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) recommended as the first-line psychological intervention. 1

First-Line Pharmacological Treatment

SSRIs

• Recommended as first-line due to high efficacy, relatively safe side effect profile, and low risk of dependence 1
• Options include:
  • Sertraline: Effective in reducing severity and frequency of panic attacks 2
  • Escitalopram
  • Paroxetine
  • Fluvoxamine

SNRIs

• Alternative first-line options:
  • Venlafaxine: Start at 20 mg once daily, titrate to 20-50 mg daily 1
  • Duloxetine: The only SNRI with FDA indication specifically for anxiety disorders (generalized anxiety disorder) 1

Psychological Interventions

• Individual Cognitive Behavioral Therapy (CBT) specifically developed for panic disorder is highly effective 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 1
• For moderate to severe panic disorder, begin with both CBT and an SSRI/SNRI simultaneously 1
• Self-help with support based on CBT can be offered as an alternative if patient declines face-to-face CBT 1

Treatment Algorithm

1. Initial Treatment:

   • For mild panic disorder: Start with CBT alone
   • For moderate to severe panic disorder: Combine CBT with an SSRI

2. Medication Management:

   • 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

3. For Inadequate Response:

   • Consider increasing the dose of antidepressant
   • Intensify CBT
   • Consider alternative or augmentation strategies 1

Short-Term Management Options

• Benzodiazepines (e.g., alprazolam) may be used for short-term treatment when the patient does not have a history of dependency and tolerance 3
• Alprazolam has demonstrated effectiveness in panic disorder in placebo-controlled studies 4
• Important caution: Benzodiazepines carry risks of dependence, especially at doses greater than 4 mg/day which may be necessary for panic disorder 4

Special Populations

• Young individuals (7-17 years): SSRIs are recommended as first-line treatment with monitoring for suicidal ideation 1
• Elderly patients: Start on lower doses and titrate more slowly 1
• Patients with hepatic/renal impairment: Require dose adjustments and careful monitoring 1

Lifestyle Modifications

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

Common Pitfalls to Avoid

1. Premature discontinuation: Treatment should continue for at least 6-12 months after symptom remission
2. Abrupt discontinuation of benzodiazepines: Can lead to withdrawal symptoms and seizures 4
3. Overlooking comorbidities: Approximately one-third of patients have comorbid psychiatric disorders 1
4. Excessive benzodiazepine use: Long-term use can lead to dependence and tolerance
5. Ignoring psychological treatment: Combined approach of medication and CBT is most effective 3

Remember that panic disorder is often chronic and rarely resolves without medical intervention 5. The combination of pharmacotherapy and cognitive behavioral therapy represents the most successful treatment strategy 3.