What is the recommended treatment for a patient with panic disorder?

Treatment of Panic Disorder

Start with an SSRI (sertraline 25-50 mg daily or escitalopram 10 mg daily) combined with cognitive behavioral therapy for optimal outcomes in panic disorder. 1, 2

First-Line Pharmacotherapy

SSRI Selection and Dosing

• Sertraline is the preferred first-line agent, starting at 25-50 mg daily and titrating by 25-50 mg every 1-2 weeks to a target dose of 50-200 mg/day 1, 2, 3
• Escitalopram is an equally preferred alternative, starting at 5-10 mg daily and titrating by 5-10 mg every 1-2 weeks to a target dose of 10-20 mg/day 1, 2
• 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, 2

Expected Response Timeline

• Statistically significant improvement may begin by week 2 2
• Clinically significant improvement is expected by week 4-6 1, 2
• Maximal therapeutic effect occurs by week 12 1, 2
• Do not abandon treatment prematurely—full response requires patience and adequate time at therapeutic doses 2

Critical Monitoring

• Monitor closely for suicidal thinking and behavior, especially in the first months and after dose adjustments (pooled risk 1% vs 0.2% placebo; number needed to harm = 143) 1, 2
• Assess treatment response at 4-6 weeks using standardized symptom rating scales 1, 2
• Monitor for serotonin syndrome, behavioral activation/agitation, and hypomania/mania 1, 2

Cognitive Behavioral Therapy Integration

• CBT should be offered as monotherapy or combined with medication 1, 2
• Combination treatment (CBT plus SSRI) is preferentially recommended over monotherapy, showing superior response rates and remission 1, 2
• Individual CBT is prioritized over group therapy due to superior clinical effectiveness 1
• CBT should include: education on anxiety, cognitive restructuring, relaxation techniques, and gradual exposure 2
• Structured duration of 12-20 sessions is recommended 2

Acute Management with Benzodiazepines

Short-Term Use Only

• Administer a benzodiazepine for rapid symptom relief in acute panic attacks 2
• Benzodiazepines should only be used short-term (first few weeks) while waiting for SSRI onset of action, then tapered and discontinued 2, 4
• Clonazepam demonstrated efficacy in controlled trials, with 74% of patients receiving 1 mg/day free of full panic attacks compared to 56% on placebo 4
• Avoid benzodiazepines entirely in patients with substance use history, respiratory disorders, or elderly patients 1, 2

Critical Warnings About Benzodiazepines

• Physical dependence develops from continued therapy, manifested by withdrawal signs and symptoms after abrupt discontinuation 4
• Acute withdrawal can include anxiety, insomnia, seizures, and life-threatening reactions 4
• Protracted withdrawal syndrome may persist for weeks to more than 12 months 4
• Use a gradual taper to discontinue benzodiazepines to reduce risk of withdrawal reactions 4

Second-Line Treatment Options

If First SSRI Fails

• Switch to a different SSRI (e.g., sertraline to escitalopram or vice versa) after 6-8 weeks at therapeutic dose with inadequate response 1, 2
• Consider venlafaxine extended-release 75-225 mg/day as an alternative first-line option for patients who fail or cannot tolerate SSRIs 1, 2
• Venlafaxine requires blood pressure monitoring due to risk of sustained hypertension 2

Medications to Avoid

• Tricyclic antidepressants should be avoided despite equal efficacy due to unfavorable risk-benefit profile, particularly cardiac toxicity 2, 5, 6
• Beta-blockers have limited evidence for panic disorder (may be used for performance anxiety only) 2
• Long-term benzodiazepines carry significant risks of dependence, tolerance, and withdrawal 2, 7, 8

Maintenance and Long-Term Management

Treatment Duration

• Continue treatment for 9-12 months after recovery 9, 2
• Systematic evaluation demonstrated efficacy maintained for up to 28 weeks following 24 weeks of initial treatment 3
• Patients should be periodically reassessed to determine the need for maintenance treatment 3

Discontinuation Strategy

• Taper gradually when discontinuing to avoid discontinuation syndrome (dizziness, fatigue, nausea, sensory disturbances, anxiety) 1, 2
• For shorter half-life SSRIs: decrease by no more than 25-50% every 1-2 weeks 2
• At least 14 days should elapse between discontinuation of an MAOI and initiation of sertraline, and vice versa 3

Common Pitfalls to Avoid

• Do not escalate SSRI doses too quickly—allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window 1
• Do not use benzodiazepines as monotherapy for long-term management—they are less effective than antidepressants and cognitive behavior therapy 7, 8
• Do not stop treatment before 9-12 months after recovery—premature discontinuation increases relapse risk 9, 2
• Do not ignore the need for CBT—combination treatment provides superior outcomes compared to medication alone 1, 2, 5, 7