Panic disorder long-term treatment

Pollack MH, Allgnlander C, Bandelow B, et al. WCA recommendations for the long-term treatment of panic disorder. CNS Spectr 2003 8(Snpplement 1) 17-30. 

Being a chronic condition, panic disorder is likely to require long-term treatment. Current clinical practice tends to favor a trial of medication for at least 3 months, with continuation for 6-12 months if there is a good clinical response, ffowever, the most appropriate time to discontinue therapy has not yet been determined, and more data from long-term follow-up studies are needed [Ballenger 1992). Clinical experience indicates that 40% of patients with panic disorder may need treatment for a year, and some 20%-40% may require continued maintenance treatment thereafter (Keller and ffanks 1993). 

The benzodiazepines (see Chapter 22) provide much more rapid relief of both generalized anxiety and panic than do any of the antidepressants. However, the antidepressants appear to be at least as effective and perhaps more effective than benzodiazepines in the long-term treatment of these anxiety disorders. Furthermore, antidepressants do not carry the risks of dependence and tolerance that may occur with the benzodiazepines. 

Currently, many physicians adopt a benzodiazepine-sparing strategy by using benzodiazepines when necessary but conservatively. That is, benzodiazepines can often be helpful when treatment is initiated or when a rapid-onset therapeutic effect is desired. They can also help improve the short-term tolerability of SSRIs by blocking the jitteriness and exacerbation of panic sometimes observed when initiating treatment with an SSRI or other antidepressant. Benzodiazepines can also be useful to top up the patient s treatment on an as-needed basis for sudden and unexpected decompensation or short-term psychosocial stressors. Finally, if a patient is not fully responsive to an antidepressant or combinations of antidepressants, long-term treatment with concomitant benzodiazepines and antidepressants may become necessary to effect full or adequate control of symptoms. Sometimes, once symptoms are suppressed for several months to a year, the benzodiazepine can be slowly discontinued and the patient maintained long-term on the antidepressant alone. The consequences of inadequate treatment of panic disorder can be very severe loss of social and oc-... 

The main objectives of treatment are to reduce the severity and frequency of panic attacks, reduce anticipatory anxiety and agoraphobic behavior, and minimize symptoms of depression or other comorbid disorders.48 The long-term goal is to achieve and sustain remission. 

Long-term efficacy and tolerability is of considerable clinical importance for any medication proposed for the treatment of panic disorder. Tricyclic antidepressants, in particular, are associated with side effects such a weight gain and anticholinergic effects, which may make them difficult for patients to tolerate long-term. 

A second issue relating to long-term medication is the effect of withdrawing medication at the end of a period of treatment. Benzodiazepines are associated with discontinuation symptoms, and their repeated use may foster the development of true physiological dependence. In a study of discontinuation of treatment for panic disorder [Rickels et al. 1993) with either alprazolam [n = 27), imipramine [n = 11) or placebo [n = 10), a withdrawal syndrome was observed in almost all patients treated with alprazolam but in few pa-... 

Panic disorder is emerging from decades of comparative neglect as an apparently intractable and poorly understood condition to become the focus of intensive interest in epidemiological, pharmacological, and clinical research. Panic disorder is a chronic and distressing condition with a profound effect on the quality of life, similar to or even worse than the effect of major depression [Markowitz et al. 1989 Weissman 1991). Effective and well-tolerated treatment that can be used safely in the long term is badly needed. 

The initial long-term data are promising however, further long-term studies are needed to confirm the initial promise of serotonin reuptake inhibitors in the treatment of panic disorder, and comparative studies of agents within this class of drugs are needed to clarify their relative profiles. 

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Lecrubier Y, Judge R Long-term evaluation of paroxetine, clomipramine and placebo in panic disorder. Acta Psychiatr Scand 95 153-160, 1997 Lecrubier Y, Puech AJ, Azcona A, et al A randomized double-blind placebo-con-trolled study of tropisetron in the treatment of outpatients with generalized anxiety disorder. Psychopharmacology 112 129, 1993 Lecrubier Y, Pletan Y, Selles A, et al Clinical efficacy of milnacipran placebo-con-trolled trials. Int Chn Psychopharmacol 11 (suppl 4 29-34, 1996 Lecrubier Y, Bakker A, Dunbar G, et al A comparison of paroxetine, clomipramine and placebo in the treatment of panic disorder. Acta Psychiatr Scand 95 145-152, 1997... 

Pohl RB, Wolkow RM, Clary CM Sertraline in the treatment of panic disorder a double-bhnd multicenter trial. Am J Psychiatry 155 1189-1195, 1998 Poirer MF, Galzin AM, et al Short-term hthium administration to healthy volunteers produces long-lasting pronounced changes in platelet serotonin uptake but not imipramine binding. Psychopharmacology 94 521-526, 1988 Poiiier-littre MF, Loo FI, Dennis T, et al Dthium treatment increases norepinephrine turnover in the plasma of healthy subjects (letter). Arch Gen Psychiatry 50 72-73, 1993... 

Richelson E, Nelson A Antagonism by neuroleptics of neurotransmitter receptors of normal brain in vitro. Eur J Pharmacol 103 197-204, 1984 Rickels K, Schweizer E The treatment of generalized anxiety disorder in patients with depressive symptomatology. J Clin Psychiatry 54 [suppl) 20-23, 1993 Rickels K, Weisman K, Norstad N, et al Buspirone and diazepam in anxiety a controlled study. J Chn Psychiatry 43(12 pt 2) 81-86, 1982 Rickels K, Feighner JP, Smith WT Alprazolam, amitriptyline, doxepin, and placebo in the treatment of depression. Arch Gen Psychiatry 42 134-141, 1985 Rickels K, Schweizer E, Weiss S, et al Maintenance drug treatment for panic disorder, 11 short- and long-term outcome after drug taper. Arch Gen Psychiatry 50 61-68, 1993... 

Because long-term exposure to high-dose benzodiazepines may place some patients at risk for physical and psychological dependence, we recommend the use of antidepressants for the treatment of panic disorder. For most patients, SSRIs should be considered first-line agents. The choice should be based on the factors discussed in Chapter 2. MAOls are usually reserved for patients whose symptoms have not responded to SSRIs and TCAs. A major caveat is that patients with panic disorder initially may be highly sensitive to the stimulant effect of small doses of antidepressants. For highly anxious patients with panic disorder, treatment may be... 

Rickels K, Schweizer E, Weiss S, et al. Maintenance drug treatment for panic disorder. II. Short- and long-term outcome after drug taper. Arch Gen Psychiatry 1993 50 61-68. 

CBT is an effective treatment for panic disorder, and has shown long-term efficacy [ 115]. CBT for panic disorder usually aims at preventing panic attacks and avoidance behaviors. However, there is a lack of data on the effect of CBT on nocturnal panic attacks. Sleep hygiene education and other CBT to reduce sleep-related worries and anxiety can be applied to avoid elevation of anxiety associated with sleep and to avoid maladaptive sleep-related behaviors that may further exacerbate sleep problems. 

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