What is the recommended treatment for panic disorder?

Treatment of Panic Disorder

The recommended first-line treatment for panic disorder is a combination of cognitive behavioral therapy (CBT) and a selective serotonin reuptake inhibitor (SSRI), with sertraline being a preferred medication option due to its proven efficacy and favorable side effect profile. 1, 2

First-Line Treatment Options

Pharmacotherapy

• SSRIs are the preferred first-line medication:
  • Sertraline: Start at 25-50 mg daily, may increase to 50-200 mg daily 3, 2
  • Other effective SSRIs include paroxetine and fluoxetine 1, 4
  • SNRIs (particularly venlafaxine) are also effective first-line options 1

Psychotherapy

• Cognitive Behavioral Therapy (CBT) is the most effective psychological treatment 1
  • Individual therapy is preferred over group therapy for moderate to severe panic disorder
  • Should include exposure techniques, cognitive restructuring, and relaxation training
  • Typically requires 12-16 sessions for optimal results

Treatment Algorithm

1. For mild panic disorder:

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

2. For moderate to severe panic disorder:

   • Begin simultaneously with both CBT and an SSRI
   • Initial SSRI dose should be lower than used for depression (e.g., sertraline 25 mg daily) to minimize initial activation symptoms
   • Gradually titrate to effective dose over 2-4 weeks

3. Assess response after 4-6 weeks:

   • If responding, continue treatment
   • If partial response, increase SSRI dose
   • If no response, switch to another SSRI or SNRI

Second-Line Treatment Options

• SNRIs (if not used first-line):

  • Venlafaxine: Particularly effective for GAD with panic 1
  • Duloxetine: Consider when comorbid pain conditions exist 1

• Tricyclic antidepressants (TCAs):

  • As effective as SSRIs but with more side effects 4, 5
  • Examples: imipramine, clomipramine

• Benzodiazepines (short-term use only):

  • Alprazolam: Effective for acute symptom relief 6, 7
  • Dosage: Start at 0.25-0.5 mg three times daily, may increase to 1-4 mg daily in divided doses 6
  • Caution: Risk of dependence, withdrawal, and tolerance; not recommended for long-term use or in patients with history of substance abuse 6, 4

Treatment Duration and Monitoring

• Continue effective medication for at least 6-12 months after symptom remission 1
• Monitor for side effects, particularly during initial treatment phase
• When discontinuing, taper gradually to avoid withdrawal symptoms:
  • SSRIs: Taper over 2-4 weeks
  • Benzodiazepines: Taper very slowly over months to avoid withdrawal symptoms 6

Special Populations

• Elderly patients: Start with lower doses and titrate more slowly 1
• Pregnant/lactating women: SSRIs may be used with caution when benefits outweigh risks 1
• Children/adolescents (6-18 years): SSRIs are first-line, with monitoring for suicidal ideation 1

Lifestyle Modifications

• Regular exercise, particularly in the morning
• Adequate sleep hygiene
• Limiting caffeine and alcohol intake
• Mindfulness and meditation practices
• Establishing consistent daily routines 1

Common Pitfalls to Avoid

1. Starting SSRIs at full dose: Begin with lower doses to minimize activation symptoms
2. Using benzodiazepines as first-line or long-term treatment: Reserve for short-term use due to dependence risk 6, 7
3. Discontinuing medications abruptly: Always taper gradually to prevent withdrawal symptoms
4. Inadequate treatment duration: Continue treatment for 6-12 months after remission to prevent relapse 1
5. Failing to address comorbid conditions: Depression, other anxiety disorders, and substance use disorders frequently co-occur with panic disorder and may require additional targeted interventions 1

By following this evidence-based approach, most patients with panic disorder can achieve significant symptom improvement and better quality of life.