Choosing initial treatment for individuals with panic disorder with or without agoraphobia*^¶Δ

SSRI: selective serotonin reuptake inhibitor; CBT: cognitive-behavioral therapy.

* This algorithm assumes that the individual does not have active suicidal ideation, plan, or intent.

¶ In some cases, symptoms of panic disorder do not cause significant psychosocial distress or interfere with functioning. These individuals may reasonably elect to forego treatment and monitor symptoms.

Δ We treat all individuals with comorbid disorders (eg, major depression, posttraumatic stress disorder, anxiety) with an SSRI plus CBT. We take into account patient preference in all treatment decisions.

◊ In cases with extreme stress, where the individual is unable to wait for medications to take effect, we treat with intensive CBT (eg, twice weekly or more) providing psychoeducation and support.

§ In cases when the individual is unable to wait one to two weeks (eg, due to severe symptoms), we move on to the next treatment decision more rapidly.

¥ Refer to UpToDate content (and associated algorithm) for subsequent treatment.

‡ We prefer gabapentin over pregabalin due to its lower likelihood for misuse than pregabalin. Mirtazapine is a reasonable alternative agent for individuals with prominent insomnia. Refer to UpToDate content for dose and titration of each of these agents.