Panic disorder – do the drugs work?

Mike is on the phone. He has suffered from panic attacks all his life, but over the last few months they have become much more common. They are recurrent, can be unexpected and the fear that they will happen is now making him more withdrawn, isolated, generally anxious and low and it is starting to affect his work and social life. He has read the self-help books, he has had some group CBT, he uses prn propranolol which sometimes helps but often doesn’t -  so, what next? 

We are all very aware of the huge rates of SSRI prescribing following a recent report by Public Health England which showed a staggering 17% of the population were prescribed one or more antidepressant prescriptions over the course of a year, and of the risks of side effects and the difficulty of withdrawal. So, we are increasingly reluctant to prescribe and agree that a non-drug approach is best. But if self-help and CBT are not enough, do the drugs even work for panic disorder and if so which one should we use first?

For a condition that is so common (panic disorder affects 1% to 5% of the population), the evidence base is amazingly thin. So, a new systematic review BMJ2022 and network meta-analysis of randomised controlled trials is very welcome. They combined the outcomes of 87 studies, including 13,000 patients and 12 different classes of drugs. It is a colossal piece of work and the authors need congratulating for completing it. The headlines are:

• SSRIs are highly effective – they provide high rates of remission with low reported adverse effects for panic disorder. Amongst SSRIs, sertraline and escitalopram had the best evidence base and therefore seem the best first-choice option for Mike.
• Beta-blockers alone were not effective. This will surprise many clinicians, including me, who have been prescribing propranolol first line in panic disorder for years! However, in combination with an SSRI they were top-ranked for improving anxiety and depression. So, if Mike has co-morbid anxiety and depression and SSRI alone is ineffective, the combination may be useful.
• Other drugs that are superior to placebo include SNRIs and TCAs, so these are potentially useful second line choices if the SSRI is ineffective or not tolerated.
• Not surprisingly benzodiazepines have short term efficacy, but no one would argue they are a good idea! Not surprisingly they were associated with an increased risk of adverse effects. NICE guidance is clear, benzos and sedating antihistamines should NOT be prescribed for panic disorder.

So, in conclusion, this new research suggests that SSRIs provide high rates of remission with low risk of adverse events for panic disorder. There is a caveat that, as is often the case in systematic reviews, that the trials included were mostly of low quality with low to moderate certainty of evidence. So, as ever, caution and individualised clinical judgment is needed in interpreting the results.  But if you and Mike feel a drug is the next best option, this is now the best evidence we have, and it suggests that ‘SSRIs offer important benefit with low risk for drug treatment of panic disorder’