Panic disorder, treatment

The acute phase of panic disorder treatment lasts about 12 weeks and should result in marked reduction in panic attacks, ideally total elimination, and minimal anticipatory anxiety and social anxiety avoidance. Treatment should be continued to prevent relapse for an additional 12 to 18 months before attempting discontinuation. 

Panic disorder Treatment of panic disorder, with or without agoraphobia (alprazolam immediate-release, extended-release, and orally disintegrating clonazepam). 

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... 

Benzodiazepines (BZDs) have been used for the treatment of depression because their sedative effects can reduce insomnia, agitation, and anxiety symptoms that frequently accompany depressed states. Considerable evidence also indicates that major depression may accompany panic and agoraphobic disorders ( 199, 200 and 201). When depression precedes the onset of panic disorder, clinical experience suggests a better response to antidepressants than to BZDs, although no studies have directly addressed this issue (202). Conversely, available evidence indicates that when depression occurs after the onset of panic disorder, treatment with either a BZD or a tricyclic may result in concomitant improvement of both the panic and depressive symptoms (198, 199, 200, 201,202 and 203). Depression, however, has been reported to be an adverse effect of BZD treatment. 

Beginning in the 1960s, ben2odia2epiae anxiolytics and hypnotics rapidly became the standard prescription dmg treatment. In the 1980s, buspkone [36505-84-7] (3), which acts as a partial agonist at the serotonin [50-67-9] (5-hydroxytryptamine, 5-HT) type lA receptor, was approved as treatment for generali2ed anxiety. More recently, selective serotonin reuptake inhibitors (SSRIs) have been approved for therapy of panic disorder and obsessive—compulsive behavior. 

SSRIs are widely used for treatment of depression, as well as, for example, panic disorders and obsessive—compulsive disorder. These dmgs are well recognized as clinically effective antidepressants having an improved side-effect profile as compared to the TCAs and irreversible MAO inhibitors. Indeed, these dmgs lack the anticholinergic, cardiovascular, and sedative effects characteristic of TCAs. Their main adverse effects include nervousness /anxiety, nausea, diarrhea or constipation, insomnia, tremor, dizziness, headache, and sexual dysfunction. The most commonly prescribed SSRIs for depression are fluoxetine (31), fluvoxamine (32), sertraline (52), citalopram (53), and paroxetine (54). SSRIs together represent about one-fifth of total worldwide antidepressant unit sales. 

Antidepressants are small heterocyclic molecules entering the circulation after oral administration and passing the blood-brain barrier to bind at numerous specific sites in the brain. They are used for treatment of depression, panic disorders, generalized anxiety disorder, social phobia, obsessive compulsive disorder, and other psychiatric disorders and nonpsychiatric states. 

Otto MW, Pollack MH, Sachs GS, et al Discontinuation of benzodiazepine treatment efficacy of cognitive-behavioral therapy for patients with panic disorder. Am J... 

Schweizer E, Patterson W, Rickels K, et al Double-blind, placebo-controlled study of a once-a-day, sustained-release preparation of alprazolam for the treatment of panic disorder. Am J Psychiatry 150 1210-1215, 1993 Seivewright N Benzodiazepine misuse by illicit drug misusers. Addiction 96 333—334, 2001... 

Treating a condition is usually cheaper than not treating it (the offset effect). A Spanish study of panic disorder patients reported an offset effect of 14% following 12 months of drug treatment (Salvador-Carulla et al, 1995). Thus, the total direct costs of health-care use during the previous year and the year following diagnosis were US 29 000 and US 46 000 respectively, but the estimated... 

An earlier study yielded data at variance with these findings (Edlund and Swann, 1987). In a small group of patients with panic disorder, disability was marked most reported a decreased quality of work and two-thirds claimed to have lost jobs or income. Half could not drive further than 5 kilometres and a third had increased their alcohol use. However, direct costs for treatment were not high, mainly because most had not sought treatment. Note that this study took place before panic disorder became generally recognized and publicized. 

Gould RA, Otto MW, Pollack MH (1995). A meta analysis of treatment outcome for panic disorder. Clin Psychol Rev 15, 819-44. 

