What is the recommended treatment for panic and anxiety?

Treatment for Panic and Anxiety

The first-line treatment for anxiety disorders should be a combination of Cognitive Behavioral Therapy (CBT) and Selective Serotonin Reuptake Inhibitors (SSRIs) or Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs), with individual CBT specifically developed for anxiety disorders being preferred over group therapy due to superior clinical and economic effectiveness. 1

Psychotherapy Options

• Cognitive Behavioral Therapy (CBT):
  • Highest level of evidence among psychotherapies for anxiety disorders 1
  • Helps patients understand and modify patterns that perpetuate anxiety
  • Teaches strategies to counter fears and break cycles of anticipatory anxiety and panic
  • Individual therapy is preferred over group therapy for better outcomes

Pharmacological Treatment

First-Line Medications:

1. SSRIs (e.g., sertraline, escitalopram, paroxetine, fluoxetine):

   • Recommended by the American College of Physicians as first-line treatment 1
   • High efficacy, relatively safe side effect profile, low risk of dependence
   • For panic disorder, treatment should start with fluoxetine 10 mg/day, increasing to 20 mg/day after one week 2
   • Dosage can be increased if no clinical improvement is observed after several weeks

2. SNRIs (e.g., venlafaxine, duloxetine):

   • Alternative first-line options 1
   • Duloxetine is the only SNRI with FDA indication specifically for generalized anxiety disorder
   • For social anxiety disorder, start venlafaxine at 20 mg once daily, titrating to 20-50 mg daily 1

Medication Management:

• Assess treatment response after 4-6 weeks of medication
• Continue effective medication for at least 6-12 months after symptom remission
• Taper gradually when discontinuing to avoid withdrawal symptoms 1
• Lower or less frequent dosing should be considered for:
  • Elderly patients
  • Patients with hepatic impairment
  • Patients with concurrent diseases or on multiple medications 2

Treatment Algorithm

1. Initial Treatment:

   • Start with individual CBT specifically developed for anxiety disorders
   • Simultaneously initiate an SSRI (e.g., fluoxetine 10-20 mg/day) or SNRI
   • For severe symptoms causing significant impairment, prioritize medication for rapid relief

2. Assessment and Adjustment:

   • Evaluate response after 4-6 weeks
   • If inadequate response:
     • Consider increasing SSRI/SNRI dose
     • Intensify CBT
     • Consider alternative or augmentation strategies

3. Maintenance Phase:

   • Continue effective medication for 6-12 months after symptom remission
   • Continue CBT techniques as needed
   • Gradually taper medication when discontinuing

Special Populations

• Young individuals (7-17 years):

  • SSRIs are recommended as first-line treatment
  • Monitor closely for suicidal ideation 1
  • Parents/guardians with anxiety may benefit from psychoeducation and support 3

• Elderly patients:

  • Start on lower medication doses and titrate more slowly
  • Consider potential drug interactions and side effects 1

• Pregnant/lactating patients:

  • Use SSRIs with caution when benefits outweigh risks 1

Lifestyle Modifications

Recommend the following evidence-based lifestyle changes:

• Establish consistent morning routine
• Regular exercise
• Good sleep hygiene
• Limited screen time before bed and after waking
• Spending time in nature
• Practicing mindfulness and meditation 1

Important Cautions

• Benzodiazepines (e.g., alprazolam):

  • Not recommended for routine use despite their effectiveness 1, 4
  • Risk of dependence with prolonged use 5
  • If used, should be short-term with careful monitoring
  • Dosage should be individualized and reduced gradually when discontinuing 5

• Treatment Resistance:

  • Reevaluate diagnosis and medication adherence
  • Consider comorbidities that may require additional targeted interventions
  • Assess for substance use that may interfere with treatment 1

By following this evidence-based approach combining psychotherapy and appropriate pharmacotherapy, most patients with anxiety disorders can achieve significant symptom reduction and improved quality of life.