Propranolol is NOT Effective for Panic Disorder
Propranolol should not be used for treating panic attacks or panic disorder, as multiple guidelines and clinical trials demonstrate it is ineffective for this indication. 1, 2, 3
Why Propranolol Fails in Panic Disorder
- Propranolol only blocks peripheral physical symptoms (rapid heart rate, tremors) but does not address the central neurobiological mechanisms underlying panic attacks 1
- The Canadian Clinical Practice Guidelines explicitly recommend against beta-blockers for panic disorder due to negative evidence 2, 3
- A 2016 systematic review and meta-analysis found insufficient evidence to support propranolol for any anxiety disorder, including panic disorder 4
Clinical Trial Evidence Against Propranolol
- A controlled trial comparing alprazolam, propranolol, and placebo found propranolol ineffective for panic disorder and agoraphobia with panic attacks, while alprazolam showed clear efficacy 5
- Another crossover trial demonstrated diazepam was significantly superior to propranolol on all measures, with 18 patients improving on diazepam versus only 7 on propranolol 6
- Propranolol failed to reduce panic attacks or phobic symptoms in these studies 6
What Propranolol IS Effective For (Important Distinction)
- Propranolol works for situational performance anxiety (public speaking, stage fright, test-taking), not panic disorder 1, 2
- For performance anxiety, use 20-40 mg taken 1 hour before the anxiety-provoking event 1, 2
- This is a completely different clinical entity from panic disorder 2
Recommended Treatment for Panic Disorder
- SSRIs and SNRIs are first-line pharmacotherapy for panic disorder 1, 2, 3
- Cognitive behavioral therapy (CBT) is also first-line treatment and should be combined with pharmacotherapy 1, 3
- Benzodiazepines (like alprazolam or diazepam) are effective for acute symptom relief but carry dependence risks 5, 6
Common Clinical Pitfall to Avoid
- Do not confuse performance anxiety with panic disorder - they require completely different treatments 1, 2
- Propranolol may provide minimal symptomatic relief for residual somatic complaints (palpitations, tachycardia) when combined with the patient's ongoing effective regimen, but it should never be monotherapy 1, 7
- Beta-blockers may induce depression, so use cautiously in panic patients with concurrent depressive illness 7