The APA guideline endorses both pharmacotherapy and specific varieties of psychotherapy for first-line treatment. Among the bases for choice, patient preference should rank high, and such factors as prior treatment, concurrent medical or psychiatric conditions, cost, and availability should be taken into account.
“In general, it is much easier for PCPs to prescribe medication, but in some ways this is unfortunate, because cognitive behavioral therapy (CBT) is equally effective and may have more staying power in the long run,” Dr. Roy-Byrne says.
Among psychotherapies, only CBT is strongly supported by extensive controlled trial data. (It is also effective in the group format.) The APA authors state that panic-focused psychodynamic psychotherapy has been validated by one randomized controlled trial and might be indicated for patients who prefer dynamic therapy. Other psychosocial treatments (e.g., supportive psychotherapy and couples/family therapy) lack research support and cannot be recommended.
“PCPs should make it their business to find out who in their community really knows how to deliver manual-based CBT for panic disorder,” Dr. Roy-Byrne recommends.
For pharmacotherapy, abundant controlled trial data support the efficacy of selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs) and benzodiazepines. These drugs are comparable in efficacy but differ in side effects and cost. Patient factors and the potential for drug-drug interactions should also be kept in mind when choosing a first treatment.
The APA authors note that benzodiazepines have the advantage of quick onset of action. Clinicians should be mindful of risks (e.g., falls in older patients, physiological dependence), however, and prescribe these drugs with caution to those with a history of substance abuse. Benzodiazepines are not appropriate monotherapy for the substantial proportion of panic patients who have concurrent depression.
The risk of self-harm or suicidal behavior is apparently small with SSRIs and SNRIs prescribed for panic but should not be ignored; the authors recommend monitoring for such side effects as agitation, insomnia, and irritability, which may increase risk of suicide or self-harm, particularly early in treatment. The short-term addition of a benzodiazepine can be helpful at this time.
SSRIs and SNRIs should be initiated at half the starting dose given to depressed patients and increased in weekly increments, as needed, to a standard therapeutic level, the APA guideline recommends.
Underdosing of SSRIs and SNRIs is often responsible for treatment failure in the primary-care setting. “Start low, go slow, but go,” Dr. Roy-Byrne advises. Prescribe benzodiazepines on a regular schedule, not as needed.
For effective treatment
Panic symptoms themselves may present barriers to treatment, the authors say. Patients are often fearful of bodily sensations caused by medication and of exposure to situations they customarily avoid, as demanded by CBT. They should be fully informed about what to expect and cautioned that a period of intensified anxiety is not uncommon in the early stages of treatment.
To monitor treatment effectiveness, formal rating scales are useful, the APA guideline suggests. “It is the only way to determine if a patient is getting better,” Dr. Roy-Byrne says. “Would you prescribe an antihypertensive and not measure BP?” He has developed an instrument for evaluating anxiety, specifically for use in primary care (J Am Board Fam Med. 2009;22:175-86).
When the first treatment is unsuccessful despite some therapeutic gains, the APA guideline suggests augmenting it with psychotherapy or a second drug. If initial treatment has failed altogether, switching to a different drug or substituting psychotherapy for medication (or vice versa) may be more logical.
According to Dr. Roy-Byrne, the question of when to refer depends on such factors as local resources, the patient’s acceptance of mental-health care, and the PCP’s experience and comfort with treating the disorder.
The American Psychiatric Association’s Practice Guideline for the Treatment of Patients With Panic Disorder, Second Edition, is available online.