General principles
- benzodiazepines are associated with a less good outcome in the long term and should not be prescribed for the treatment of individuals with panic disorder
- sedating antihistamines or antipsychotics should not be prescribed for the treatment of panic disorder
Pharmacological interventions - antidepressant medication
- antidepressants should be the only pharmacological intervention used in the longer term management of panic disorder
- the two classes of antidepressants that have an evidence base for effectiveness are the selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs).
Unless otherwise indicated, an SSRI licensed for panic disorder should be offered
If an SSRI is not suitable or there is no improvement after a 12-week course and if a further medication is appropriate, imipramine or clomipramine may be considered
When prescribing an antidepressant, the healthcare professional should consider the following
- side effects on the initiation of antidepressants may be minimised by starting at a low dose and increasing the dose slowly until a satisfactory therapeutic response is achieved
- if the person is showing improvement on treatment with an antidepressant, the medication should be continued for at least 6 months after the optimal dose is reached, after which the dose can be tapered
- if there is no improvement after a 12-week course, an antidepressant from the alternative class (if another medication is appropriate) or another form of therapy should be offered
- stopping antidepressants abruptly can cause discontinuation/withdrawal symptoms. To minimise the risk of discontinuation/withdrawal symptoms when stopping antidepressants, the dose should be reduced gradually over an extended period of time
- all people prescribed antidepressants should be informed that, although the drugs are not associated with tolerance and craving, discontinuation/withdrawal symptoms may occur on stopping or missing doses or, occasionally, on reducing the dose of the drug. These symptoms are usually mild and self-limiting but occasionally can be severe, particularly if the drug is stopped abruptly
- healthcare professionals should inform people that the most commonly experienced discontinuation/withdrawal symptoms are dizziness, numbness and tingling, gastrointestinal disturbances (particularly nausea and vomiting), headache, sweating, anxiety and sleep disturbances
- if discontinuation/withdrawal symptoms are mild, the practitioner should reassure the person and monitor symptoms. If severe symptoms are experienced after discontinuing an antidepressant, the practitioner should consider reintroducing it (or prescribing another from the same class that has a longer half-life) and gradually reducing the dose while monitoring symptoms
Monitoring pharmacological interventions:
- when a new medication is started, the efficacy and side-effects should be reviewed within 2 weeks of starting treatment and again at 4, 6 and 12 weeks
- at the end of 12 weeks, an assessment of the effectiveness of the treatment should be made, and a decision made as to whether to continue or consider an alternative intervention
- if medication is to be continued beyond 12 weeks, the individual should be reviewed at 8- to 12-week intervals, depending on clinical progress and individual circumstances
Notes:
- tranquilisers:
- benzodiazepine tranquilisers:
- such as chlordiazepoxide, diazepam
- these should not be prescribed for longer than 7 days, in order to avoid dependency
- azaspirones such as buspirone
- recommended for short-term use only
- beta blocking agents may be useful if palpitations are a problem
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