Combination therapy best for panic disorder

When it comes to panic disorder, medication alone is rarely sufficient to provide relief from symptoms.

Part of the challenge in treating panic disorder is that it has many manifestations and varied symptoms. The disorder itself is characterized by recurring episodes of sudden, uncontrollable fear or panic. These episodes are usually made more frightening by cardiovascular symptoms (such as shortness of breath, heart palpitations, or chest pain), nausea or other forms of gastrointestinal distress, and neurological problems such as faintness and trembling.

Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, and benzodiazepines (antianxiety medications, such as Valium and Ativan) are all about equally effective at alleviating symptoms of panic disorder. About 50% to 70% of patients typically respond to medication during the first few months of treatment.

But 25% to 50% of patients who stop taking a medication, perhaps because of concern about sedation or other side effects, suffer a relapse within six months. In part, this may be due to the fact that abruptly stopping medications can result in uncomfortable withdrawal symptoms.

Studies have shown, however, that combining medication with some type of psychotherapy is often more effective than medication alone, and reduces the risk of relapse.

The Cochrane Collaboration, an internationally respected organization that reviews medical evidence, concluded that the most effective approach for treating panic disorder combines antidepressants and cognitive behavioral therapy. (This type of psychotherapy teaches patients to recognize and change ways of thinking that make panic symptoms worse.)

In the immediate or “acute phase,” a period that generally lasts two to four months, the goal is to help someone recover from a debilitating panic attack, get any other symptoms under control, and avoid triggering repeat panic attacks. Although the studies defined treatment response in various ways, the Cochrane reviewers evaluated results to determine whether interventions helped patients achieve substantial improvement in symptoms.

Taken together, the studies reported that, during the acute phase, therapy that combined antidepressants and psychotherapy (including cognitive behavioral therapy) was about 24% more likely to produce substantial symptom improvement than antidepressant treatment alone, and about 17% more likely to produce substantial improvement than psychotherapy alone.

During the maintenance phase, the goal of treatment is to help a patient avoid having more panic attacks and resume normal functioning. During this phase, the reviewers also concluded that combination therapy appeared superior to either approach alone.

Because many patients eventually stop treatment, the Cochrane reviewers also examined what happened six to 24 months after patients stopped taking antidepressants or undergoing psychotherapy. At this point, combination therapy continued to be more effective than antidepressant treatment alone, but it was no better than psychotherapy alone. Since psychotherapy achieved the same long-term results as a solo treatment, the reviewers recommended offering either combination therapy or psychotherapy alone as a first-line option to patients.

Of course, questions remain. It’s still not clear whether medication and psychotherapy should be offered concurrently or sequentially, and whether people who don’t respond to one medication should switch to another agent within the same class (such as from one SSRI to another) or to another type of medication (like a tricyclic antidepressant). There is also a dearth of evidence about the effectiveness of psychotherapies other than cognitive behavioral therapy — such as relaxation training, stress management, and hypnosis — for alleviating symptoms of panic disorder.

Even so, the available evidence suggests that combination therapy is most likely to provide relief from symptoms of panic disorder.

What combination of drugs and psychotherapy has helped you or someone you know with panic disorder? Do you think both approaches are necessary?

Dr. Michael Miller has been on staff of the Beth Israel Deaconess Medical Center, a large teaching hospital in Boston, for more than 25 years. He is also an Assistant Professor of Psychiatry at Harvard Medical School.

Anxiety and Phobias
Anxiety disorders—which include panic attacks, post-traumatic stress disorder, obsessive-compulsive disorder, and phobias—are among the most common mental illnesses, affecting about 23 million American adults. Thankfully, never before have there been so many therapies to help control anxiety. Coping With Anxiety and Phobias is a special report from Harvard Medical School that provides up-to-date information on these treatments, as well as information on the many types of anxiety disorders, their symptoms, causes, and getting a proper diagnosis.

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