SSRIs

By ERIC D. Peselow, M.D. | August 1, 1996

Dr. Peselow serves as medical director at the Freedom from Fear Clinic in Staten Island, N.Y. He is also a research professor of psychiatry at the New York University School of Medicine.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy is often considered an effective treatment for panic disorder (Barlow and others 1984, 1989). There are those who regard it as a first-line treatment for panic disorder with some considering it to be as or more effective than medication (Clark and others). Though this is highly controversial, it is clear that for individuals with phobic avoidance in conjunction with the panic, CBT's use of imagery and in vivo exposure has been found to benefit this specific population.

As noted, for those with incomplete response to medication, a trial of cognitive therapy (including thought restructuring, relaxation training and in vivo exposure to phobic situations) and education about the illness is often helpful for both acute and long-term treatment. Though there are virtually no data regarding the combined approach, medications appear to offer rapid symptom relief from the panic attack while CBT offers an array of long-term coping skills.

Conclusion

During the last 15 years, we have gained extensive knowledge regarding the pharmacological management of panic disorder. We have discovered new agents and learned new strategies. Pharmacologic treatment of panic disorder is extremely effective, with treatment failures being related to inadequate dosage, lack of initial careful management or inadequate length of treatment as the major factors of nonresponse. All of this knowledge has led to more beneficial outcomes for patients with panic disorder.

Table 1DSM-IV Criteria for a Panic Attack
A discrete period of intense fear or discomfort in which four (or more) of the following symptoms develop abruptly and reach a peak within 10 minutes:

Palpitations, pounding heart or accelerated heart rate (tachycardia)
Sweating
Trembling or shaking
Sensations of shortness of breath or smothering
Feeling of choking
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, lightheaded or faint
Derealization (feelings of unreality) or depersonalization (being detached from oneself)
Fear of losing control or "going crazy"
Fear of dying
Paresthesia (numbness or tingling sensations)
Chills or hot flushes
DSM-IV Criteria for Panic Disorder

Recurrent unexpected panic attacks and
At least one of the attacks has been followed by one month or more of one (or more) of the following:
a. Persistent concern about having additional attacks
b. Worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy")
c. A significant change in behavior related to the attacks
Table 2Practical Approach to Treatment of Panic TCAs
Imipramine
Start with 10 mg for 1 day
Then 20 mg for 2 days
Then 30 mg for 2 days
Then 40 mg for 1-2 days
Then 50 mg for 1-2 days
Give 75-100 mg for 1 week (week 2)
Give 125-150 mg for 1 week (week 3)
Give 175-200 mg for 1 week (week 4)

Increase to 250-300 mg range as clinically indicated
Nortriptyline(Drug information on nortriptyline)
Start with 10 mg for 1-2 days
Then 20 mg for 2-3 days
Then 30 mg for 2-3 days
Then 40 mg for 2-3 days
Then 50 mg for 2-3 days

Give 75 mg for 1 week (week 3)
Give 100 mg for 1 week (week 4)

Increase to 125-150 mg range as clinically indicated
MAOIs
Start with 15 mg phenelzine(Drug information on phenelzine) for 1-3 days

Then 30 mg phenelzine for 3-4 days

Then 45 mg phenelzine for 1 week (week 2)

Increase to 60-90 mg range as clinically indicated

Overall length of antidepressant treatment is a minimum of 6-8 weeks

(See also Table 3)
Table 3 Practical Approach to Treatment of Panic (Cont.) SSRIs
Fluoxetine(Drug information on fluoxetine)
Start with 5 mg fluoxetine (or in extreme cases use liquid form and give 1/2-1 cc or 2-4 mg) over 1 week and then increase to 10 mg for 1 week, 15-20 mg for 1-3 weeks up to a relative maximum of 40-60 mg. Because of possibility of activation it is often necessary to start with coexistent fluoxetine + a benzodiazepine, the latter for alleviating anticipatory anxiety. In general, due to long half-life of fluoxetine, an 8- to 12-week treatment period is necessary.

Paroxetine(Drug information on paroxetine)
Start with 1/2 pill (10 mg) for 2-6 days and then increase to 20 mg for 1-2 weeks. If no or incomplete response, may increase by 10 mg weekly up to a maximum of 50 mg. Treat for 8-12 weeks.

Sertraline(Drug information on sertraline)
Start with 25 mg (1/2 pill) for 2-6 days and if no side effects, increase dose to 50 mg for 1 week. Increase over 2nd and 3rd week to 75-100 mg range and hold for 1-2 weeks. If no significant response, increase to 150 mg for 2 weeks and if necessary increase up to 200 mg. Treat for 8-12 weeks. May need an adjunctive benzodiazepine to treat anticipatory anxiety but activation effect is not as strong as with fluoxetine.

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All of the following medical conditions are considered part of the differential diagnosis of panic disorder except:
a. coronary artery disease
b. metastatic cancer
c. irritable bowel syndrome
d. epilepsy
e. vestibular dysfunction

Select the correct statement
a. Tricyclic antidepressants are generally considered the treatment of choice in panic disorder.
b. Paroxetine (Paxil), which was recently approved by the FDA for the treatment of panic disorder, has been shown to be clearly more efficacious than sertraline (Zoloft) or fluoxetine (Prozac) in reducing the frequency of panic attacks.
c. Double-blind studies have confirmed the efficacy of the antidepressant/benzodiazepine combination in the initial treatment of panic disorder.
d. Despite adequate pharmacologic treatment, panic disorder is a lifelong illness and as many as 50% of individuals will have relapses.
e. Cognitive behavioral treatment has clearly been shown to be inferior to drug therapy in the treatment of panic disorder.

A panic attack may be characterized by all of the following symptoms except:
a. headaches
b. palpitations
c. nausea
d. derealization/depersonalization
e. sweating

All of the following statements are true except:
a. In the initial treatment of panic disorder it is best to start at a low dose of medication to avoid side effects such as palpitations and agitation, which may frighten the patient and mimic a panic attack.
b. Depression, social phobia, and substance abuse are often comorbid in panic disorder patients.
c. Long-term usage of benzodiazepines in the treatment of panic disorder is never indicated.
d. At least one-third of individuals with panic disorder develop avoidance (agoraphobia) to places where previous panic attacks have begun.
e. The rationale for using a benzodiazepine/antidepressant combination in the initial phase of panic disorder is that the benzodiazepine will work quickly on the anticipatory anxiety while antidepressants act more slowly to block the panic attacks and also alleviate comorbid depressive symptoms when present.

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