What is the recommended treatment for panic disorder?

Treatment of Panic Disorder

For panic disorder, the recommended first-line treatment is a combination of cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs), with SSRIs being the preferred pharmacological intervention due to their efficacy and favorable side effect profile. 1

Pharmacological Treatment Options

First-Line Medications

• SSRIs are recommended as first-line pharmacotherapy for panic disorder due to their effectiveness in reducing panic symptoms and eliminating panic attacks 1
• Specific SSRIs with demonstrated efficacy include:
  • Paroxetine - FDA approved for panic disorder with significant evidence showing both short and long-term efficacy 2, 3
  • Sertraline - FDA approved for panic disorder with favorable efficacy data 4
  • Escitalopram - Recommended particularly for elderly patients due to favorable safety profile and low potential for drug interactions 5
• SNRIs such as venlafaxine are also suggested as effective options for treating anxiety disorders 6

Second-Line Medications

• Benzodiazepines (such as alprazolam) have demonstrated effectiveness in panic disorder but are generally considered second-line due to:
  • Risk of dependence and withdrawal syndromes 7, 8
  • Less effective than antidepressants and CBT for long-term management 1
• Alprazolam has shown efficacy in clinical studies for panic disorder, with 37-83% of patients achieving zero panic attacks 9

Psychotherapy Approaches

• Cognitive Behavioral Therapy (CBT) is strongly recommended as a first-line treatment for panic disorder 1
• CBT should be structured with approximately 14 sessions over 4 months, with each individual session lasting 60-90 minutes 6
• Individual therapy is generally preferred over group therapy due to superior clinical and economic effectiveness 6
• For patients who cannot or do not want face-to-face CBT, self-help with support based on CBT principles is suggested 6

Combination Therapy

• Evidence suggests that combination treatment (CBT plus SSRI) may be more effective than either treatment alone 6
• The Child-Adolescent Anxiety Multimodal Study (CAMS) showed that combination therapy improved:
  • Primary anxiety symptoms (clinician report)
  • Global functioning
  • Response to treatment
  • Remission rates 6

Treatment Algorithm

1. Initial Assessment:

   • Evaluate severity of panic symptoms, frequency of attacks, presence of agoraphobia, and comorbid conditions 6
   • Screen for suicidal ideation as panic disorder patients with comorbid depression are at higher risk 7

2. First-Line Treatment:

   • Begin with SSRI (paroxetine, sertraline, or escitalopram) 2, 4
   • Start with a subtherapeutic "test" dose as initial side effects can include increased anxiety 6
   • Gradually increase dose at 1-2 week intervals for shorter half-life SSRIs or 3-4 week intervals for longer half-life SSRIs 6
   • Concurrently refer for CBT if available 1

3. Monitoring and Adjustment:

   • Assess response using standardized symptom rating scales 6
   • Allow 4-6 weeks for full therapeutic effect of SSRIs 7
   • If partial response, optimize dosage within therapeutic range 6

4. For Inadequate Response:

   • Switch to alternative SSRI or SNRI 6
   • Consider adding benzodiazepine for short-term management of severe symptoms 8
   • Intensify CBT approach 6

Special Populations

Elderly Patients

• Prefer sertraline or escitalopram due to favorable safety profiles and lower drug interaction potential 5
• Use lower doses of benzodiazepines if needed (e.g., lorazepam 0.25-0.5 mg with maximum 2 mg/24 hours) 5
• Avoid paroxetine and fluoxetine in older adults due to higher rates of adverse effects 5

Adolescents

• Combination of CBT and SSRI is suggested for anxiety disorders in patients 6-18 years old 6
• Parental oversight of medication regimens is essential 6
• SSRIs are recommended as first-line pharmacotherapy for adolescents with anxiety disorders 6

Treatment Duration

• For first episodes, continue treatment for at least 4-12 months after symptom remission 5
• For recurrent panic disorder, longer-term or indefinite treatment may be beneficial 5
• Long-term maintenance of SSRI therapy has been shown to prevent relapse 3

Common Pitfalls to Avoid

• Starting with full therapeutic doses of SSRIs can worsen anxiety initially 6
• Abrupt discontinuation of shorter-acting SSRIs (particularly paroxetine) can lead to withdrawal symptoms 6
• Underestimating the chronicity of panic disorder - it rarely resolves without intervention 4
• Focusing only on somatic symptoms without addressing the underlying anxiety disorder 4