What is the treatment for panic disorder?

Treatment of Panic Disorder

Cognitive-behavioral therapy (CBT) combined with a selective serotonin reuptake inhibitor (SSRI) is the most effective treatment approach for panic disorder, offering superior outcomes compared to either treatment alone. 1

First-Line Treatments

Psychotherapy

• Cognitive-behavioral therapy (CBT) is the first-line psychotherapeutic intervention for panic disorder, particularly for mild to moderate presentations 1
• CBT helps patients understand the nature of panic disorder and provides strategies to counter panic-related fears, breaking the cycle of anticipatory anxiety, panic, and avoidance 2
• CBT typically consists of 12-15 sessions in either individual or group format 2

Pharmacotherapy

• SSRIs (such as paroxetine, sertraline, fluoxetine, fluvoxamine, escitalopram, citalopram) are the first-line pharmacological treatment for panic disorder 3, 4
• SSRIs have demonstrated efficacy in reducing the severity of panic symptoms and eliminating panic attacks 5
• Paroxetine has specific FDA approval for panic disorder, with efficacy established in 10-12 week trials 3

Combination Treatment

• The combination of CBT and an SSRI has been shown to be more effective than either treatment alone, improving primary anxiety symptoms, global functioning, treatment response, and remission rates 1
• This combination approach is particularly beneficial for more severe presentations of panic disorder 1
• Long-term maintenance of treatment gains is better with combination therapy, as initial response to treatment strongly predicts long-term outcomes 1

Alternative Pharmacological Options

• Serotonin-norepinephrine reuptake inhibitors (SNRIs) can be considered as an alternative when SSRIs are not effective or not tolerated 1
• SNRIs have shown efficacy in improving clinician-reported anxiety symptoms, though they may cause more fatigue/somnolence than placebo 1
• Benzodiazepines (such as alprazolam) are effective for short-term symptom relief but are less effective than antidepressants and CBT for long-term management 6, 5
• For alprazolam specifically, dosing may start at 0.5 mg three times daily and can be increased to a maximum of 10 mg daily in divided doses, though most patients respond to 5-6 mg daily 6

Treatment Considerations and Monitoring

• When using SSRIs, treatment should be initiated at a low dose and gradually increased to minimize side effects 3
• Long-term maintenance treatment is often necessary due to the chronicity of panic disorder and high relapse rates when treatment is discontinued 7
• For benzodiazepines, the lowest effective dose should be used, and gradual discontinuation is essential to prevent withdrawal symptoms 6
• Regular monitoring for treatment response using standardized symptom rating scales is recommended 1

Special Populations

• For elderly patients or those with advanced liver disease, lower starting doses of medications are recommended (e.g., 0.25 mg two or three times daily for alprazolam) 6
• Cultural adaptations to CBT may be necessary for certain populations, including addressing culturally specific beliefs about symptoms and using culturally appropriate metaphors 1
• For patients with somatic manifestations of panic, interoceptive exposure techniques can be particularly helpful 1

Common Pitfalls and Caveats

• Abrupt discontinuation of benzodiazepines should be avoided due to withdrawal risks; dose should be reduced gradually, typically by no more than 0.5 mg every 3 days 6
• Some patients may require an even slower tapering schedule for benzodiazepines 6
• Reliance on benzodiazepines alone without addressing underlying anxiety mechanisms through CBT may lead to dependence without resolving the core disorder 5
• Inadequate duration of SSRI treatment is a common cause of relapse; treatment should typically be maintained for at least 6-12 months after symptom resolution 7