What is the best medication for a patient with anxiety and panic attacks?

Best Medication for Anxiety with 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 as the first-line treatment for anxiety with panic attacks. 1, 2

Primary Treatment Recommendation

Selective serotonin reuptake inhibitors (SSRIs), particularly sertraline, represent the gold standard first-line pharmacotherapy for panic disorder with anxiety. 1, 2 The FDA has approved sertraline specifically for panic disorder in adults, with or without agoraphobia, based on robust evidence from multiple controlled trials. 2

Optimal Dosing Strategy

• Week 1: Start sertraline 25 mg daily to minimize initial anxiety or agitation that can paradoxically occur when initiating SSRIs 1
• Week 2 onward: Increase to 50 mg daily 1
• Titration: Escalate by 25-50 mg increments every 1-2 weeks based on tolerability, avoiding rapid dose increases that risk overshooting the therapeutic window 1
• Target dose: 50-200 mg/day, with single daily dosing sufficient due to adequate half-life 1

Expected Response Timeline

• Week 2: Statistically significant improvement may begin 1
• Week 6: Clinically significant improvement expected 1
• Week 12 or later: Maximal therapeutic benefit achieved 1

Do not abandon treatment before 12 weeks at therapeutic doses, as SSRI response follows a logarithmic curve requiring patience. 1

Alternative First-Line SSRI Options

If sertraline is not tolerated, escitalopram 10-20 mg/day or fluoxetine 20-40 mg/day are reasonable alternatives. 1 These SSRIs demonstrate comparable efficacy for panic disorder with moderate to high strength of evidence. 1

Avoid paroxetine and fluvoxamine as initial choices due to higher discontinuation syndrome risk and potentially increased suicidal thinking compared to other SSRIs. 1 While paroxetine is FDA-approved and effective for panic disorder 3, 4, 5, its withdrawal profile makes it less favorable as a first-line agent. 1

Second-Line Option: SNRIs

Venlafaxine extended-release 75-225 mg/day is suggested as a second-line alternative if SSRIs fail or are not tolerated. 6, 7 However, venlafaxine requires blood pressure monitoring due to risk of sustained hypertension and ranks lower than SSRIs in overall tolerability. 7

Critical Monitoring Requirements

Suicidality Warning

Monitor closely for suicidal thinking and behavior, especially during the first months and after dose changes. 1 The pooled risk is 1% versus 0.2% with placebo (number needed to harm = 143). 1

Common Early Side Effects

Expect nausea, headache, insomnia, nervousness, and initial anxiety/agitation, which typically resolve with continued treatment. 1 Sexual dysfunction may persist long-term. 7

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 cost-effectiveness. 1 A structured course of 12-20 CBT sessions targeting anxiety-specific cognitive distortions and exposure techniques is recommended. 1

Treatment Duration

Continue sertraline for at least 9-12 months after achieving remission to prevent relapse. 1 The FDA label notes that efficacy in maintaining response was demonstrated for up to 28 weeks following initial treatment in placebo-controlled trials. 2

Critical Pitfalls to Avoid

• Never escalate doses too quickly: Allow 1-2 weeks between increases to assess tolerability 1
• Never discontinue abruptly: Taper gradually to avoid withdrawal symptoms 1
• Never abandon treatment prematurely: Full response requires 12+ weeks at therapeutic doses 1
• Never use benzodiazepines as first-line monotherapy: Reserve for short-term adjunctive use only due to dependence risk, tolerance, and paradoxically worse long-term outcomes 1

Why Sertraline Over Other SSRIs

Sertraline has the strongest evidence base specifically for panic disorder among SSRIs, with FDA approval based on three 10-12 week trials demonstrating superiority over placebo. 2 It has been shown to reduce severity and frequency of panic attacks, baseline anxiety, and confer protection from relapse for up to 36 weeks following withdrawal. 8 Sertraline is also economically viable and has demonstrated comparable efficacy to cognitive behavioral therapy. 8