What is the recommended treatment plan for a middle-aged adult patient with panic disorder and agoraphobia, including psychotherapeutic model, psychosocial interventions, medications, dose, directions, possible major side effects, and any drug interactions?

Treatment Plan for Panic Disorder with Agoraphobia

Psychotherapeutic Model

Individual cognitive-behavioral therapy (CBT) with therapist-guided in vivo exposure is the most effective psychotherapy approach for panic disorder with agoraphobia. 1, 2

• CBT should include the following specific components: education on panic mechanisms, cognitive restructuring to challenge catastrophic misinterpretations, interoceptive exposure to feared bodily sensations, and graded in vivo exposure to agoraphobic situations 1, 3
• Therapist-guided exposure in situ (where the therapist accompanies the patient to feared situations) produces superior outcomes compared to therapist-prescribed exposure alone, with greater reduction in agoraphobic avoidance, improved overall functioning, and fewer panic attacks during follow-up 4
• Treatment should consist of 12-14 sessions delivered twice weekly initially, then weekly 3, 4
• Individual CBT is prioritized over group therapy due to superior clinical and cost-effectiveness 1, 2

Pharmacotherapy

Start with an SSRI as first-line medication, specifically sertraline or escitalopram, due to their established efficacy, favorable side effect profiles, and lower discontinuation syndrome risk. 1, 2, 5

Sertraline (Preferred Option)

• Starting dose: 25 mg daily for the first week 1, 5
• Titration: Increase by 25-50 mg every 1-2 weeks as tolerated 1, 2
• Target dose: 50-200 mg/day (mean effective dose approximately 131-151 mg/day) 5
• Timing: Once daily, morning or evening 5

Escitalopram (Alternative First-Line)

• Starting dose: 5-10 mg daily 1, 2
• Titration: Increase by 5-10 mg increments every 1-2 weeks 1
• Target dose: 10-20 mg/day 1, 2
• Advantage: Lowest risk of drug-drug interactions among SSRIs and lower discontinuation syndrome risk 1

Expected Timeline for Response

• Statistically significant improvement may begin by week 2 1, 2
• Clinically meaningful improvement expected by week 6 1, 2
• Maximal therapeutic benefit achieved by week 12 or later 1, 2

Major Side Effects

Common SSRI Side Effects (emerge within first few weeks, typically resolve with continued treatment):

• Nausea, diarrhea, dry mouth, heartburn 1
• Headache, dizziness 1
• Somnolence or insomnia 1
• Sexual dysfunction 1
• Nervousness, tremor 1
• Initial anxiety or agitation (reason for low starting dose) 1

Critical Warning

• All SSRIs carry a boxed warning for suicidal thinking and behavior (pooled absolute rates 1% versus 0.2% for placebo, NNH = 143) 1
• Close monitoring is essential, especially in the first months and following dose adjustments 1

Drug Interactions

• Escitalopram has the least effect on CYP450 isoenzymes, resulting in the lowest propensity for drug interactions among SSRIs 1
• Sertraline has moderate CYP450 interactions 1
• Avoid combining with MAO inhibitors, other serotonergic agents (risk of serotonin syndrome), and use caution with NSAIDs/anticoagulants (increased bleeding risk) 5

Combined Treatment Approach

Combining SSRI medication with CBT provides superior outcomes compared to either treatment alone for moderate to severe panic disorder with agoraphobia. 1, 6

• During acute phase treatment, combined therapy is superior to antidepressant alone (RR 1.24,95% CI 1.02-1.52) or psychotherapy alone (RR 1.17,95% CI 1.05-1.31) 6
• The combination produces more dropouts due to medication side effects than psychotherapy alone (NNH approximately 26) 6
• After acute phase treatment, combined therapy remains more effective than pharmacotherapy alone (RR 1.61,95% CI 1.23-2.11) 6

Psychosocial Interventions

Patient Education

• Explain that panic attacks are not dangerous or life-threatening 1
• Educate about the fight-or-flight response and how catastrophic misinterpretations of bodily sensations perpetuate panic 3
• Discuss the expected timeline for medication response (6-12 weeks for full benefit) 1
• Warn about initial increase in anxiety during first 1-2 weeks of SSRI treatment 1

Family Involvement

• Provide psychoeducation to family members about panic and agoraphobia symptoms 1
• Consider screening and treatment for family members who struggle with anxiety themselves 1

Adjunctive Self-Management Strategies

• Breathing techniques and progressive muscle relaxation 1
• Grounding strategies (sensory awareness of environmental details) 1
• Regular cardiovascular exercise 1
• Mindfulness practices 1

Treatment Duration and Follow-Up

Acute Phase (First 12 Weeks)

• Monitor weekly during CBT sessions 1, 4
• Assess medication response and side effects at weeks 2,4,6,8, and 12 1
• Use standardized scales: Hamilton Anxiety Scale, Clinical Global Impression, panic attack frequency, Mobility Inventory for agoraphobic avoidance 4

Continuation Phase

• Continue effective medication for minimum 9-12 months after achieving remission to prevent relapse 1
• Monthly follow-up until symptoms stabilize, then every 3 months 1
• Monitor for treatment adherence, side effects, and functional improvement 1

If Inadequate Response After 8-12 Weeks at Therapeutic Doses

• Switch to a different SSRI (e.g., sertraline to escitalopram or vice versa) 1
• Consider SNRI (venlafaxine XR 75-225 mg/day or duloxetine 60-120 mg/day) as second-line option 1
• Ensure CBT with therapist-guided exposure has been implemented 4
• Reassess diagnosis and screen for comorbid conditions 1

Discontinuation

• Taper medication gradually over several weeks to months to avoid discontinuation syndrome 1
• Sertraline requires gradual taper: reduce by 25-50 mg every 1-2 weeks 1
• Maintain CBT skills practice during and after medication taper 6

Critical Pitfalls to Avoid

• Do not use benzodiazepines as first-line treatment due to dependence, tolerance, and withdrawal risks; reserve only for short-term use 1, 2, 7
• Do not use tricyclic antidepressants due to unfavorable risk-benefit profile, particularly cardiac toxicity 1
• Do not use beta-blockers (atenolol, propranolol) as they lack efficacy for panic disorder 2
• Do not escalate SSRI doses too quickly; allow 1-2 weeks between increases to assess tolerability 1
• Do not abandon treatment prematurely; full response may take 12+ weeks 1
• Patients with anxiety commonly avoid follow-through on referrals; proactively assess and address barriers to treatment adherence 1
• Do not prescribe CBT without therapist-guided in vivo exposure component, as this reduces effectiveness for agoraphobic avoidance 4