Several treatment strategies exist, most assuming the necessity of a multi-dimensional approach. The essential steps in the treatment are the provision of information, controlling the panic attacks, behavioural therapy, psychotherapy and maintenance treatment.
As many patients are depressed and demoralised due to suffering panic attacks, treatment should first be focused on the panic attacks, while preparing the patient for the psychological treatment that will follow. The treatment of mild depressive symptoms should be considered only once the panic disorder (PD) is under control and if the depressive symptoms persist.
Broad approaches to treatment include a pharmacological agent, which is often an antidepressant, and psychological treatment (Muzina and Malone, 1997).
Several classes of drugs have been found to be effective in the treatment of PD, especially antidepressants: tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs) and selective serotonin re-uptake inhibitors (SSRIs). Antidepressants have been used to treat patients with PD almost since these drugs were first introduced. Other agents include benzodiazepines (BZDs). Anxiolytics, such as buspirone, are not effective in treating PD.
Traditionally, BZDs were considered as one of the first-line agents given their efficacy in generalised anxiety. The BZDs most used are the high-potency agents (alprazolam, lorazepam and clonazepam), as they have a rapid onset of action with an almost immediate reduction of panic symptoms, whereas antidepressants require 3 to 6 weeks to achieve a therapeutic effect. These drugs may have no antidepressant effects, despite reports to the contrary, and therefore may reduce the anxiety symptoms, but will have no effect on the depressive part of the disorder (Sheehan and Raj, 1998).
The ability to reduce anticipatory anxiety between attacks is thought advantageous by some clinicians. However, the 'as needed' use of BZDs should not replace the use of the prescribed daily doses and according to some authors, may even increase the development of depency on BZDs. These drugs have a high compliance rate and are associated with a high subjective tolerance.
However, BZDs present with undesirable side effects such as sedation, psychomotor impairment and significant interactions with alcohol. Although some of these adverse side effects may decrease after 4-6 weeks of treatment, subjective experience of impaired concentration may remain. The most serious risk with this class of medication is physical dependence (Gorman et al., 1997). Withdrawal symptoms and the recurrence of panic symptoms during drug tapering are substantial risks during long-term treatment. BZDs are also associated with a significant relapse rate in the PD once medication is discontinued.
The use of BZDs in combination with antidepressants has an advantage since the initial anxiety that may be precipitated by the antidepressant may be prevented. Many patients do not stop the use of the BZD as planned by the clinician. There is also evidence that BZDs interfere with psychological therapies, in panic treatment.
The irreversible mono amine oxidase inhihitors ( MAOIs) are believed to be the most potent agents for the treatment of panic, but their considerable side effects and dietary restrictions limit their use (Bell and Nutt, 1998). The benefits of MAOIs include an antidepressant effect and a low risk of dependence. However, sexual difficulties, particularly problems with orgasm, may occur, as well as hypotension and weight gain.
The MAOIs are frequently reserved for severe, refractory panic cases due to their potential for fatal hypertensive crises if dietary restrictions are not adhered to rigorously. However, phenelzine may be useful when atypical depression or social phobia is present.
Moclobemide, a reversible selective inhibitor of monoamine oxidase A (RIMA), has been proven to be effective in a wide range of depressive disorders as well as for PD (Tiller et al., 1997). There is a widely held perception that this agent is not as effective in treating PD as the older MAOIs, although it is better tolerated.
TCAs, especially imipramine and clomipramine, are regularly prescribed for the treatment of PD, effectively decreasing the frequency and severity of attacks and also diminishing agoraphobia. Clomipramine, the most serotonergic of the TCAs, was shown to cause a significant decrease in the total number of panic attacks compared with both placebo and imipramine after 12 weeks of treatment. TCAs have the benefits of once-a-day dosing, low risk of dependence and no dietary restrictions. However, their side effects may lead to relatively high rates of non-compliance. The use of the other TCAs seems to be restricted by the fact that noradrenergic agents are less effective than serotonergic agents in treating PD (Johnson et al., 1995).
