What is the recommended treatment for a young adult experiencing panic attacks?

Treatment of Panic Attacks in Young Adults

For young adults experiencing panic attacks, initiate treatment with cognitive behavioral therapy (CBT) as first-line, and if pharmacotherapy is needed, start with sertraline 25 mg daily for one week, then increase to 50-200 mg daily based on response. 1, 2, 3

Initial Assessment and Severity Stratification

• Screen using the Generalized Anxiety Disorder-7 (GAD-7) scale to categorize severity: mild (0-9), moderate (10-14), or moderate to severe/severe (15-21), recognizing that panic disorder typically onsets in late adolescence/young adulthood. 4, 1

• Assess for comorbid conditions, particularly depression, as anxiety disorders co-occur with depressive disorders in approximately 56% of cases and significantly increase suicide risk. 4, 1, 2

• Rule out alternative causes of panic symptoms including thyroid disease and substance use before confirming diagnosis. 4

Treatment Algorithm by Severity

Mild Symptoms (GAD-7: 0-9)

• Provide education about panic attacks and active monitoring. 1
• Recommend self-help resources based on CBT principles. 1
• Prescribe structured physical activity and exercise programs. 1

Moderate Symptoms (GAD-7: 10-14)

• Refer to educational and support services. 1
• Consider low-intensity psychological interventions delivered by trained professionals. 1

Moderate to Severe/Severe Symptoms (GAD-7: 15-21)

• Initiate high-intensity CBT delivered by licensed mental health professionals using treatment manuals that include cognitive change techniques, behavioral activation, biobehavioral strategies, education, and relaxation strategies. 1
• Consider pharmacotherapy with SSRIs or SNRIs as first-line agents. 1, 2

Cognitive Behavioral Therapy (First-Line Treatment)

CBT should be offered before or alongside medication as it demonstrates improved symptoms, decreased relapse rates, and minimal side effects with no difference in attrition rates compared to control groups. 1, 2

• CBT has the strongest evidence of efficacy for anxiety disorders and should be delivered by licensed mental health professionals. 1
• Treatment includes cognitive restructuring, exposure techniques, behavioral activation, and relaxation training. 1
• Group psychosocial interventions can address stress reduction, positive coping strategies, and managing physical symptoms. 1

Pharmacological Treatment

First-Line SSRI Selection

Start with sertraline due to superior tolerability and favorable side effect profile in head-to-head comparisons. 2, 3

• Sertraline dosing for panic disorder: Begin at 25 mg daily for the first week, then titrate to 50-200 mg daily based on clinical response and tolerability (mean effective dose in clinical trials: 131-144 mg/day). 3

• Alternative first-line SSRI: escitalopram, using a "start low, go slow" approach. 2

• Avoid paroxetine and fluoxetine as initial choices due to higher rates of adverse effects and drug interactions. 2

Alternative First-Line: SNRIs

• SNRIs (venlafaxine, duloxetine) are equally effective first-line options with statistically significant improvement in anxiety across 126 placebo-controlled trials. 1, 2

Common Side Effects to Anticipate and Counsel About

• Nausea and vomiting, diarrhea, dizziness, dry mouth, fatigue, headache, sexual dysfunction, sweating, tremor, and weight gain. 1, 2
• Approximately two-thirds of patients receiving SSRIs/SNRIs experience at least one adverse effect, requiring proactive counseling. 2

Treatment Monitoring and Duration

• Assess response after 4-6 weeks of treatment at an adequate dose. 2

• Conduct monthly assessments until symptoms subside to evaluate compliance with psychological referrals, assess medication adherence and side effects, and monitor symptom relief. 1

• Continue treatment for 4-12 months for initial episodes. 2

• Gradually taper when discontinuing to minimize withdrawal symptoms. 2

Critical Pitfalls to Avoid

• Recognize that only 20% of people with anxiety disorders seek care, highlighting the need for proactive screening and follow-up, as cautiousness and avoidance are cardinal features that lead to poor treatment follow-through. 4, 1

• Monitor for suicidality, particularly in young adults aged 18-24 years who have slightly increased risk (OR = 2.30) with antidepressant use. 2

• Do not overlook comorbid depression, which occurs in approximately 56% of patients with anxiety disorders and conveys the greatest risk for suicide attempts. 4, 1

• Ensure regular follow-up as patients with anxiety may not follow through on referrals or treatment recommendations. 1

Special Considerations for Young Adults

• Panic disorder and agoraphobia typically onset in late adolescent/young adult years, making this a critical period for intervention. 4

• Untreated anxiety disorders lead to impairments in social, educational, occupational, health, and mental health outcomes extending into adulthood. 4

• Among adolescents with anxiety, 24% have suicidal ideation and 6% make suicide attempts, with generalized anxiety disorder plus comorbid depression conveying the greatest risk. 4