What is the recommended treatment for panic disorder?

Treatment of Panic Disorder

The recommended first-line treatment for panic disorder is a combination of Selective Serotonin Reuptake Inhibitors (SSRIs) and Cognitive Behavioral Therapy (CBT), with sertraline or escitalopram being preferred due to their favorable safety profiles and efficacy. 1, 2, 3

Pharmacological Treatment

First-Line Medications

• SSRIs are the first-line pharmacological treatment for panic disorder, with sertraline and escitalopram being particularly recommended due to their favorable safety profiles and low potential for drug interactions 1, 4
• Paroxetine is FDA-approved for panic disorder but should be used with caution, especially in elderly patients, due to higher rates of adverse effects 4, 2
• SNRIs such as venlafaxine are effective alternatives for treating panic disorder 1

Dosing Considerations

• Start with lower doses of SSRIs and gradually increase to therapeutic levels, as starting with full therapeutic doses can initially worsen anxiety symptoms 1
• For elderly patients, use reduced doses (e.g., sertraline starting at 25-50 mg daily) with careful monitoring 4, 3

Treatment Duration

• Continue pharmacological treatment for at least 4-12 months after symptom remission for first episodes 1
• For recurrent panic disorder, longer-term or indefinite treatment may be beneficial 1
• Avoid abrupt discontinuation of shorter-acting SSRIs to prevent withdrawal symptoms 1

Psychotherapy Approaches

Cognitive Behavioral Therapy (CBT)

• CBT is highly effective for panic disorder and should be structured with approximately 14 sessions over 4 months 1
• Individual sessions should last 60-90 minutes and are generally preferred over group therapy due to superior clinical effectiveness 1
• Self-help with professional support based on CBT principles is a viable alternative for patients who cannot or do not want face-to-face CBT 1

Combination Therapy

• The combination of CBT plus an SSRI is more effective than either treatment alone, showing improved anxiety symptoms, global functioning, response rates, and remission rates 1
• This combined approach should be considered the optimal treatment strategy for most patients with panic disorder 1

Special Populations

Elderly Patients

• Sertraline and escitalopram are preferred for elderly patients due to their favorable safety profiles and lower potential for drug interactions 1, 4
• Lower starting doses and slower titration schedules are recommended for elderly patients 4

Children and Adolescents

• For patients 6-18 years old with anxiety disorders, a combination of CBT and SSRI is recommended 1
• Parental oversight of medication regimens is essential for younger patients 1

Common Pitfalls to Avoid

• Starting with full therapeutic doses of SSRIs can temporarily worsen anxiety symptoms; begin with lower doses and gradually increase 1
• Abrupt discontinuation of shorter-acting SSRIs can lead to withdrawal symptoms; taper medications slowly when discontinuing 1
• Benzodiazepines, while effective for short-term symptom relief, carry significant risks of dependence and withdrawal and should not be considered first-line treatment for long-term management 5, 6
• Neglecting to continue treatment for an adequate duration (at least 4-12 months after remission) can lead to relapse 1

Treatment Algorithm

1. Initial Treatment: Start with an SSRI (preferably sertraline or escitalopram) at a low dose and gradually increase to therapeutic levels, while simultaneously initiating CBT 1, 7
2. Monitoring: Assess response after 4-6 weeks of adequate dosing 5
3. Inadequate Response: If response is inadequate, consider switching to another SSRI or an SNRI 1
4. Maintenance: After symptom remission, continue treatment for at least 4-12 months 1
5. Discontinuation: When appropriate, taper medication slowly to minimize withdrawal symptoms 1