Medication for Panic Disorder
Start with an SSRI—specifically sertraline 25-50 mg daily or escitalopram 10-20 mg daily—as first-line pharmacological treatment for panic disorder, with gradual titration to therapeutic doses of 50-200 mg/day for sertraline or 10-20 mg/day for escitalopram. 1, 2, 3
First-Line Treatment: SSRIs
Preferred Agents
Sertraline and escitalopram are the top-tier first-line agents due to their established efficacy in panic disorder, favorable side effect profiles, and lower risk of discontinuation symptoms compared to other SSRIs. 1, 2
Sertraline is FDA-approved for panic disorder and has demonstrated significantly greater improvement in panic attack frequency compared to placebo (approximately 2 fewer panic attacks per week), with benefits also seen on Clinical Global Impression scores. 3, 4
Paroxetine is also FDA-approved for panic disorder and effective, but carries higher risks of discontinuation syndrome and potentially increased suicidal thinking compared to sertraline or escitalopram, making it a second-choice SSRI. 1, 5, 6
Dosing Strategy
Start sertraline at 25 mg daily for the first week to minimize initial anxiety or agitation that commonly occurs with SSRIs, then increase to 50 mg daily after week 1. 2, 3
Titrate sertraline by 25-50 mg increments every 1-2 weeks as tolerated, targeting a therapeutic dose of 50-200 mg/day. 1, 3
For escitalopram, start at 5-10 mg daily and titrate by 5-10 mg increments every 1-2 weeks to a target of 10-20 mg/day. 1
Do not escalate doses too quickly—allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window. 2
Expected Timeline and Monitoring
Statistically significant improvement may begin by week 2, with clinically significant improvement expected by week 6, and maximal therapeutic benefit achieved by week 12 or later. 1, 2
Monitor closely for suicidal thinking and behavior, especially in the first months and after dose changes, with a pooled risk of 1% versus 0.2% for placebo (number needed to harm = 143). 1, 2
Common side effects include nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea, somnolence, and dizziness—most emerge within the first few weeks and typically resolve with continued treatment. 1
Second-Line Treatment: SNRIs
If inadequate response after 8-12 weeks at therapeutic doses of an SSRI, consider switching to venlafaxine extended-release 75-225 mg/day, which is effective for panic disorder but requires blood pressure monitoring due to risk of sustained hypertension. 1, 7
Duloxetine 60-120 mg/day is an alternative SNRI option, particularly beneficial for patients with comorbid pain conditions. 1
Combination with Psychotherapy
Combining SSRI treatment with cognitive behavioral therapy (CBT) provides superior outcomes compared to either treatment alone for panic disorder, with individual CBT preferred over group therapy. 1, 2, 7
CBT should include education on panic symptoms, cognitive restructuring to challenge catastrophic thinking, relaxation techniques, and gradual exposure to feared situations. 1
Treatment Duration
Continue effective medication for at least 9-12 months after achieving remission to prevent relapse, as demonstrated in placebo-controlled trials showing lower relapse rates with continued SSRI treatment. 1, 2, 3
Discontinue medication gradually by tapering to avoid withdrawal symptoms, particularly with shorter half-life SSRIs like sertraline and paroxetine. 1, 2
Critical Pitfalls to Avoid
Avoid benzodiazepines as first-line treatment due to risks of dependence, tolerance, and withdrawal—reserve them only for short-term use in acute situations or when SSRIs/SNRIs are ineffective. 1, 7, 8
Do not use tricyclic antidepressants as first-line agents due to their unfavorable risk-benefit profile, particularly cardiac toxicity in overdose, initial "jitteriness" or activation, and high rate of troublesome side effects. 1, 9, 7
Do not abandon treatment prematurely—full response may take 12+ weeks, and patience in dose escalation is crucial for optimal outcomes. 1, 2
Assess for comorbid depression, which frequently occurs with panic disorder and supports the use of antidepressants as a logical first-line choice. 9, 6