Pharmacotherapy of Panic Disorder

Several pharmacological agents have proven effective in the treatment of patients with panic disorder, although psychological therapies, including behavioral and cognitive-behavioral treatments, have a place in the comprehensive approach to treatment of panic disorder (12). Nonpharmacological therapies may be tried first, particularly for patients with mild symptoms. Most patients, however, require pharmacological management for optimal functioning. Alprazolam 2 to 6 mg per day or clonazepam 1 to 4 mg per day may be used first for patients with mild to moderately severe panic disorder that is not complicated by depression.

The benzodiazepines should not be routinely prescribed for patients with a personal or strong family history of substance abuse. Antidepressants should be used for patients with crippling symptoms, those with a history of substance abuse, those who do not tolerate benzodiazepines, or those with prominent depression. Tricyclic antidepressants such as imipramine or nortriptyline are effective in standard doses, although some patients respond to lower amounts. For the most severely ill or treatmentrefractory patients, a monoamine oxidase inhibitor should be used. Antidepressants may be combined with benzodiazepines, especially early in treatment.

The duration of treatment should be flexible. Many patients require treatment for two years or more to achieve maximal benefit before tapering can be attempted; indefinite pharmacologic management may be required for some patients (13).