Yes — there is some evidence for both Duloxetine (brand name Cymbalta) and Mirtazapine (brand name Remeron) in treating Panic Disorder (PD), but the strength of the evidence and their status relative to first-line treatments differs. Below is a summary of what the research says, what the caveats are, and how to interpret this in a clinical context.
Duloxetine (Cymbalta)
Evidence:
- There is an open-label study of 15 people with panic disorder (with or without agoraphobia) treated with duloxetine 60-120 mg/day for 8 weeks. Significant improvement on the Panic Disorder Severity Scale (PDSS) and other measures of anxiety, depression, and quality of life were found.
- A case-report describes a patient with panic disorder plus somatic/gastric symptoms who improved on duloxetine.
- More broadly, duloxetine has been discussed in reviews of anxiety disorders (though more so for generalized anxiety disorder [GAD]) as having potential efficacy for “anxiety spectrum” conditions.
- However — a major recent review of pharmacotherapy for panic disorder states that SSRIs remain first-line, and the SNRI class (specifically Venlafaxine) is an “acceptable early option”; it does not robustly list duloxetine as a formally established first-line agent for panic disorder.
Interpretation:
- Duloxetine shows promising but limited evidence for panic disorder.
- Because the main trials are small, open-label (i.e., uncontrolled), and there is no large randomized controlled trial (RCT) placing duloxetine clearly into first-line status for panic, its use for PD is more “off-label / second-line” compared to the SSRIs with stronger evidence.
- If a patient has panic disorder plus significant comorbidities (e.g., depression, pain symptoms, somatic symptoms) where duloxetine’s dual serotonin-and-norepinephrine action (and its pain/physical-symptom benefits) are advantageous, a clinician might consider duloxetine—but this should be done with awareness of the evidence limitations.
Mirtazapine (Remeron)
Evidence:
- There is an open-label pilot study of mirtazapine in panic disorder: 28 patients entered, 19 completed, 12 weeks of active treatment following 3-week placebo run-in. Results suggested improvement.
- There is a randomized trial comparing mirtazapine versus fluoxetine in panic disorder; it found no significant difference between groups in some key metrics (number of panic attacks, Hamilton Anxiety Scale, Sheehan Phobic Scale), but the global evaluation of phobic anxiety favored mirtazapine.
- A meta-analysis of antidepressants in depression with anxiety symptoms found mirtazapine superior to placebo for anxiety/somatization—but this is in depression populations, not strictly panic disorder.
- A recent evidence‐based pharmacotherapy review for panic disorder lists mirtazapine among medications with “limited evidence”: > “Mirtazapine, bupropion, and reboxetine … effective for short-term treatment of panic disorder, resulting in fewer symptoms and number of panic attacks” (though the evidence base is small).
Interpretation:
- Mirtazapine has even more limited evidence for panic disorder than duloxetine.
- The evidence is small-scale, and not yet robust enough to qualify mirtazapine as a standard first-line treatment for PD in most guidelines.
- It may be considered as a possible alternative or adjunct in certain situations (e.g., if first-line SSRIs/SNRIs cannot be used due to side-effects or specific patient factors), but with the caveat that the evidence is modest.
Summary & Clinical Implications
- For panic disorder, first-line treatments with the strongest evidence remain SSRIs (e.g., paroxetine, sertraline) and SNRIs with more evidence such as venlafaxine.
- Duloxetine is promising, but evidence is still limited. Its dual serotonin-norepinephrine mechanism may offer advantages in patients with comorbid depression or somatic/pain symptoms, but it is not yet “standard first choice” for panic disorder based on large RCTs.
- Mirtazapine is a possible alternative, but due to limited data it would typically be considered when standard treatments are not suitable or have failed.
- When using either duloxetine or mirtazapine for panic disorder, it’s important to:
- Ensure adequate trial duration (often several weeks) before judging effectiveness.
- Monitor for side-effects (e.g., mirtazapine may cause sedation or weight gain; duloxetine may raise blood pressure, cause nausea, etc.)
- Combine with psychotherapy (especially cognitive-behavioural therapy or panic-specific behavioural interventions) for best outcomes.
- Review guideline status in the country/region (because regulatory approvals, local guidelines, and insurance coverage may differ).
- Consider the individual patient’s profile (comorbid conditions, side-effect sensitivity, previous medication response) to decide whether selecting a “less-well-proven” agent is appropriate vs sticking with a well-proven first-line agent.
If you like, I can look up all published trials (RCTs, open-label, case series) of duloxetine and mirtazapine in panic disorder (including effect sizes, remission rates) and also check whether any guideline in Taiwan or East Asia comments on their use for PD. Would you like me to do that?
