What is the recommended treatment for panic disorders?

Treatment of Panic Disorder

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line pharmacological treatment for panic disorder, with Cognitive Behavioral Therapy (CBT) as the recommended psychotherapeutic approach, often used in combination for optimal outcomes. 1

First-Line Pharmacological Treatment

SSRIs

• Recommended as first-line due to:
  • High efficacy
  • Relatively safe side effect profile
  • Low risk of dependence 1
• Options include:
  • Sertraline
  • Escitalopram
  • Paroxetine
  • Fluvoxamine 1
• Dosing for fluoxetine (example):
  • Initial: 10 mg/day for 1 week
  • Then increase to 20 mg/day
  • May consider dose increase after several weeks if no clinical improvement
  • Maximum studied dose: 60 mg/day 2

SNRIs (Alternative First-Line)

• Venlafaxine is an alternative first-line option
  • Starting dose: 20 mg once daily
  • Titration range: 20-50 mg daily 1
• Duloxetine is the only SNRI with FDA indication specifically for anxiety disorders (generalized anxiety disorder) 1

Psychotherapy

• Individual Cognitive Behavioral Therapy (CBT) specifically developed for anxiety disorders is strongly recommended 1
• Individual therapy is preferred over group therapy due to superior clinical and economic effectiveness 1
• For mild cases with minimal functional impairment, CBT alone may be sufficient initially
• For moderate to severe panic disorder, treatment should begin with both CBT and an SSRI/SNRI simultaneously 1
• If patient declines face-to-face CBT, self-help with support based on CBT can be offered 1

Second-Line Treatment Options

Benzodiazepines

• May be used for short-term treatment and in non-responsive cases 3
• Alprazolam has demonstrated efficacy in panic disorder in placebo-controlled studies 4
• Important caveats:
  • Should only be used when patient has no history of dependency
  • Risk of tolerance and withdrawal symptoms
  • Higher dropout rates due to adverse effects compared to placebo 5
  • Not recommended for long-term use 6

Tricyclic Antidepressants

• As effective as SSRIs but less well tolerated 3, 6
• Consider as a third-line option when SSRIs and SNRIs are ineffective or not tolerated

Treatment Monitoring and Adjustment

• Assess response after 4-6 weeks of medication 1
• Continue effective medication for at least 6-12 months after symptom remission 1
• Taper gradually when discontinuing to avoid withdrawal symptoms 1, 2
• If inadequate response:
  1. Consider increasing the dose of current medication
  2. Intensify CBT
  3. Consider adding or switching to alternative medication 1

Special Populations

Young Individuals (7-17 years)

• SSRIs are recommended as first-line treatment
• Monitor closely for suicidal ideation 1

Elderly Patients

• Start on lower doses of medications
• Titrate more slowly 1
• Limit to smallest effective dose to prevent ataxia or oversedation 4

Patients with Hepatic/Renal Impairment

• Require dose adjustments and careful monitoring 1
• Lower or less frequent dosing recommended for hepatic impairment 2, 4

Common Pitfalls to Avoid

1. Premature discontinuation: Continue treatment for 6-12 months after symptom remission to prevent relapse 1

2. Abrupt discontinuation: Always taper gradually to avoid withdrawal symptoms, especially with benzodiazepines 2, 4

3. Overreliance on benzodiazepines: Despite rapid onset of action, they should not be used as monotherapy for long-term management due to dependency risks 3, 6

4. Inadequate dosing: Some patients may require higher doses than initial recommendations; assess response and adjust accordingly 1

5. Neglecting comorbidities: Approximately one-third of patients have comorbid psychiatric disorders that may require additional targeted interventions 1