What is the best medication for treating panic attacks?

Best Medication for Panic Attacks

Sertraline is the best first-line medication for panic attacks, starting at 25 mg daily for the first week, then increasing to 50 mg daily, with a target therapeutic dose of 50-200 mg/day. 1, 2, 3

Why Sertraline is Preferred

Sertraline has the most favorable drug interaction profile among SSRIs, lower risk of discontinuation syndrome compared to paroxetine, and is FDA-approved specifically for panic disorder. 2, 3

• The FDA label explicitly indicates sertraline for panic disorder treatment in adults, with or without agoraphobia 3
• Sertraline demonstrates superior tolerability compared to tricyclic antidepressants while maintaining equivalent efficacy 2, 4
• Clinical trials show sertraline significantly reduces panic attack frequency compared to placebo, with improvements in Clinical Global Impression scores and quality of life measures 4

Dosing Strategy and Timeline

Start low at 25 mg daily to minimize initial anxiety or agitation, a common pitfall that causes treatment discontinuation. 1

• Increase to 50 mg daily after week 1 1
• Allow 1-2 weeks between dose escalations to assess tolerability and avoid overshooting the therapeutic window 1
• Statistically significant improvement may begin by week 2, but clinically significant improvement typically requires 6 weeks, with maximal benefit at 12 weeks or later 1
• Do not abandon treatment before 12 weeks, as SSRIs follow a logarithmic response curve requiring patience 1

Critical Monitoring Requirements

Monitor for suicidal thinking and behavior, especially in the first months and after dose changes, with a pooled risk of 1% versus 0.2% placebo (NNH = 143). 1

• Common early side effects include nausea, headache, insomnia, nervousness, and initial anxiety/agitation, which typically resolve with continued treatment 1
• Never discontinue sertraline abruptly—taper gradually to avoid withdrawal symptoms 1

Alternative SSRI Options

If sertraline is not tolerated, escitalopram 10-20 mg/day or fluoxetine 20-40 mg/day are reasonable alternatives. 1

• Citalopram and escitalopram have the least effect on CYP450 isoenzymes and lower propensity for drug interactions 2
• Avoid paroxetine due to higher discontinuation syndrome risk, greater anticholinergic effects, and increased risk of suicidal thinking compared to other SSRIs 1, 2, 5
• Fluvoxamine should also be avoided due to similar concerns 1

Combination with Psychotherapy

Combining sertraline with cognitive behavioral therapy (CBT) provides superior outcomes to either treatment alone for panic disorder. 1

• Individual CBT is preferred over group therapy for superior clinical and health-economic effectiveness 1
• A treatment course of 12-20 structured CBT sessions targeting anxiety-specific cognitive distortions and exposure techniques is recommended 1
• The American Academy of Child and Adolescent Psychiatry supports combination treatment as preferential over monotherapy 6

When SSRIs Fail

If multiple SSRI trials fail, venlafaxine (an SNRI) is the next alternative, though it ranks lower in overall tolerability. 1

• SNRIs as a class improve primary anxiety symptoms based on clinician report with high strength of evidence 6
• Venlafaxine and duloxetine have sufficient data supporting their use 6

Role of Benzodiazepines

Benzodiazepines should not be used as first-line monotherapy due to dependence risk. 2

• Alprazolam is FDA-approved for panic disorder and effective, but carries risk of dependence and withdrawal syndromes 7, 8, 9
• Benzodiazepines may be used short-term in combination with SSRIs during the first weeks to bridge the delayed onset of SSRI effect, but only in patients without history of substance dependence 9, 10
• Reserve benzodiazepines for treatment-resistant cases or very short-term use only 10

Treatment Duration

Continue sertraline for at least 9-12 months after recovery to prevent relapse. 6, 2

• The FDA label supports efficacy in maintaining response for up to 28 weeks following initial treatment 3
• Periodically re-evaluate the long-term usefulness for the individual patient 3

Common Pitfalls to Avoid

• Starting at too high a dose, causing initial anxiety worsening and treatment abandonment 1
• Escalating doses too quickly without allowing adequate time to assess response 1
• Stopping treatment prematurely before 12 weeks when full response has not yet occurred 1
• Abrupt discontinuation leading to withdrawal syndrome 1
• Using paroxetine as first-line, which has higher discontinuation syndrome risk 1, 2
• Using benzodiazepines as monotherapy, creating dependence without addressing underlying pathophysiology 2