What is the best medication for an adult experiencing severe anxiety/panic attacks and feeling overwhelmed?

Best Medication for Severe Anxiety/Panic Attacks in Adults

For an adult experiencing severe anxiety and panic attacks, start sertraline (an SSRI) at 50 mg daily, which is FDA-approved for panic disorder and has the strongest evidence for efficacy and tolerability in acute panic presentations. 1, 2

Immediate Management

Sertraline is the preferred first-line agent because it:

• Has FDA approval specifically for panic disorder treatment 1
• Demonstrates equivalent efficacy to other SSRIs but with superior tolerability (lower discontinuation rates due to adverse events: 12% vs 18% for paroxetine) 2
• Shows 82% response rates in panic disorder trials 2
• Reduces both panic attack frequency and baseline anxiety symptoms 3

Dosing Strategy

Start sertraline at 50 mg daily and titrate as follows: 1, 4

• Increase by 50 mg increments every 1-2 weeks based on response 5
• Therapeutic range: 50-150 mg daily for panic disorder 3
• Maximum dose: 200 mg daily 1

Assess response at 4 weeks and 8 weeks using standardized measures of panic symptoms 5

Critical Warning About Initial Worsening

Warn the patient that SSRIs can paradoxically increase anxiety or agitation during the first 1-2 weeks of treatment 6, 7

• This is a known adverse effect that typically resolves within 2 weeks 6
• Rare cases of sertraline-induced panic attacks have been reported 7
• If initial anxiety worsening is intolerable, consider temporary adjunctive benzodiazepine (see below)

Short-Term Adjunctive Treatment (If Needed)

For severe, overwhelming symptoms requiring immediate relief while waiting for SSRI onset (2-4 weeks): 5, 4

• Consider short-term benzodiazepine use (e.g., clonazepam 0.5 mg twice daily or lorazepam 0.5-1 mg as needed) 5
• Benzodiazepines are NOT recommended for long-term routine use due to risks of tolerance, dependence, and cognitive impairment 5
• Taper and discontinue benzodiazepines once SSRI reaches therapeutic effect (typically 4-6 weeks) 5

If Inadequate Response After 8 Weeks

If symptoms remain stable or worsen after 8 weeks at therapeutic doses: 5

1. First option: Switch to a different SSRI (escitalopram) or SNRI (venlafaxine 150-225 mg daily) 5
2. Second option: Add cognitive behavioral therapy (CBT), which has strong evidence for enhancing medication response 5

Essential Non-Pharmacologic Component

Strongly recommend CBT as adjunctive treatment 8, 5, 4

• CBT is equally effective as medication alone and combination therapy (medication + CBT) shows superior outcomes 8, 4
• Psychological therapy should be initiated concurrently with medication, not delayed 8

Treatment Duration

Continue treatment for at least 4-12 months after symptom remission for a first episode 6

• Sertraline demonstrates relapse prevention efficacy for up to 36 weeks following acute treatment 3
• For recurrent panic disorder, longer-term or indefinite treatment may be necessary 6

Common Pitfalls to Avoid

Never discontinue sertraline abruptly 6, 5

• Taper gradually over 3+ weeks to avoid discontinuation syndrome (dizziness, paresthesias, anxiety, irritability) 6
• Sertraline has less risk of discontinuation syndrome compared to paroxetine, but tapering is still essential 5

Do not use benzodiazepines as monotherapy 4

• While benzodiazepines provide rapid symptom relief, they are less effective than antidepressants and CBT for long-term panic disorder management 4

Monitor for treatment-emergent side effects: 1, 2

• Gastrointestinal disturbances (most common) 5
• Sexual dysfunction 8
• Weight gain (less common with sertraline than paroxetine: <1% vs 7%) 2