What is the recommended medication for treating panic attacks?

Medication for Panic Attacks

SSRIs are the first-line medication for panic disorder, with sertraline (starting at 25 mg daily, titrating to 50-200 mg/day) or escitalopram (starting at 5-10 mg daily, titrating to 10-20 mg/day) as the preferred initial agents due to their established efficacy, favorable safety profiles, and lower discontinuation symptom risk. 1, 2, 3

First-Line Treatment: SSRIs

Sertraline is the top-tier choice for panic disorder based on multiple controlled trials demonstrating significant reduction in panic attack frequency, severity, and associated anxiety, with proven relapse prevention for up to 36 weeks following medication withdrawal. 4, 5, 6

Sertraline Dosing Protocol

• Start at 25 mg daily for the first week to minimize initial anxiety or activation symptoms that commonly occur with SSRIs 3
• Increase to 50 mg daily after week 1, then titrate by 25-50 mg increments every 1-2 weeks as tolerated 2, 3
• Target therapeutic range: 50-200 mg/day (most patients respond to 50-100 mg/day) 4, 5
• Maximum dose: 200 mg/day 4

Alternative SSRI: Escitalopram

• Start at 5-10 mg daily, increase by 5-10 mg increments every 1-2 weeks 2
• Target dose: 10-20 mg/day 2
• Preferred when sertraline is not tolerated or available 2

Fluoxetine as Third Option

• Start at 10 mg daily for panic disorder (lower than depression dosing) 7
• Increase to 20 mg daily after 1 week, with further increases only after several weeks if no improvement 7
• Maximum studied dose: 60 mg/day 7
• Advantage: longer half-life minimizes discontinuation symptoms and allows for occasional missed doses 2

Expected Response Timeline

Do not abandon treatment prematurely—SSRIs follow a logarithmic response pattern: 1, 2, 3

• Week 2: Statistically significant improvement may begin
• Week 6: Clinically significant improvement expected
• Week 12 or later: Maximal therapeutic benefit achieved

Critical Monitoring and Side Effects

Common Side Effects (emerge within first few weeks)

• Nausea, headache, insomnia, sexual dysfunction, dry mouth, diarrhea, somnolence, dizziness 1, 2, 3
• Most resolve with continued treatment—counsel patients to persist through initial side effects 1

Serious Warnings

• Suicidal thinking and behavior: All SSRIs carry a black box warning through age 24; pooled risk is 1% vs 0.2% placebo (NNH = 143) 1, 2
• Monitor closely in first months and after dose changes 1, 2
• Behavioral activation, agitation, hypomania, serotonin syndrome, abnormal bleeding 1

Second-Line Treatment: SNRIs

Venlafaxine extended-release (75-225 mg/day) is effective for panic disorder but requires blood pressure monitoring due to risk of sustained hypertension. 2, 3

Duloxetine (60-120 mg/day) is particularly useful when comorbid pain conditions exist. 2, 3

Treatment Duration

• Continue medication for 9-12 months minimum after achieving remission to prevent relapse 1
• Taper gradually when discontinuing—abrupt cessation causes withdrawal symptoms, particularly with shorter half-life SSRIs like sertraline and paroxetine 2, 8
• Panic disorder is a chronic condition; many patients require long-term or indefinite treatment 7, 4

Medications to Avoid or Use Cautiously

Avoid as First-Line

• Benzodiazepines: Reserve for short-term adjunctive use only (first 2-4 weeks while waiting for SSRI onset) or treatment-resistant cases without substance abuse history 9, 8
• Tricyclic antidepressants: Equally effective but poorly tolerated, cause initial "jitteriness," and are cardiotoxic in overdose 10, 9
• MAOIs: Effective but dietary restrictions and hypertensive crisis risk preclude first-line use 10, 9

Paroxetine Caution

• While effective, paroxetine has higher risk of discontinuation syndrome and potentially increased suicidal thinking compared to other SSRIs—use only when first-tier agents fail 2

Combination with Psychotherapy

Cognitive behavioral therapy (CBT) targeting panic-specific cognitions and graded exposure should be combined with medication for optimal outcomes, as CBT demonstrates efficacy comparable to or exceeding pharmacotherapy alone. 1, 2

Special Populations

Elderly Patients

• Start at half the usual adult dose (e.g., sertraline 12.5-25 mg daily) 7, 4, 8
• Elderly have fewer panic symptoms but same treatment principles apply 8
• SSRIs strongly preferred over TCAs or benzodiazepines due to better tolerability and lower fall/cognitive impairment risk 8

Children and Adolescents (6-18 years)

• SSRIs are recommended for panic disorder in this age group 1
• Use same agents (sertraline, fluoxetine, escitalopram) with weight-based or lower starting doses 1
• Enhanced monitoring for suicidal ideation is critical 1

Algorithm for Treatment Failure

If inadequate response after 8-12 weeks at therapeutic doses: 2

1. Switch to a different SSRI (e.g., sertraline to escitalopram or vice versa)
2. Consider SNRI (venlafaxine XR or duloxetine)
3. Add CBT if not already implemented
4. Consider short-term benzodiazepine augmentation in selected cases without substance abuse history

Key Clinical Pitfalls to Avoid

• Starting at too high a dose—causes intolerable activation and treatment discontinuation 2, 3, 8
• Escalating doses too quickly—allow 1-2 weeks between increases to assess tolerability 2
• Abandoning treatment before 12 weeks—maximal benefit takes time 1, 2, 3
• Abrupt discontinuation—always taper gradually over weeks to months 2, 8
• Using benzodiazepines as monotherapy—dependence risk and lack of antidepressant effect for common comorbid depression 9, 8