For Panic Disorder (PD)—characterized by recurrent unexpected panic attacks and anticipatory anxiety—antidepressants, especially those that modulate serotonin, are first-line treatments due to their efficacy in both acute and long-term management. Here’s a structured overview:
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First-Line Antidepressants
Well-supported by clinical trials and guidelines:
1. SSRIs (Selective Serotonin Reuptake Inhibitors)
Highly effective and generally well-tolerated, though they may initially worsen anxiety in the first 1–2 weeks.
- Paroxetine – FDA-approved; potent, but can be sedating and cause weight gain.
- Sertraline – FDA-approved; good balance of efficacy and tolerability.
- Fluoxetine – FDA-approved; activating; long half-life helps with discontinuation.
- Citalopram / Escitalopram – Commonly used off-label with good tolerability.
- Fluvoxamine – Effective but less commonly used in PD.
Clinical Note:
Start low and go slow, as people with panic disorder are often sensitive to activation effects (e.g., jitteriness, insomnia).
2. SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)
- Venlafaxine XR – FDA-approved for PD; similar to SSRIs in efficacy.
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Second-Line or Adjunctive Antidepressants
Used when first-line drugs fail or are not tolerated:
3. TCAs (Tricyclic Antidepressants)
- Imipramine – Effective, especially pre-SSRI era; anticholinergic side effects are a concern.
- Clomipramine – Strong serotonin activity; used occasionally.
4. MAOIs (Monoamine Oxidase Inhibitors)
- Phenelzine – Effective, particularly in treatment-resistant PD, but high burden of side effects and dietary restrictions.
5. Atypical Antidepressants
- Mirtazapine – Not first-line but may help when insomnia or appetite issues coexist.
- Bupropion – Not recommended; can exacerbate anxiety and panic.
💊 Non-Antidepressant Options Often Used in Combination
- Benzodiazepines (e.g., clonazepam, alprazolam): Rapid relief; useful short-term or as adjunct, but risk of dependence.
- Beta-blockers: Not effective for panic disorder.
🧪 Summary Table
|
Class |
Drug |
FDA-approved for PD |
Notes |
|
SSRI |
Paroxetine |
Yes |
Sedating, weight gain |
|
SSRI |
Sertraline |
Yes |
Good tolerability |
|
SSRI |
Fluoxetine |
Yes |
Activating, long half-life |
|
SNRI |
Venlafaxine XR |
Yes |
Effective, can raise BP |
|
TCA |
Imipramine |
麱 No |
Effective but more side effects |
|
MAOI |
Phenelzine |
麱 No |
Effective; dietary restrictions |
|
Atypical |
Bupropion |
No |
Can worsen panic symptoms |
|
Atypical |
Mirtazapine |
麱 No |
May help with comorbid insomnia |
Would you like a side-by-side comparison of panic disorder vs social anxiety in terms of pharmacological response, or suggestions for how to sequence meds in treatment-resistant PD?
