*5.2.1.2 Efficacy of antidepressants in long-term treatment of panic disorder*

The SSRIs i.e., citalopram, fluvoxamine, paroxetine, the SNRIs venlafaxine and duloxetine and the TCAs, all remain effective in the treatment of panic disorder over the long-term [5, 15, 22, 52].

### *5.2.1.3 Side effects of antidepressants*

In order to avoid or at least alleviate adverse effects, it is recommended that the starting daily dose of antidepressant drugs be lower than the recommended effective dose, and that the daily dose increase will be gradual in the first weeks of treatment. Psycho-education of patients with panic disorder about side effects and slow onset of action of antidepressants is very important. The assessment of outcome should be made only after several weeks of treatment.

#### *5.2.1.4 Dropout rates in treatment of panic disorder with antidepressants*

During pharmacological treatment of panic disorder 18% of patients treated with SSRIs, 1–12% of patients treated with venlafaxine and about 30% of patients treated with TCAs dropout prematurely [5, 50, 64].

#### *5.2.2 Benzodiazepines*

There are a number of clinical studies, with many years of experience, which indicated that benzodiazepines are effective in treating patients with panic disorders. The benzodiazepines are superior to placebo in the acute phase treatment of panic disorder [11, 63]. They have strong effects on somatic symptoms of anxiety and sleep problems. In addition, Benzodiazepines have a fast onset of action, i.e., they produce effects as soon as an effective dose is administered. For half an hour to an hour after taking benzodiazepine, panic symptoms are reduced, and patients feel easier. No other drug can do this [11]. The correct dosage of benzodiazepine involves a gradual increase in dose to a dose that removes symptoms and does not

**123**

**Table 2.**

*Panic Attacks and Panic Disorder*

patient [47].

benzodiazepines [47].

*DOI: http://dx.doi.org/10.5772/intechopen.86898*

*5.2.2.1 Length of treatment with benzodiazepines*

cause significant adverse effects, with regular taking more than once a day. Dosage

Due to the possible occurrence of dependence and abstinence syndrome, the duration of therapy with benzodiazepines should be short, for several weeks. However, because of the chronic character of the disease, sometimes they should be administered for several months, even for a year with continuous monitoring of the

When benzodiazepines are prescribed for long-term use, dependence may occur manifested by dose escalation and problems withdrawing the medication [47, 63].

In panic disorder trials, dropout rates due to side effects are about 15% for

SSRIs and venlafaxine should both be considered first-line agents for treatment of panic disorder. SSRIs and venlafaxine are effective in acute and long-term treatment, have an acceptable side effect profile and acceptable dropout rate [16, 48, 57]. TCAs may have a slower onset than SSRIs. In addition, TCAs have a less tolerable side effect profile than SSRIs given that they have more anticholinergic effects, and are generally less safe than SSRIs. Finally, reported dropout rates are higher for

In summary, benzodiazepines as monotherapy should not be regarded as a firstline treatment in view of their side effect profile and in view of their lack of efficacy

Studies reported that more than half of the patients interrupt treatment within several months to years [62, 64]. But considering, often relapsing course of panic disorder long-term treatment is recommended [3, 7, 12, 22, 43]. Most guidelines refer to expert consensus and suggest pharmacotherapy for at least a year [6].

**Drug name Start Recommended Maximum** Alprazolam 1 2–4 6 Clonazepam 0.25–0.5 1.5–3 6 Diazepam 5–10 40–50 50 Lorazepam 1–3 2.5–7.5 10 Bromazepam 3 3–9 15

of benzodiazepines effective in panic disorder is shown in **Table 2**.

*5.2.2.2 Side effects and risks involved in treatment with benzodiazepines*

*5.2.2.3 Dropout rates in treatment with benzodiazepines*

*5.2.3 First-line pharmacotherapy of panic disorder*

*5.2.4 Optimal duration of pharmacotherapy of panic disorder*

TCAs compared to SSRIs [5, 6, 62].

in treating comorbid conditions.

*Dosage of benzodiazepines effective in panic disorder.*

**Benzodiazepines**

*5.2.1.2 Efficacy of antidepressants in long-term treatment of panic disorder*

over the long-term [5, 15, 22, 52].

*Dosage of antidepressants effective in panic disorder.*

Antidepressants SSRIs (mg/day)

SNRIs

TCAs

**Table 1.**

*5.2.1.3 Side effects of antidepressants*

*5.2.2 Benzodiazepines*

should be made only after several weeks of treatment.

treated with TCAs dropout prematurely [5, 50, 64].

*5.2.1.4 Dropout rates in treatment of panic disorder with antidepressants*

The SSRIs i.e., citalopram, fluvoxamine, paroxetine, the SNRIs venlafaxine and duloxetine and the TCAs, all remain effective in the treatment of panic disorder

**Drug name Start Recommended Maximum**

Citalopram 10 20–40 40 Escitalopram 5 10–20 20 Fluoxetine 10 20–40 60 Paroxetine 10 20–40 60 Sertraline 50 50–100 150

Venlafaxine 37.5 75–225 300 Duloxetine 30 60–120 120

Clomipramine 25 100–150 250 Imipramine 25 100–150 300

In order to avoid or at least alleviate adverse effects, it is recommended that the starting daily dose of antidepressant drugs be lower than the recommended effective dose, and that the daily dose increase will be gradual in the first weeks of treatment. Psycho-education of patients with panic disorder about side effects and slow onset of action of antidepressants is very important. The assessment of outcome

During pharmacological treatment of panic disorder 18% of patients treated with SSRIs, 1–12% of patients treated with venlafaxine and about 30% of patients

There are a number of clinical studies, with many years of experience, which indicated that benzodiazepines are effective in treating patients with panic disorders. The benzodiazepines are superior to placebo in the acute phase treatment of panic disorder [11, 63]. They have strong effects on somatic symptoms of anxiety and sleep problems. In addition, Benzodiazepines have a fast onset of action, i.e., they produce effects as soon as an effective dose is administered. For half an hour to an hour after taking benzodiazepine, panic symptoms are reduced, and patients feel easier. No other drug can do this [11]. The correct dosage of benzodiazepine involves a gradual increase in dose to a dose that removes symptoms and does not

**122**

cause significant adverse effects, with regular taking more than once a day. Dosage of benzodiazepines effective in panic disorder is shown in **Table 2**.
