What is the recommended treatment for panic attacks?

Treatment of Panic Attacks

Cognitive-behavioral therapy (CBT) should be offered as first-line treatment for panic attacks, either alone or in combination with an SSRI (sertraline or escitalopram), with combination therapy showing superior outcomes for achieving remission. 1, 2

First-Line Treatment Algorithm

Psychotherapy as Primary Treatment

• CBT specifically designed for panic disorder is the gold standard, focusing on elimination of catastrophic misinterpretations of physical sensations, breaking the cycle of anticipatory anxiety, panic, and avoidance 1, 3
• CBT typically requires 12-15 sessions in individual or group format and provides stable long-term effects that persist after treatment termination 3, 4
• If CBT-trained therapists are unavailable, problem-solving approaches based on CBT principles should be considered for patients concerned about prior panic attacks 1

Pharmacotherapy Options

SSRIs as First-Line Agents:

• Start with sertraline 25-50 mg daily or escitalopram 10 mg daily due to favorable efficacy and tolerability profiles 2
• Begin with a subtherapeutic "test" dose to minimize initial anxiety or agitation, particularly important since panic patients are hypersensitive to physical sensations 2
• Titrate slowly at 1-2 week intervals for shorter half-life SSRIs (sertraline, escitalopram) or 3-4 week intervals for fluoxetine 2
• For panic disorder specifically, fluoxetine should be initiated at 10 mg/day for 1 week, then increased to 20 mg/day, with most patients responding to 20 mg/day 5
• Expect 4-6 weeks for clinically significant improvement and up to 12 weeks for maximal therapeutic effect 2

SNRIs as Alternative First-Line:

• Venlafaxine extended-release can be offered for patients who fail or cannot tolerate SSRIs, with demonstrated efficacy across anxiety disorders including panic 1, 2
• SNRIs improve primary anxiety symptoms with high strength of evidence, though may not separate from placebo for parent-reported anxiety or global function 1, 2

Combination Therapy Strategy

• Combination treatment (CBT plus SSRI) is preferentially recommended over monotherapy for panic disorder, showing superior response rates and remission compared to either treatment alone 1, 2, 6
• Combined therapy demonstrates relative risk of response 1.24 times better than antidepressants alone and 1.16 times better than psychotherapy alone during acute treatment 6
• After acute-phase treatment termination, combined therapy remains more effective than pharmacotherapy alone (RR=1.61) but equally effective as psychotherapy alone 6

Treatment Duration and Maintenance

• Continue antidepressant treatment for 9-12 months after recovery to prevent relapse 1
• Panic disorder is a chronic condition; periodic reassessment is necessary to determine need for continued treatment 5
• Assess treatment response within 4-6 weeks of reaching therapeutic dose using standardized symptom rating scales 2

Treatment-Resistant Cases

• If inadequate response after 6-8 weeks at therapeutic dose, switch to a different SSRI or consider SNRI (venlafaxine) 2
• For patients requiring higher doses, fluoxetine can be titrated above 20 mg/day, though doses above 60 mg/day have not been systematically studied 5

Role of Benzodiazepines

Benzodiazepines should be used cautiously and are NOT first-line:

• Avoid benzodiazepines entirely in patients with substance use history, respiratory disorders, or elderly patients 2
• While effective for acute panic symptoms, benzodiazepines are less effective than antidepressants and CBT for long-term management 7
• High-dose benzodiazepine combination with in vivo exposure is counter-productive in the long term 4
• If benzodiazepines are used for panic disorder, alprazolam can be initiated at 0.5 mg three times daily, with dose increases at 3-4 day intervals to maximum 4 mg/day for anxiety or up to 10 mg/day for panic disorder 8
• Gradual taper is mandatory when discontinuing: decrease by no more than 0.5 mg every 3 days, with some patients requiring even slower reduction 8

Discontinuation Guidance

• Taper SSRIs gradually when discontinuing to avoid discontinuation syndrome (dizziness, fatigue, nausea, sensory disturbances, anxiety) 2
• For alprazolam discontinuation, reduce by no more than 0.5 mg every 3 days under close supervision; some patients may prove resistant to all discontinuation regimens 8
• Fluoxetine's long half-life minimizes discontinuation risk as plasma concentrations decrease gradually 5

Critical Pitfalls to Avoid

• Do not combine high-dose benzodiazepines with exposure therapy, as this undermines long-term CBT effectiveness 4
• Do not stop antidepressants before 9-12 months after recovery, as relapse is frequent 1
• Do not use psychological debriefing for recent traumatic events, as it does not reduce panic, anxiety, or PTSD symptoms 1
• Monitor for serotonin syndrome, behavioral activation/agitation, and hypomania/mania during SSRI initiation and dose adjustments 2