First-Line Medication for Panic Disorder According to NICE
Paroxetine (option d) is the most suitable first-line choice for treating panic disorder according to NICE guidelines, as SSRIs—particularly paroxetine and sertraline—are recommended as first-line pharmacotherapy for panic disorder. 1, 2
Why SSRIs Are First-Line
SSRIs are explicitly recommended as first-line treatment by multiple international guidelines including NICE, with paroxetine specifically approved and studied extensively for panic disorder. 1, 3, 4
Paroxetine was the first SSRI approved specifically for panic disorder with or without agoraphobia, demonstrating significant superiority over placebo in reducing panic attack frequency and associated symptoms. 3, 5
Clinical efficacy is well-established: In controlled trials, 51% of paroxetine recipients (10-60 mg/day) had no full panic attacks by weeks 7-9 of treatment, compared to 37% with clomipramine and significantly fewer with placebo. 3
Long-term efficacy is maintained: Paroxetine's effectiveness continues through 6 months of treatment and reduces relapse risk, with response rates increasing to 85% by weeks 34-36 in extension studies. 3
Why Benzodiazepines Are NOT First-Line
Lorazepam (option a) and diazepam (option b) are reserved for acute panic attacks or short-term use only, not as first-line treatment for panic disorder itself. 6, 4
Major dependency risk: Benzodiazepines carry significant risk of promoting dependence with corresponding withdrawal syndromes upon discontinuation, which constitutes a major contraindication to first-line use. 4, 7
Guidelines explicitly recommend benzodiazepines as second-line agents due to dependence risks and lack of adequate long-term study support. 2
Limited role: Benzodiazepines may be combined with SSRIs only in the first weeks of treatment to provide immediate symptom relief while awaiting SSRI onset of action. 7
Why Other Options Are Incorrect
Buspirone (option c) is not mentioned in any panic disorder guidelines or evidence and lacks established efficacy for this indication. 3, 4, 5
Imipramine (option e), while a tricyclic antidepressant with proven anti-panic efficacy, is less well tolerated than SSRIs and not considered first-line treatment. 7
Critical Implementation Points
Start with subtherapeutic "test" doses of SSRIs, as initial adverse effects can paradoxically include increased anxiety or agitation. 2
Expect delayed onset: SSRIs have a lag time of potentially 12 weeks before maximal benefit, which is longer than when used for depression alone. 4, 5
Gradual dose escalation is necessary due to tolerability concerns in panic disorder patients. 4
Common adverse effects include headache, nausea, somnolence, dry mouth, and insomnia (18-25% incidence), though these are generally better tolerated than tricyclic side effects. 3
Superior tolerability profile: Paroxetine demonstrates better overall tolerability than clomipramine with lower incidence of anticholinergic effects, lacks benzodiazepine-type dependence potential, and is safer in overdose than tricyclics. 3, 8