What treatment options are available for a patient with anxiety and panic attacks?

Treatment for Anxiety and Panic Attacks

For adults with anxiety and panic attacks, start with an SSRI (sertraline 25-50 mg daily or escitalopram 10 mg daily) combined with cognitive-behavioral therapy, as this combination provides superior outcomes compared to either treatment alone. 1, 2

First-Line Pharmacotherapy

SSRIs are the recommended first-line medication class for both generalized anxiety disorder and panic disorder in adults. 3, 4, 5

Specific SSRI Recommendations:

• Sertraline: Start 25-50 mg daily (preferred due to favorable efficacy and tolerability profile) 2, 6, 7
• Escitalopram: Start 10 mg daily (alternative first-line option with low drug interaction potential) 2
• Fluoxetine: Start 10 mg daily for panic disorder, increase to 20 mg after 1 week; may titrate up to 60 mg/day as needed 8

Dosing Strategy:

• Begin with a subtherapeutic "test" dose to minimize initial anxiety or agitation, particularly important in panic disorder where patients are hypersensitive to physical sensations 2
• Titrate slowly at 1-2 week intervals for shorter half-life SSRIs (sertraline, escitalopram) 2
• Expect 4-6 weeks for clinically significant improvement and up to 12 weeks for maximal therapeutic effect 2
• Monitor for side effects including serotonin syndrome, behavioral activation/agitation, and hypomania/mania during initiation 2

First-Line Psychotherapy

Cognitive-behavioral therapy (CBT) specifically developed for anxiety disorders should be offered either as monotherapy for mild-to-moderate cases or in combination with SSRIs. 3, 1, 9

CBT Components:

• Education about anxiety and panic physiology 3
• Graduated exposure to feared stimuli (cornerstone of treatment) 3
• Cognitive restructuring to challenge catastrophizing and negative predictions 3
• Relaxation techniques including deep breathing and progressive muscle relaxation 3
• Interoceptive exposure for patients with somatic panic manifestations 1
• Typically consists of 12-15 sessions in individual or group format 9

Combination Treatment Approach

Combination therapy (CBT + SSRI) is preferentially recommended over monotherapy for moderate-to-severe presentations, showing superior response rates and remission compared to either treatment alone. 1, 2

• Initial response to combination treatment strongly predicts long-term outcomes, making this approach particularly valuable for sustained benefit 1
• Combination therapy demonstrates better long-term maintenance of treatment gains 1

Second-Line Pharmacotherapy

SNRIs (venlafaxine extended-release) can be offered as an alternative when SSRIs fail or are not tolerated. 3, 2

• Venlafaxine improves clinician-reported anxiety symptoms with high strength of evidence 3, 2
• May cause more fatigue/somnolence than placebo 3
• Start low and titrate gradually 3

Acute/As-Needed Management

Benzodiazepines (alprazolam) may be used short-term for acute symptom relief or during SSRI initiation, but carry significant risks. 10, 4, 5

Alprazolam Dosing (if used):

• Anxiety: Start 0.25-0.5 mg three times daily, maximum 4 mg/day in divided doses 10
• Panic disorder: Start 0.5 mg three times daily, may increase by no more than 1 mg/day every 3-4 days; doses of 5-6 mg/day are commonly needed 10
• Maximum studied dose: 10 mg/day for panic disorder 10

Critical Benzodiazepine Warnings:

• Avoid entirely in patients with substance use history, respiratory disorders, or elderly patients 2
• High risk of dependence and tolerance, particularly with doses >4 mg/day and prolonged duration 10
• Reserve for short-term use only (4-10 weeks maximum) or treatment-resistant cases 10, 4, 5
• Can be combined with SSRIs in first weeks to bridge until SSRI onset of action 5
• Must taper gradually when discontinuing (decrease by no more than 0.5 mg every 3 days; some patients require slower taper) 10

Treatment-Resistant Cases

If inadequate response after 6-8 weeks at therapeutic SSRI dose:

• Switch to a different SSRI 2
• Consider SNRI (venlafaxine) 2
• Reassess diagnosis and comorbidities 2

Maintenance and Monitoring

• Assess treatment response within 4-6 weeks of reaching therapeutic dose using standardized symptom rating scales 2
• Panic disorder and anxiety disorders are chronic conditions; continuation treatment is reasonable for responders 10, 8
• Periodically reassess the need for continued treatment 10, 8
• Maintain patients on the lowest effective dosage 8

Discontinuation Protocol

When discontinuing SSRIs, taper gradually to avoid discontinuation syndrome (dizziness, fatigue, nausea, sensory disturbances, anxiety). 2

• A gradual dose reduction is recommended rather than abrupt cessation 8
• If intolerable symptoms occur, resume previous dose and taper more slowly 8
• Fluoxetine has lower risk of discontinuation symptoms due to long half-life 8

Special Population Considerations

For children and adolescents (6-18 years):

• SSRIs are recommended for social anxiety, generalized anxiety, separation anxiety, and panic disorder 3
• Combination CBT + SSRI shows superior outcomes 3
• Parental oversight of medication regimens is paramount 2

For elderly patients:

• Sertraline and escitalopram are preferred due to favorable safety profiles and low drug interaction potential 2
• Consider lower or less frequent dosing 8