What is the recommended treatment for a patient with panic attacks, considering their medical history and potential substance abuse?

Treatment of Panic Attacks

Start sertraline 25 mg daily for the first week, then increase to 50 mg daily, with a target therapeutic dose of 50-200 mg/day, combined with cognitive behavioral therapy (CBT) for optimal outcomes. 1, 2

First-Line Pharmacotherapy

SSRIs are the drug of choice for panic disorder, with sertraline specifically FDA-approved for this indication 2, 3, 4. The evidence strongly supports SSRIs over benzodiazepines for long-term management due to superior safety profile, lack of dependence risk, and sustained efficacy 1.

Dosing Strategy

• Start low and go slow: Begin sertraline at 25 mg daily for the first week to minimize initial anxiety or agitation, which is a common early side effect 1
• Titrate gradually: Increase to 50 mg daily after week 1, then escalate by 25-50 mg increments every 1-2 weeks as tolerated 1
• Target dose: Aim for 50-200 mg/day, with most patients responding to 100-150 mg daily 1, 2
• Single daily dosing is sufficient due to sertraline's adequate half-life at therapeutic doses 1

Expected Timeline

• Week 2: Statistically significant improvement may begin 1
• Week 6: Clinically significant improvement expected 1
• Week 12: Maximal therapeutic benefit achieved 1
• Allow 8-12 weeks at therapeutic dose before declaring treatment failure 5, 1, 3

Combining with Psychotherapy

Combination therapy with CBT provides superior outcomes to either treatment alone 5, 6, 1. This represents the most successful treatment strategy for panic disorder 4.

CBT Structure

• 12-20 structured sessions targeting anxiety-specific cognitive distortions and exposure techniques 1
• Individual CBT is preferred over group therapy for superior clinical and health-economic effectiveness 6, 1
• Sessions should last 60-90 minutes over approximately 4 months 6

Monitoring and Safety

Critical Monitoring Points

• Suicidal ideation: Monitor closely, especially in the first months and after dose changes, with pooled risk of 1% vs 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
• Sexual dysfunction may persist as a long-term side effect 1

Substance Abuse Considerations

If a history of substance abuse is present, assess its impact on treatment and refer to risk reduction or substance management programs 7. Benzodiazepines should be avoided in patients with substance abuse history due to dependence risk 1.

Alternative First-Line Options

If sertraline is not tolerated:

• Escitalopram 10-20 mg/day 5, 1
• Paroxetine 20-40 mg/day 7, 8
• Avoid paroxetine and fluvoxamine if possible due to higher discontinuation syndrome risk 1

Treatment-Resistant Cases

Second-Line Options

• SNRIs (venlafaxine XR 75-225 mg/day) if SSRIs are not tolerated or effective 5, 6
• Augmentation strategies for incomplete response: consider pregabalin/gabapentin, buspirone, or beta blockers 5, 3

Short-Term Benzodiazepine Use

Benzodiazepines should be reserved for short-term use only and avoided for chronic management 1, 3, 4, 9. When necessary:

• Use slower-onset, longer-acting benzodiazepines (e.g., clonazepam over alprazolam) 3
• May be used temporarily during first 2-4 weeks of SSRI initiation to bridge until onset of effect 9
• Never use long-term except in treatment-refractory cases without substance abuse history 3, 4
• Benzodiazepines carry risks of tolerance, dependence, and may paradoxically worsen long-term outcomes 1

Treatment Duration

• Continue for minimum 9-12 months after achieving remission to prevent relapse 1
• Efficacy in maintaining response demonstrated for up to 52 weeks 2
• Taper gradually when discontinuing to avoid withdrawal symptoms 1

Critical Pitfalls to Avoid

• Do not escalate doses too quickly: Allow 1-2 weeks between increases to assess tolerability 1
• Do not abandon treatment before 12 weeks: Full response requires patience due to logarithmic response curve 1
• Do not use benzodiazepines for chronic management: Risk of dependence and potential worsening of outcomes 1, 3
• Do not discontinue abruptly: Taper gradually to avoid withdrawal symptoms 1
• Screen for bipolar disorder before starting SSRIs, as these patients require mood stabilization first 5
• Do not use beta-blockers for chronic anxiety disorders—they lack evidence and may worsen depression 5