazepine use (2-4 weeks) while waiting for SSRI/SNRI effect 2

3. If first-line treatment is ineffective after 4-6 weeks:

   • Switch to another SSRI or SNRI 1
   • Consider increasing the dose of current medication
   • Intensify CBT

Monitoring and Treatment Duration

• Assess response after 4-6 weeks of medication 1
• Continue effective medication for at least 6-12 months after symptom remission 1
• Taper medication gradually when discontinuing to avoid withdrawal symptoms 1, 7
  • For benzodiazepines like alprazolam, reduce by no more than 0.5 mg every 3 days 7
  • Some patients may require even slower tapering 7

Special Considerations

• Elderly patients: Start with lower doses (e.g., alprazolam 0.25 mg two or three times daily) and titrate more slowly 1, 7
• Patients with hepatic or renal impairment: Require dose adjustments and careful monitoring 1
• Treatment-resistant cases: Reevaluate diagnosis, medication adherence, and consider alternative or augmentation strategies 1

Lifestyle Modifications

• Establish a consistent morning routine
• Regular exercise, particularly in the morning
• Good sleep hygiene
• Limit screen time before bed and after waking
• Spend time in nature
• Practice mindfulness and meditation 1

Common Pitfalls to Avoid

• Prescribing benzodiazepines as first-line treatment for long-term use
• Stopping medications abruptly, particularly benzodiazepines
• Failing to combine pharmacotherapy with CBT, which is the most successful treatment strategy 4
• Not monitoring for side effects, particularly during the initial treatment phase
• Inadequate duration of treatment leading to symptom recurrence