What is the recommended treatment for panic attacks?

Treatment of Panic Attack

Start with an SSRI (sertraline 25-50 mg daily or escitalopram 10 mg daily) as first-line pharmacotherapy for panic disorder, combined with cognitive behavioral therapy when possible. 1

Acute Panic Attack Management

For immediate treatment of an active panic attack:

• Administer a benzodiazepine for rapid symptom relief 2
• Alprazolam can be initiated at 0.5 mg three times daily, with dose increases every 3-4 days up to a maximum of 4 mg daily in divided doses 3
• Benzodiazepines should only be used short-term (first few weeks) while waiting for SSRI onset of action, then tapered and discontinued 1, 4
• Avoid benzodiazepines entirely in patients with substance use history, respiratory disorders, or elderly patients 1

First-Line Long-Term Treatment

Preferred SSRIs

Begin with sertraline or escitalopram due to superior evidence for efficacy and tolerability: 1

• Sertraline: Start 25-50 mg daily, titrate by 25-50 mg every 1-2 weeks to target dose of 50-200 mg/day 1, 5
• Escitalopram: Start 5-10 mg daily, titrate by 5-10 mg every 1-2 weeks to target dose of 10-20 mg/day 1
• Critical: Begin with a subtherapeutic "test" dose to minimize initial anxiety or agitation that commonly occurs with SSRI initiation in panic disorder patients who are hypersensitive to physical sensations 1

Expected Timeline

• Statistically significant improvement may begin by week 2 1
• Clinically significant improvement expected by week 4-6 1
• Maximal therapeutic effect by week 12 1, 6
• Do not abandon treatment prematurely; full response requires patience 1

Alternative First-Line SSRIs

If sertraline or escitalopram are not tolerated:

• Paroxetine 20-60 mg/day is FDA-approved for panic disorder and highly effective 7, 8
• Warning: Paroxetine has higher risk of discontinuation syndrome and potentially increased suicidal thinking compared to other SSRIs 1
• Fluoxetine has a longer half-life beneficial for patients who occasionally miss doses 9

Second-Line Options

If inadequate response after 6-8 weeks at therapeutic SSRI dose:

• Switch to a different SSRI (e.g., sertraline to escitalopram) 1
• Consider venlafaxine extended-release 75-225 mg/day as an alternative first-line option for patients who fail or cannot tolerate SSRIs 1, 9
• Venlafaxine requires blood pressure monitoring due to risk of sustained hypertension 1

Cognitive Behavioral Therapy Integration

CBT should be offered as monotherapy or combined with medication: 1

• Combination treatment (CBT plus SSRI) is preferentially recommended over monotherapy, showing superior response rates and remission 1
• Individual CBT is prioritized over group therapy due to superior clinical effectiveness 9
• CBT should include: education on anxiety, cognitive restructuring, relaxation techniques, and gradual exposure 9
• Structured duration of 12-20 sessions recommended 9

Monitoring and Safety

Side Effect Profile

Common SSRI side effects (emerge within first few weeks, typically resolve with continued treatment): 1, 9

• Nausea, headache, insomnia, sexual dysfunction
• Diarrhea, dry mouth, dizziness, somnolence
• Nervousness, tremor, vivid dreams

Critical Monitoring

• Monitor closely for suicidal thinking and behavior, especially in first months and after dose adjustments (pooled risk 1% vs 0.2% placebo; number needed to harm = 143) 1
• Assess treatment response at 4-6 weeks using standardized symptom rating scales 1
• Monitor for serotonin syndrome, behavioral activation/agitation, and hypomania/mania 1

Treatment Duration and Discontinuation

• Continue treatment for 9-12 months after recovery 2
• Taper gradually when discontinuing to avoid discontinuation syndrome (dizziness, fatigue, nausea, sensory disturbances, anxiety) 1
• For shorter half-life SSRIs: decrease by no more than 25-50% every 1-2 weeks 1
• Some patients may require even slower tapering 1

Medications to Avoid

• Tricyclic antidepressants should be avoided due to unfavorable risk-benefit profile, particularly cardiac toxicity, despite equal efficacy 9, 4, 6
• Beta-blockers have limited evidence for panic disorder (may be used for performance anxiety only) 1, 9
• Long-term benzodiazepines carry significant risks of dependence, tolerance, and withdrawal 1, 4

Treatment-Resistant Cases

If two adequate SSRI trials fail:

• Consider pregabalin where benzodiazepines are contraindicated 1
• Ensure CBT has been adequately implemented 1
• Re-evaluate diagnosis and comorbidities 1