What are the best medications for panic disorder?

The COVID-19 pandemic is continuing to worsen mental health around the world; early studies from 2020 were already showing an increased prevalence of depression, anxiety, and panic disorder, and studies from 2021 demonstrate continued increasing rates of these mental health disorders. With several Food and Drug Administration (FDA) approved medications for panic disorder currently available in the United States, choosing an initial medication for patients with a new diagnosis can feel overwhelming. A newly published systematic review and network meta-analysis sought to identify the most effective medications for panic disorder and found that sertraline and escitalopram had the best balance of benefit and adverse events.

The systematic review and network meta-analysis examined the literature through June 2021 regarding pharmaceutical options for panic disorder. The researchers looked for randomized controlled trials (RCTs) that included adults aged 18 years and older and cited outcomes related to either benefit (remission rates) and/or harm (including somnolence, gastrointestinal problems, and cognitive impairment). They identified 87 studies with a total of 12,800 participants and followed appropriate systematic review methodology to extract and synthesize the data. Most of the studies compared medication treatment to placebo, so the authors conducted a network meta-analysis to compare outcomes among the various medication classes and medications identified in the systematic review:

Our network meta-analysis identified 11 current drug classes for the treatment of panic disorder, highlighting benzodiazepines, tricyclic antidepressants, and SSRIs as the highest ranked treatments for remission based on SUCRA values. Although benzodiazepines were associated with the lowest probability of dropout, they were also associated with the highest risk of adverse events. Overall, SSRIs provided high benefit (remission) with low risk of adverse events. Across individual SSRIs, sertraline and escitalopram were identified as the most efficacious agents with low risk of adverse events.

The researchers also evaluated included studies for risk of bias, and they noted that "[t]he findings were...based on studies of moderate to very low certainty levels of evidence, mostly as a result of within study bias, inconsistency, and imprecision of the findings reported." Nevertheless, this study's comprehensive and rigorous comparisons may still help guide treatment decisions for patients presenting with panic disorder.

Medications are a useful tool for treating panic disorder, but cognitive behavioral therapy is very effective as well (number needed to treat for complete remission of panic after 3-4 months = 2). Accessing support resources can be beneficial; I included a list of mental health resources developed during the pandemic in this blog post from 2020, and I especially like this one from the World Health Organization that emphasizes the importance of simple self-care habits. 

It's also important to precisely diagnose patients to guide treatment recommendations. This 2015 AFP article on "Diagnosis and Management of Generalized Anxiety Disorder and Panic Disorder in Adults" includes diagnostic criteria for both Generalized Anxiety Disorder and panic disorder along with an overview of treatment options - both pharmaceutical and non-pharmaceutical - to discuss with patients. There's also an AFP By Topic on Anxiety Disorders if you'd like to read more.