Originally introduced for the treatment of depression, SSRIs were also proven effective in the management of PD (Bell and Nutt, 1998). Paroxetine was the first SSRI to be registered for the treatment of PD. Findings of clinical efficacy with this class of drugs further reinforce hypotheses of serotonergic dysfunction in patients with the condition.
Boyer concluded that the SSRIs are, in aggregate, superior to alprazolam and imipramine in the treatment of panic disorder. These findings underscore the importance of serotonin reuptake inhibitors in the treatment of PD and indirectly add to the evidence that serotonergic abnormalities may have a role in its aetiology (Boyer, 1995).
Fluoxetine was effective in trials, but the worrying activating side effects, even at doses of 10 mg/day, have highlighted the need to initiate treatment at doses considerably lower than prescribed in the treatment of depression (Gorman et al., 1987; Schneier et al., 1990). Fluvoxamine is the most studied SSRI and was superior to maproteline and ritanserin and equivalent to clomipramine in the treatment of PD (Hoehn-Saric et al., 1993; den Boer and Westenberg, 1990). Paroxetine has recently been approved for this indication (Oehrberg et al., 1995). Sertraline has been shown to be more effective than placebo (Gorman and Wolkow, 1994). Citalopram studies have shown that this antidepressant is as effective as the other agents and several studies have shown minimal side effects (Wade et al., 1997; Lepola et al., 1998).
Available evidence suggests that, with respect to efficacy, tolerability and relative safety, the SSRIs are the most favourable treatment choice for patients with PD. The evidence presented here shows the potential of citalopram and paroxetine in the treatment of PD. The use of the SNRI, venlafaxine, has also been supported by recent trials.
There are indications that the SSRIs have a more rapid onset of efficacy in PD than the TCAs. Treatment response may be evident after 4-6 weeks.
Approximately 75% of PD patients with agoraphobia develop a relapse of symptoms within 6 months of discontinuing treatment. Patients continuing with half of the original dose demonstrate a high therapeutic response throughout the 1-year maintenance period. Up to 20% of patients suffer a severe, chronic course of panic disorder and 50% show recurrent or mild chronic symptoms, whereas 30% have fully recovered 4 years following the clinical trial (Noyes et al., 1989).
These data emphasise the need for long-term maintenance treatment for PD. Longer duration of treatment seems to increase clinical response. The present strategy for first episode patients is to treat a patient for 1 year, slowly taper and then attempt a drug-free period. Patients with more than one episode may need to be treated indefinitely (Sheehan and Raj, 1998).
Once medication has been used to control the spontaneous panic attacks, there are various psychological treatment options that can be applied in PD. Psychotherapy is the treatment of mental disorders based on verbal communication between a patient and a therapist. It uses techniques such as interpretation, behavioural exercises, support and reassurance in order to alter maladaptive patterns of behaviour. Different types of psychotherapy focus on different aspects of the problem.
The first psychological goal is to treat the phobic avoidance behaviour, usually through exposure therapy (Emmelkamp and Wessels, 1975).
Next, attention is given to psychosocial issues. Patients may have developed low self-esteem, have marital or family problems and may also feel that they are now reliant on medication to function well, or even normally. In order to combat these feelings, patients need to be well informed about their disorder so that they can feel more in control of their symptoms and hence their lives. When possible, family members should be enlisted to help patients cope with their illness. Basic medical counselling and psychoeducation may be as good as short-term cognitive or behavioural therapy, as it may fulfil the educational role of traditional psychological treatments.
The third phase of the psychological treatment is the expansion of cognitive behavioural therapy (CBT). Several variations and combinations of behavioural and cognitive treatment approaches have demonstrated efficacy in the reduction and/or elimination of panic attacks and agoraphobia. Cognitive behavioural approaches treat panic attacks directly. These treatments involve cognitive restructuring by changing maladaptive thought processes and are generally useful in combination with behavioural techniques.
Factsheet: Treating mental disorder
Last updated: 20.12.2011