Figure 19.8 A schematic representation of the GABAa receptor shift hypothesis. This proposes that patients with panic disorder have dysfunctional GABAa receptors such that the actions of drugs that behave as antagonists in normal subjects are expressed as inverse agonism in panic patients. It is unlikely that this theory extends to generalised anxiety disorder (GAD), for which benzodiazepine agonists are highly effective treatments, but it could explain why these drugs are relatively ineffective at treating panic disorder. (Based on Nutt et al. 1990)...

Work Group on Panic Disorder. Practice guideline for the treatment of patients with panic disorder. Am J Psychiatry 1998 155(suppl 5) 1—34. 

A Phase II study was recently completed whereby Org-25935 was compared against placebo for the ability to improve negative symptoms in 246 subjects maintained on a stable dose of an atypical antipsychotic (data not disclosed) [46]. A second Phase II study in progress (200 patients) is designed to assess the efficacy of Org-25935 as a stand-alone therapy versus placebo, using olanzapine as the active control [46]. Org-25935 is also being investigated in separate Phase II studies as a treatment for panic disorder and for recidivism in subjects with alcohol dependence [46]. 

Benjamin, J., Levine, J., Fux, M. et al. Double-blind, placebo-controlled, crossover trial of inositol treatment for panic disorder. Am. ]. Psych. 152 1084-1086,1995. 

Palatnik, A., Frolov, K., Fux, M., Benjamin, J. Double-blind, controlled, crossover trial of inositol versus fluvoxamine for the treatment of panic disorder./. Clin. Psychopharmacol. 21 335-339, 2001. 

Data from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision. Washington, DC American Psychiatric Association, 2000 429-484 Baldwin DS, Anderson IM, Nutt DJ, et al. Evidence-based guidelines for the pharmacological treatment of anxiety disorders Recommendations from the British Society for Psychopharmacology. J Psychopharmacology 2005 19 567-596 and Katon WJ. Panic disorder. N EnglJ Med 20062554 2560-2567. 

Data from Katon WJ. Panic disorder. N Engl J Med 2006 354 2360-2367 Bandelow B, Zohar J, Hollander E, etal. Guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders. World J Biol Psychiatry 2002,3 171-199 Work Group on Panic Disorder. Practice guideline for the treatment of patients with panic disorder. Am J Psychiatry 1998 155(Supp 5) l-34 and EffexorXR[package insert]. Philadelphia, PA Wyeth Pharmaceuticals, Inc., August 2006. 

The current SSRIs in the United States inclnde fluoxetine, fluvoxamine, sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro). All effectively treat major depression. In addition, one or more of the SSRIs has been shown effective in the treatment of dysthymic disorder, the depressive phase of bipolar disorder, premenstrual dysphoric disorder, panic disorder, social phobia, obsessive-compnlsive disorder, bnlimia nervosa, and binge-eating disorder. 

The symptoms of a panic attack are so frightening that an unusually large number of those with panic disorder (in comparison to other psychiatric illnesses) seek treatment on their own accord. However, easily half of those who seek treatment do so in general medical settings such as hospital emergency rooms and the offices of primary care physicians. Easily mistaken for severe and even life-threatening medical conditions such as asthma attacks and heart attacks, panic disorder results in disproportionately higher health care utilization than other anxiety disorders. 

Substance-Induced Anxiety Disorder. Numerous medicines and drugs of abuse can produce panic attacks. Panic attacks can be triggered by central nervous system stimulants such as cocaine, methamphetamine, caffeine, over-the-counter herbal stimulants such as ephedra, or any of the medications commonly used to treat narcolepsy and ADHD, including psychostimulants and modafinil. Thyroid supplementation with thyroxine (Synthroid) or triiodothyronine (Cytomel) can rarely produce panic attacks. Abrupt withdrawal from central nervous system depressants such as alcohol, barbiturates, and benzodiazepines can cause panic attacks as well. This can be especially problematic with short-acting benzodiazepines such as alprazolam (Xanax), which is an effective treatment for panic disorder but which has been associated with between dose withdrawal symptoms. 

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