Best Medication for Panic Disorder
SSRIs, specifically sertraline or paroxetine, are the best first-line medications for panic disorder, with sertraline having FDA approval and the most robust evidence base for efficacy, tolerability, and long-term relapse prevention. 1, 2, 3
First-Line Treatment: SSRIs
Sertraline is the preferred SSRI for panic disorder based on:
- FDA approval specifically for panic disorder treatment in adults, with demonstrated superiority over placebo in three 10-12 week trials 1
- Dosing range of 50-200 mg/day, with most patients responding at 50-175 mg/day 2, 4
- Superior efficacy on multiple outcome measures including panic attack frequency (79-80% reduction), Clinical Global Impression scores, and quality of life measures 4, 5
- Long-term relapse prevention demonstrated up to 28 weeks following initial response, with maintained efficacy up to 52 weeks 1, 2
- Effectiveness regardless of prior benzodiazepine use, making it suitable even for patients who failed or partially responded to benzodiazepines 5
Paroxetine is an alternative FDA-approved SSRI for panic disorder with comparable efficacy 3
Practical Implementation
- Start at 25-50 mg daily and titrate slowly to avoid early activation/agitation 6, 4
- Expect initial response by week 2-6, with maximal improvement by week 12 or later 6
- Continue treatment for at least 52 weeks after achieving response to prevent relapse 1
- Monitor for common adverse effects in the first few weeks: nausea, diarrhea, headache, insomnia, sexual dysfunction 6
- Screen for suicidal ideation, particularly in patients under age 24, as SSRIs carry a boxed warning (absolute risk 1% vs 0.2% placebo) 6
Second-Line Options When SSRIs Fail
If sertraline or other SSRIs are ineffective or not tolerated after an adequate 8-12 week trial:
- Benzodiazepines (alprazolam 1-4 mg/day, clonazepam 1-4 mg/day) provide rapid anxiety relief but carry dependence risk 7, 8, 9
- Pregabalin (300-600 mg/day in divided doses) has demonstrated second-line efficacy 7, 8
- Gabapentin (900-3600 mg/day) is particularly useful with comorbid pain conditions 7, 8
Essential Combination Strategy
Always combine pharmacotherapy with Cognitive Behavioral Therapy (CBT), as combination therapy yields superior outcomes to either approach alone 6, 7, 10
- Individual CBT is preferred over group therapy for superior clinical effectiveness 7
- CBT provides more durable response with lower relapse rates compared to medication discontinuation (26-52% relapse with sertraline discontinuation vs. lower rates with CBT) 6
Common Pitfalls to Avoid
- Premature switching: Allow full 8-12 weeks for SSRI response before declaring treatment failure 8
- Inadequate dosing: Many patients require doses at the higher end of the range (150-200 mg/day for sertraline) 2, 4
- Monotherapy reliance: Failing to combine medication with CBT reduces overall treatment success 7, 10
- Abrupt discontinuation: Taper slowly to minimize withdrawal symptoms and prevent relapse 6