What is the first-line medication for an adult male with panic disorder and depression, presenting with frequent emergency room (ER) visits?

From the Guidelines

For an adult male with panic disorder and depression who has had 3 emergency room visits in 2 weeks, a selective serotonin reuptake inhibitor (SSRI) would be the first-line medication, as recommended by recent guidelines 1. Specifically, sertraline (Zoloft) starting at 25-50 mg daily and gradually increasing to 100-200 mg daily, or escitalopram (Lexapro) starting at 5-10 mg daily and increasing to 10-20 mg daily would be appropriate choices. These medications effectively treat both conditions simultaneously, which is important given the patient's frequent ER visits suggesting severe symptoms. The patient should be informed that SSRIs typically take 2-4 weeks to show full therapeutic effect, though some improvement may be noted earlier. During this initial period, a short-term benzodiazepine like lorazepam 0.5-1 mg as needed (maximum 3 times daily for 2-4 weeks) might be considered to manage acute panic symptoms, though with caution due to dependency risk. Common side effects of SSRIs include initial nausea, headache, and insomnia, which often resolve within 1-2 weeks. The patient should take the medication at the same time daily, continue even if feeling better, and not discontinue without medical supervision. Regular follow-up within 1-2 weeks is essential to monitor response and adjust treatment if needed. SSRIs work by increasing serotonin levels in the brain, which helps regulate mood and anxiety, addressing both the depression and panic symptoms. Some studies suggest that serotonin-norepinephrine reuptake inhibitors (SNRIs) may also be effective, but the evidence is less strong compared to SSRIs 1. It's also important to consider the patient's preferences and the potential side effects of the medication when making a treatment decision, as recommended by the American College of Physicians 1. Overall, the goal of treatment is to improve the patient's symptoms and quality of life, while minimizing the risk of adverse effects. Key considerations in treatment selection include:

• Efficacy in treating both panic disorder and depression
• Potential side effects and their impact on the patient's quality of life
• The patient's preferences and values
• The need for regular follow-up and monitoring to adjust treatment as needed. Given the recent evidence and guidelines, SSRIs remain the first-line treatment option for this patient population 1.

From the FDA Drug Label

Sertraline Hydrochloride Oral Concentrate is indicated for the treatment of major depressive disorder in adults Sertraline Hydrochloride Oral Concentrate is indicated for the treatment of panic disorder in adults, with or without agoraphobia, as defined in DSM-IV The first line medication for panic disorder and depression in an adult male with 3 ER visits in 2 weeks is sertraline 2, 2, 2.

• Sertraline is indicated for the treatment of major depressive disorder and panic disorder in adults.
• The efficacy of sertraline in the treatment of panic disorder was demonstrated in three double-blind, placebo-controlled studies of adult outpatients who had a primary diagnosis of panic disorder (DSM-III-R), with or without agoraphobia.
• The efficacy of sertraline in the treatment of major depressive disorder was established in six to eight week controlled trials of adult outpatients whose diagnoses corresponded most closely to the DSM-III category of major depressive disorder.

From the Research

First-Line Medication for Panic Disorder and Depression

The treatment of panic disorder and depression in adults involves various pharmacological and psychotherapeutic options.

• Selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines are standard first-line pharmacologic treatments for panic disorder 3, 4.
• Many other antidepressants can be considered as alternatives to SSRIs, including serotonin-norepinephrine reuptake inhibitors, serotonin multimodal agents, tricyclic antidepressants, monoamine oxidase inhibitors, and mirtazapine 3.
• Certain anticonvulsants and antipsychotics may be helpful; however, the evidence base is limited 3.

Efficacy of Specific Medications

• Sertraline has been shown to be effective in the treatment of panic disorder, with significant improvements in panic attack frequency and clinician and patient assessments of improvement 5.
• Venlafaxine extended-release has also been found to be effective in the treatment of panic disorder, with lower mean panic attack frequency and higher response and remission rates 6.
• A network meta-analysis found that most medications, including diazepam, alprazolam, clonazepam, paroxetine, venlafaxine, clomipramine, fluoxetine, and adinazolam, are more effective than placebo in the treatment of panic disorder 7.

Comparison of Medication Classes

• The classes of medication examined, including SSRIs, SNRIs, TCAs, MAOIs, and BDZs, were all found to be more effective than placebo in the treatment of panic disorder 7.
• TCAs were ranked as the most effective class, followed by BDZs and MAOIs, while SSRIs were ranked fifth and SNRIs were ranked lowest 7.
• BDZs were associated with a lower dropout rate compared to placebo and were ranked first in terms of tolerability, while the other classes did not show any difference in dropouts compared to placebo 7.