What is the recommended treatment for panic disorder?

Treatment of Panic Disorder

SSRIs are the first-line pharmacological treatment for panic disorder due to their high efficacy, relatively safe side effect profile, and low risk of dependence. 1

First-Line Treatment Options

Pharmacotherapy

• SSRIs (sertraline, escitalopram, paroxetine, fluvoxamine):

  • Paroxetine is FDA-approved specifically for panic disorder 2
  • Start at low doses and gradually titrate to minimize side effects
  • Efficacy demonstrated in clinical trials with significantly higher rates of panic-free patients compared to placebo 2
  • Continue effective medication for at least 6-12 months after symptom remission 1

• SNRIs (venlafaxine, duloxetine):

  • Alternative first-line options if SSRIs are not tolerated
  • Duloxetine is the only SNRI with FDA indication for anxiety disorders (generalized anxiety disorder) 1
  • Initial dose for venlafaxine: 20 mg once daily, titrating to 20-50 mg daily 1

Psychotherapy

• Cognitive Behavioral Therapy (CBT):
  • Highly effective standalone treatment for mild cases
  • Individual CBT is preferred over group therapy due to superior clinical and economic effectiveness 1
  • For moderate to severe panic disorder, combine CBT with SSRI/SNRI simultaneously 1
  • Self-help with support based on CBT can be offered if patient declines face-to-face therapy 1

Treatment Algorithm

1. Initial Assessment:

   • Evaluate severity of panic attacks, presence of agoraphobia, functional impairment
   • Screen for comorbidities (depression, substance use, other anxiety disorders)

2. Treatment Selection:

   • Mild panic disorder: Start with CBT alone
   • Moderate to severe panic disorder: Start with both CBT and SSRI/SNRI simultaneously 1

3. Medication Selection:

   • First choice: SSRI (paroxetine, sertraline)
   • Alternative: SNRI (venlafaxine, duloxetine)
   • Short-term use only: Benzodiazepines (clonazepam) for immediate symptom relief while waiting for SSRI/SNRI effect 3, 4

4. Treatment Monitoring:

   • Assess response after 4-6 weeks of medication 1
   • If inadequate response, consider:
     • Increasing dose of antidepressant
     • Intensifying CBT
     • Adding other medications

Special Considerations

Benzodiazepines

• Clonazepam has demonstrated efficacy in clinical trials for panic disorder 3
• Should be used cautiously due to risk of dependence and withdrawal
• Best reserved for short-term use or treatment-resistant cases 4
• Withdrawal symptoms can be severe and include anxiety, insomnia, irritability, and seizures 3
• Use gradual tapering when discontinuing to avoid withdrawal reactions 3

Special Populations

• Children and adolescents: SSRIs are first-line with careful monitoring for suicidal ideation 1
• Elderly patients: Start on lower doses and titrate more slowly 1
• Pregnancy/lactation: SSRIs may be used with caution when benefits outweigh risks 1
• Hepatic/renal impairment: Dose adjustments and careful monitoring required 1

Treatment-Resistant Cases

• Reassess diagnosis and medication adherence
• Consider combination therapy (SSRI + CBT) if not already implemented 5
• Consider alternative medication classes or augmentation strategies 6
• Evaluate for comorbidities that may be complicating treatment 1

Common Pitfalls and Caveats

1. Inadequate dosing or duration: Ensure adequate trial period (at least 4-6 weeks) before concluding treatment failure 1

2. Abrupt discontinuation: Always taper benzodiazepines and antidepressants gradually to avoid withdrawal symptoms 3

3. Overlooking comorbidities: Depression, substance use, and other anxiety disorders frequently co-occur with panic disorder and may require additional targeted interventions 1

4. Relying solely on medication: Combined treatment with CBT and medication shows superior outcomes compared to either treatment alone 4

5. Prolonged benzodiazepine use: While effective for short-term symptom relief, long-term use carries significant risks of dependence and tolerance 4, 3