Treatment Pathway

Treatment of Panic Disorder

Panic disorder is characterized by recurrent unexpected panic attacks with intense physical symptoms. It often leads to persistent worry about future attacks and behavioral avoidance.

APA (American Psychiatric Association)NICE (UK)BAP (British Association for Psychopharmacology)CANMATWFSBP

Symptoms Causes Treatment When to See a Doctor Related Questions

Panic disorder is characterized by recurrent unexpected panic attacks with intense physical symptoms. It often leads to persistent worry about future attacks and behavioral avoidance.

First-Line Treatment Principles

✓Establish accurate diagnosis with standardised rating scales (PHQ-9, GAD-7, YMRS, PANSS)
✓SSRIs or SNRIs as first-line for depression, anxiety disorders, OCD, and PTSD
✓Lithium or valproate as mood stabilisers in bipolar disorder
✓Antipsychotics for schizophrenia; clozapine for treatment-resistant cases
✓Psychotherapy (CBT, IPT, DBT) as first-line or adjunct in most psychiatric conditions

Medications Used in Panic Disorder

FluoxetineSSRI

Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used as a first-line treatment for depression, anxiety disorders, OCD, and PTSD.

SertralineSSRI

Sertraline is a selective serotonin reuptake inhibitor (SSRI) used as a first-line treatment for depression, anxiety disorders, OCD, and PTSD.

ParoxetineSSRI

Paroxetine is a selective serotonin reuptake inhibitor (SSRI) used as a first-line treatment for depression, anxiety disorders, OCD, and PTSD.

CitalopramSSRI

Citalopram is a selective serotonin reuptake inhibitor (SSRI) used as a first-line treatment for depression, anxiety disorders, OCD, and PTSD.

EscitalopramSSRI

Escitalopram is a selective serotonin reuptake inhibitor (SSRI) used as a first-line treatment for depression, anxiety disorders, OCD, and PTSD.

FluvoxamineSSRI

Fluvoxamine is a selective serotonin reuptake inhibitor (SSRI) used as a first-line treatment for depression, anxiety disorders, OCD, and PTSD.

Non-Pharmacological Management

•Psychotherapy: CBT for depression, anxiety, OCD, PTSD; DBT for borderline PD; ACT for chronic conditions
•Regular aerobic exercise: 150 min/week — reduces depression scores comparably to antidepressants in mild-moderate MDD
•Sleep hygiene: critical in depression, bipolar, and anxiety — circadian rhythm stabilisation
•Alcohol and substance avoidance: major driver of psychiatric deterioration
•Social support and peer support groups
•Mindfulness-based cognitive therapy (MBCT) to prevent MDD relapse
•Crisis planning: safety plan, emergency contacts, medication access

Treatment Goals

🎯Remission: PHQ-9 <5, GAD-7 <5; minimal/no symptoms for ≥2 months

🎯Functional recovery: return to work/study and social functioning

🎯Relapse prevention: maintenance therapy in recurrent disorders

🎯Quality of life improvement — patient-reported outcomes

🎯Safety: minimise suicide risk; substance use recovery

Monitoring Parameters

◆Validated symptom scales: PHQ-9 (depression), GAD-7 (anxiety), MADRS, YMRS — at each visit
◆Side effect monitoring: weight, metabolic parameters (antipsychotics), thyroid (lithium), LFTs (valproate)
◆Lithium levels: 5–7 days after initiation/dose change; then every 3–6 months when stable (target 0.6–1.0 mmol/L)
◆ECG: QTc monitoring with antipsychotics (ziprasidone, amisulpride, haloperidol)
◆Metabolic syndrome screening: waist circumference, BP, fasting glucose, lipids — annually on antipsychotics
◆AIMS for tardive dyskinesia (antipsychotics) — 6-monthly

Escalation Criteria

→Active suicidal ideation with intent/plan → emergency psychiatric assessment; hospitalisation if risk confirmed
→Psychotic relapse in schizophrenia → urgent psychiatric review; consider clozapine if ≥2 antipsychotic failures
→Bipolar manic episode → inpatient; optimise mood stabiliser; antipsychotic augmentation
→Treatment-resistant depression (≥2 failed SSRI trials) → augmentation (lithium, aripiprazole), referral, TMS/ECT consideration

Special Populations

Pregnancy: SSRIs (sertraline preferred) generally acceptable; avoid paroxetine (cardiac defects); valproate contraindicated; specialist review

Elderly: lower starting doses; risk of QTc prolongation; avoid TCA (anticholinergic); falls risk with sedating agents

Adolescents: black-box warning — monitor for suicidality in first weeks of antidepressant treatment

Intellectual disability: behavioural approaches first-line; medication at lower doses; monitor for hidden side effects

Clinical Insights

Differential Diagnosis

Conditions that mimic Panic Disorder — key distinguishing features & tests

Evidence & Guidelines

Clinical trials, guideline strength, and treatment recommendations

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