SSRI: selective serotonin reuptake inhibitor; SNRI: serotonin-norepinephrine reuptake inhibitor; MAOI: monoamine oxidase inhibitor.
* This algorithm reviews the approach to choosing pharmacologic management of panic disorder after initial treatment (with an SSRI and initial stabilization of severe symptoms). Augmentation with cognitive-behavioral therapy is a reasonable option at any point (if not already done).
¶ We consider an adequate therapeutic trial to be four to six weeks at the maximum tolerated dose within the dose range. Refer to UpToDate content for information on medication starting doses and target dose range.
Δ Our preference is to try sequential trials of two SSRI followed by one SNRI (ie venlafaxine) for those with minimal to no response to adequate medication trials. Refer to UpToDate content for discussion of dose and titration of SSRIs and SNRIs.
◊ We typically treat with sequential augmentation trials in individuals with partial response. We typically switch medications sequentially in individuals with minimal to no response to medications.
§ Our preference is to use the long-acting agent clonazepam. Acceptable alternative option is lorazepam. Refer to UpToDate content for dose and titration of benzodiazepines.
¥ Limited data support these agents in the treatment of panic disorder.‡ Individuals must be able to adhere to medication and dietary restrictions. MAOIs cannot be used concurrently with SSRIs/SNRIs/tricyclic antidepressants. Adequate wash-out period prior to beginning MAOI is based on half-life of medication discontinuing. Refer to UpToDate content for more information on prescribing MAOI.