From the Guidelines
The first line therapy for panic attacks should be selective serotonergic reuptake inhibitors (SSRIs), as recommended by the American Academy of Child and Adolescent Psychiatry (AACAP) for patients with panic disorder 1. When considering medication, SSRIs such as sertraline, escitalopram, or fluoxetine are typically recommended, with dosages and treatment durations varying based on individual patient needs.
- Key considerations for SSRI treatment include:
- Starting with a low dose and gradually increasing as needed and tolerated
- Continuing treatment for at least 6-12 months after symptom improvement to maintain efficacy and prevent relapse
- Monitoring for potential side effects and adjusting the treatment plan accordingly In addition to medication, cognitive-behavioral therapy (CBT) can be a valuable adjunctive treatment for panic attacks, focusing on techniques such as identifying and challenging catastrophic thoughts, exposure to feared sensations, and breathing/relaxation techniques.
- Lifestyle modifications, including:
- Regular exercise
- Adequate sleep
- Limiting caffeine and alcohol
- Practicing mindfulness can also complement formal treatment and improve overall outcomes for patients with panic attacks. It is essential to weigh the potential benefits and risks of each treatment approach, considering the individual patient's needs and circumstances, and to prioritize treatments with the strongest evidence base, such as SSRIs, as recommended by AACAP 1.
From the FDA Drug Label
Panic Disorder Initial Treatment In the controlled clinical trials of fluoxetine supporting its effectiveness in the treatment of panic disorder, patients were administered fluoxetine doses in the range of 10 to 60 mg/day (see CLINICAL TRIALS) Treatment should be initiated with a dose of 10 mg/day. After 1 week, the dose should be increased to 20 mg/day.
First line therapy for panic attacks is fluoxetine, with a recommended initial dose of 10 mg/day, increasing to 20 mg/day after 1 week 2.
- The dose may be increased after several weeks if no clinical improvement is observed.
- Fluoxetine doses above 60 mg/day have not been systematically evaluated in patients with panic disorder.
From the Research
First-Line Therapy for Panic Attacks
- Selective serotonin reuptake inhibitors (SSRIs) are considered the first-line treatment for panic disorder, as they are effective and well tolerated 3, 4, 5, 6.
- SSRIs have been proven to be superior to pill-placebo in the treatment of panic disorder, agoraphobia, and associated symptoms such as depression 6.
- Other antidepressants, such as tricyclic antidepressants and monoamine oxidase inhibitors, can be effective but have more side effects and are less well tolerated 3, 7.
- Benzodiazepines can be used as a temporary measure, especially in combination with SSRIs, but should be reserved for short-term use and for treatment-resistant patients who do not have a history of dependence and tolerance 3, 4, 5.
- Cognitive behavioral therapy (CBT) is the psychologic treatment of first choice and has strong evidence supporting its use in the treatment of panic disorder 3, 5.
Combination Therapy
- Combining an antidepressant with exposure in vivo produces the greatest treatment gains, and future research should be directed towards the investigation of a combination of SSRIs with exposure therapy 6.
- Temporary co-administration of benzodiazepines with SSRIs can be considered, especially in the first weeks of treatment 4.
Alternative Therapies
- Other antidepressants, such as serotonin-norepinephrine reuptake inhibitors, serotonin multimodal agents, and mirtazapine, can be considered as alternatives to SSRIs 5.
- Certain anticonvulsants and antipsychotics may be helpful, but the evidence base is limited 5.
- Buspirone, beta blockers, and hydroxyzine can be considered third-line agents, but the evidence supporting their use is limited 5.