Comorbidities are common in patients with PD and predict greater difficulty achieving remission (Box).1,3-6
Comorbidities: How they affect panic disorder treatment
The most common psychiatric conditions that co-occur with panic disorder (PD) are other anxiety disorders, mood disorders, personality disorders, and substance use disorders.1 Carefully assess the severity and degree of impairment or distress arising from each condition to prioritize treatment goals. For example, treating panic attacks would be a lower priority in a patient with untreated bipolar disorder.
Assessing comorbid substance abuse is important in selecting PD treatments. Benzodiazepines should almost always be avoided in patients with a history of drug abuse—illicit or prescribed. Although complete abstinence should not be a prerequisite for beginning PD treatment, detoxification and concomitant substance abuse treatment are essential.3
Comorbid mood disorders also affect the course of PD treatment. Antidepressants are effective for treating depression and PD, whereas benzodiazepines are not effective for depression.4 Antidepressants in patients with bipolar disorder are controversial because these medications might induce mixed or elevated mood states or rapid cycling. In these complicated patients, consider antidepressants lower in the treatment algorithm.5
Other conditions to consider before beginning treatment include pregnancy or the possibility of becoming pregnant in the near future and suicidal ideation. PD is associated with increased risk for suicidal ideation and progression to suicide attempts, particularly in patients with a comorbid mood or psychotic disorder.6 In addition, consider the potential impact of medications on comorbid medical conditions.
Treatment begins with education
The goal of treatment is remission of symptoms, ideally including an absence of panic attacks, agoraphobic avoidance, and anticipatory anxiety.1 The Panic Disorder Severity Scale self-report is a validated measure of panic symptoms that may be useful in clinical practice.7
The first step in treatment is educating patients about panic attacks, framing them as an overreactive fear circuit in the brain that produces physical symptoms that are not dangerous. Using a brain model that shows the location of the amygdala, hippocampus, and prefrontal cortex—which play crucial roles in generating and controlling anxiety and fear—can make this discussion more concrete.8 Although highly simplified, such models allow clinicians to demonstrate that excessive reactivity of limbic regions can be reduced by both top-down (cortico-limbic connections via cognitive-behavioral therapy [CBT]) and bottom-up (pharmacotherapy directly acting on limbic structures) approaches. Such discussions lead to treatment recommendations for CBT, pharmacotherapy, or their combination.
No single treatment has emerged as the definitive “best” for PD, and no reliable predictors can guide specific treatment for an individual.3 Combining CBT with pharmacotherapy produces higher short-term response rates than either treatment alone, but in the long term, combination treatment does not appear to be superior to CBT alone.9 Base the initial treatment selection for PD on patient preference, treatment availability and cost, and comorbid medical and psychiatric conditions. For an Algorithm to guide treatment decisions, see this article at CurrentPsychiatry.com.
Algorithm: Treatment for panic disorder: A suggested algorithm
aPoor response to an SSRI should lead to a switch to venlafaxine extended-release, and vice versa
bBenzodiazepines are relatively contraindicated in geriatric patients and patients with a history of substance abuse or dependence
CBT: cognitive-behavioral therapy; MAOI: monoamine oxidase inhibitor; SSRI: selective serotonin reuptake inhibitor; TCA: tricyclic antidepressant; Ven XR: venlafaxine extended-release
First-line treatments
Psychotherapy. CBT is the most efficacious psychotherapy for PD. Twelve to 15 sessions of CBT has demonstrated efficacy for PD, with additional effects on comorbid anxiety and depressive symptoms.10 No large clinical trials of CBT have used cognitive restructuring alone; all have included at least some component of exposure that requires the patient to confront feared physical sensations. Gains during treatment may be steady and gradual or sudden and uneven, with rapid improvement in some but not all symptoms. CBT and pharmacotherapy have demonstrated similar levels of benefit in short-term trials, but CBT has proven superior in most9 but not all11 trials evaluating long-term outcomes, particularly compared with pharmacotherapy that is discontinued during follow-up. Although less studied, group CBT also may be considered if a patient cannot afford individual CBT.
Pharmacotherapy. Evidence supports selective serotonin reuptake inhibitors (SSRIs), venlafaxine extended-release (XR), benzodiazepines, and tricyclic antidepressants (TCAs) as effective treatments for PD.3 No class of medication has demonstrated superiority over others in short-term treatment.3,12 Because of the medical risks associated with benzodiazepines and TCAs, an SSRI or venlafaxine XR should be the first medication option for most patients. Fluoxetine, paroxetine, sertraline, and venlafaxine XR are FDA-approved for PD. Paroxetine is associated with weight gain and may increase the risk for panic recurrence upon discontinuation more than sertraline, making it a less favorable option for many patients.13 Start doses at half the normal starting dose used for treating major depressive disorder and continue for 4 to 7 days, then increase to the minimal effective dose. For a Table3 that lists dosing recommendations for antidepressants to treat PD, see this article at CurrentPsychiatry.com. If there is no improvement by 4 weeks, increase the dose every 2 to 4 weeks until remission is achieved or side effects prevent further dose increases.