Pharmacological treatment of panic disorder

There have been considerable developments in the pharmacological treatment of panic disorder (PD) over the past 40 years. Initially the tricyclic antidepressants were found to be effective in treating panic attacks but in recent years selective serotonin reuptake inhibitors (SSRIs) have become the first-line pharmacological therapy. Despite their benefits, SSRIs still have some adverse effects, including an initial transient increase in anxiety. Newer antidepressants such as venlafaxine and mirtazapine have also shown some efficacy, whilst some of the older antidepressants, such as the monoamine oxidase inhibitors (MAOIs), remain useful in treatment-resistant cases. In the past benzodiazepines were widely used, but with concerns over dependence and withdrawal their use has declined, although they remain useful as short-term adjunctive therapy on antidepressant initiation and in resistant cases. Psychological therapies, particularly cognitive–behavioural therapy (CBT), also have an important role in management, but it is not yet clear whether combining pharmacological and psychotherapeutic treatments confers any additional benefit.