What is the recommended treatment for severe panic attacks?

Treatment of Severe Panic Attacks

For severe panic attacks, initiate treatment with an SSRI (sertraline 25-50 mg daily or escitalopram 5-10 mg daily) combined with cognitive behavioral therapy (CBT), as combination treatment provides superior outcomes compared to either modality alone. 1, 2

First-Line Pharmacological Treatment

SSRIs are the recommended first-line medications due to their established efficacy and favorable safety profile in panic disorder. 1, 3, 4

Preferred SSRI Options:

• Sertraline: Start at 25-50 mg daily, titrate by 25-50 mg increments every 1-2 weeks to a target dose of 50-200 mg/day 2, 4, 5

  • FDA-approved for panic disorder with or without agoraphobia 4
  • Demonstrated significant reduction in panic attack frequency, clinician-rated improvement, and quality of life scores compared to placebo 6

• Escitalopram: Start at 5-10 mg daily, titrate by 5-10 mg increments every 1-2 weeks to a target dose of 10-20 mg/day 2

  • Has the least effect on CYP450 isoenzymes, resulting in lower propensity for drug interactions 1

Alternative SSRI Options:

• Paroxetine: FDA-approved for panic disorder 3, but should be reserved for when first-tier SSRIs fail due to higher risk of discontinuation syndrome and potentially increased suicidal thinking compared to other SSRIs 1, 2

• Fluoxetine: May be used with dosing adjustments at 3-4 week intervals due to longer half-life 1

Combination with Psychotherapy

Combine medication with CBT from treatment initiation for optimal outcomes. 1, 2

• Individual CBT is superior to group therapy for anxiety disorders, with large effect sizes (Hedges g = 1.01) 2
• CBT should include: education on anxiety mechanisms, cognitive restructuring to challenge distortions, relaxation techniques, and gradual exposure when appropriate 2
• Combination CBT plus sertraline improved primary anxiety, global function, response to treatment, and remission of disorder compared to either treatment alone (moderate strength of evidence) 1

Expected Response Timeline and Monitoring

• Statistically significant improvement may begin by week 2, with clinically significant improvement expected by week 6, and maximal therapeutic benefit achieved by week 12 or later 2
• Start with a subtherapeutic "test" dose as initial adverse effects of SSRIs can include anxiety or agitation 1
• Assess response using standardized scales (GAD-7 or HAM-A) at regular intervals 2
• Monitor closely for suicidal thinking, especially in the first months and after dose adjustments (pooled risk difference 0.7% vs placebo, NNH=143) 2
• Assess compliance monthly until symptoms subside, as patients with anxiety often avoid follow-through 2

Treatment Duration

Continue medication for at least 9-12 months after recovery to prevent relapse, as panic disorder often has a chronic and relapsing course. 1, 2, 7

• Long-term maintenance efficacy has been demonstrated in relapse prevention trials for both sertraline and paroxetine 3, 4
• Discontinue medication gradually to avoid withdrawal symptoms, particularly with shorter half-life SSRIs like paroxetine and sertraline 1, 2
• Discontinuation syndrome is characterized by dizziness, fatigue, myalgias, nausea, insomnia, vertigo, paresthesias, and anxiety 1

Medications to Avoid or Use with Caution

Avoid benzodiazepines as first-line treatment due to risks of dependence, cognitive impairment, and not addressing underlying pathology. 2, 8, 9

• Reserve benzodiazepines (e.g., alprazolam) for short-term adjunctive use only during acute crises or in the first weeks of SSRI treatment before onset of response 8, 9
• One study showed 63% of patients receiving benzodiazepines within 1 week of trauma met criteria for PTSD at 6 months compared to only 23% receiving placebo 1
• Alprazolam at doses >4 mg/day has potential to cause severe emotional and physical dependence, with 7-29% of patients unable to completely taper off therapy 10

Avoid tricyclic antidepressants due to unfavorable risk-benefit profile, particularly cardiac toxicity, despite equal efficacy to SSRIs. 2, 8, 9

Special Prescribing Considerations

• Citalopram: Avoid daily doses exceeding 40 mg due to QT prolongation risk associated with Torsade de Pointes, ventricular tachycardia, and sudden death 1
• Fluvoxamine: Greater potential for drug-drug interactions via multiple CYP450 pathways (CYP1A2, CYP2C19, CYP2C9, CYP3A4, CYP2D6) 1
• All SSRIs: Contraindicated with MAOIs due to increased risk of serotonin syndrome 1
• Start serotonergic drugs at low doses and increase slowly, monitoring especially in first 24-48 hours after dosage changes 1

Common Pitfalls to Avoid

• Inadequate follow-up: Patients with panic disorder often avoid follow-through on referrals, requiring proactive monthly assessment until symptom resolution 2
• Premature discontinuation: Stopping medication before 9-12 months increases relapse risk 1, 2
• Rapid dose escalation: While faster up-titration may be indicated for severe presentations, higher doses can be associated with more adverse effects without necessarily greater magnitude of response 1
• Using benzodiazepines as monotherapy: This does not address underlying pathology and carries significant dependence risk 2, 8