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Treatment Guidelines for Panic Disorder

The following treatment guidelines are meant as a reference tool only, and are not intended as treatment advice or to replace the clinical decision-making process of psychiatrists or other health professionals who administer these treatments. In clinical practice there are often good reasons why treatment approaches differ from what is described here.

 

If the individual also suffers from Bipolar Disorder, then all medication use should follow the treatment recommendations for Bipolar Disorder with a comorbid Anxiety Disorder.

If the individual is also in the midst of an active Major Depressive Episode, then follow the treatment recommendations for a Major Depressive Episode.

Step 1:  Either start a course of psychotherapy alone (option a), or combine psychotherapy with an antidepressant (options a and b):

  1. Begin a course of psychotherapy.
    • If after 12-15 sessions the Panic Disorder symptoms resolve fully, go to Step 5.
    • If after 8 sessions there is no improvement, or if after 15 sessions there is not a complete recovery, go to Step 1b while continuing the therapy.
    • If the individual prefers not to start psychotherapy, or if it is not readily available in the person's community, then start with Step 1b. Keep in mind that psychotherapy could always be started at any later point if the Panic Disorder symptoms do not resolve fully with the following medication strategies.
  2.  
  3. Start an SSRI or Venlafaxine.

    If a rapid effect is required, or if there is significant disability that is being caused by the Panic Disorder symptoms, a benzodiazepine could be added at the same time according to Step 2.

    • Therapeutic effects of the SSRI or Venlafaxine usually do not begin before 4 weeks of taking the medication on a daily basis, but a check-up with a physician should be offered after 1-2 weeks of starting the medication to check for any side-effects.
    • If there are no signs of improvement even after 6 weeks of treatment, including two weeks at an increased dose, or if the medication is not well tolerated due to side-effects, taper and discontinue the medication and at the same time repeat Step 1b with a different medication.
    • On the other hand, if after 4-6 weeks there are signs of improvement, then continue the treatment with check-ups with a physician every 2 weeks.
      • As long as the Panic Disorder symptoms continue to improve, there is no need to increase the dose.
      • But if in a given 2-week period the symptoms show no further signs of improvement, the dose should then be increased. It is recommended to wait about 2 weeks after every dose increase to give a chance for improvements to take place before deciding to increase the dose further.
    • If with this approach the Panic Disorder symptoms resolve completely, go to Step 5.
    • On the other hand, if after 2 weeks at the maximum tolerated dose the condition has not resolved completely, go to Step 2.

Step 2:  Add a benzodiazepine.

    • It is recommended to use a longer-acting benzodiazepine such as Clonazepam or Diazepam.
    • These could be taken regularly (daily), or on an as-needed basis to control or prevent the Panic Attacks.
    • Some people may prefer not to use a benzodiazepine, especially on a regular basis, as this could potentially lead to dependence and a difficult time weaning-off of it. If so, skip this step and go to Step 3.
    • The effects of the benzodiazepine should be apparent within a matter of days. If after about 2 weeks, with attempts at optimizing the dose, the Panic Disorder symptoms do not resolve, go to Step 3, with or without stopping the benzodiazepine.
    • On the other hand, if the symptoms resolve completely, go to Step 5.
    • It is possible that after some time of being effective the benzodiazepine may start to lose its effect, as tolerance to this medication can occur. In that case, go to Step 3, with or without stopping the benzodiazepine.

Step 3:  Add one of the following medications:

    • For any of these medications, begin at a low dose, and consider increasing every 2 weeks based on symptom response and tolerability. So long as adequate signs of improvement continue to be seen at a given dose, it need not be increased.
    • If with this approach the Panic Disorder symptoms resolve completely, go to Step 5.
    • If the medication chosen is not fully effective even after 2 weeks at the maximum tolerated dose, then it can either be stopped or continued, but another medication from Step 3 should be tried, or Step 4 should be tried.
    • Use caution if combining any of these Step 3 medications with each other or with a benzodiazepine, as significant sedation and impaired concentration could occur.

Step 4:  Replace the SSRI or Venlafaxine with a Tricyclic Antidepressant.

Step 5:  Maintenance treatment.

    • Even once the condition has resolved completely, individuals should continue to have check-ups with their physicians on a regular basis.
    • Medications that were effective in helping to treat the Panic Disorder symptoms should be continued for 6 months to a year.
    • Benzodiazepines may become less effective over time as the body becomes tolerant to their effects. A very gradual taper and discontinuation of any benzodiazepines should be considered once the individual has recovered from the condition.
    • If psychotherapy was effective, booster sessions can be offered every month for a year.

 

For references in support of the above guidelines, see here.

 

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