Evidence-based pharmacotherapy for panic disorder

Ho-Suk Suh

doi:10.5124/jkma.2010.53.10.913

J Korean Med Assoc > Volume 53(10); 2010 > Article

Suh: Evidence-based pharmacotherapy for panic disorder

Pharmacotherapeutics

Journal of the Korean Medical Association

Journal of the Korean Medical Association 2010; 53(10): 913-921.

Published online: October 11, 2010

DOI: http://dx.doi.org/10.5124/jkma.2010.53.10.913

Evidence-based pharmacotherapy for panic disorder

Ho-Suk Suh, MD

Department of Psychiatry, School of Medicine, CHA University, Seoul, Korea. freud@cha.ac.kr

Received September 17, 2010 Accepted September 24, 2010

This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Panic disorder is characterized by acute panic attack accompanied by autonomic symptoms such as tachycardia, sweating, dyspnea, chest pain, dizziness, and tremors, as well as anticipatory anxiety and avoidant behaviors. 30% of the general population may have suffered isolated episodes of panic attack, and epidemiologic studies have demonstrated that the lifetime prevalence of panic disorder is around 4.8%. Panic disorder is commonly comorbid with the other psychiatric disorders, and 30% of patients with panic disorder show treatment resistance and a chronic waxing and waning course. Therefore, adequate treatment guidelines and strategies for panic disorder by evidence-based pharmacotherapy are needed and some treatment guidelines for panic disorder have already been developed in foreign countries. In this article, among the foreign guidelines for the pharmacological treatment of panic disorder, those by World Federation of Societies of Biological Psychiatry (WFSBP) in particular were reviewed. Also, the recently developed Korean Medication Algorithm Project for Panic Disorder 2008 by the Korean Academy of Anxiety Disorder was reviewed.

Panic disorder; Pharmacotherapy; Algorithm; Evidence-based medicine

References

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders 1980;3rd edn. Washington, DC: American Psychiatric Association. 230-232.

2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders 1994;4th edn. Washington, DC: American Psychiatric Association. 393-444.

3. Kessler RC, Chiu WT, Jin R, Ruscio AM, Shear K, Walters EE. The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2006;63:415-424.

4. van Balkom AJ, van Boeijen CA, Boeke AJ, van Oppen P, Kempe PT, van Dyck R. Comorbid depression, but not comorbid anxiety disorders, predicts poor outcome in anxiety disorders. Depress Anxiety 2008;25:408-415.

5. Katsching H, Amering M. The long-term course of panic disorder and its predictor. J Clin Psychopharmacol 1998;18:6-11.

6. Pollack MH, Otto MW, Tesar GE, Cohen LS, Melzter Brody S, Rosenbaum JF. Long-term outcome after acute treatment with alprazolam and clonazepam for panic disorder. J Clin Psychopharmacol 1993;13:257-263.

7. Marchesi C, Cantoni A, Fontó S, Giannelli MR, Maggini C. Predictors of symptom resolution in panic disorder after one year of pharmacological treatment: a naturalistic study. Pharmacopsychiatry 2006;39:60-65.

8. American Psychiatric Association. Practice guideline for the treatment for patients with panic disorder. Work Group on Panic Disorder. American Psychiatric Association. Am J Psychiatry 1998;155:1-34.

9. Baldwin DS, Anderson IM, Nutt DJ, Bandelow B, Bond A, Davidson JR, den Boer JA, Fineberg NA, Knapp M, Scott J, Wittchen HU. British Association for Psychopharmacology. Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2005;19:567-596.

10. Canadian Psychiatric Association. Clinical practice guidelines. Management of anxiety disorders. Can J Psychiatry 2006;51:9S-91S.

11. Executive Committee for Korean Medication Algorithm for Panic Disorder. Korean medication algorithm project for panic disorder 2008 2008;Seoul: ML Communication.

12. National Institute for Clinical Excellence, NICE. Clinical guideline 22, Management of anxiety (panic disorder, with or without agoraphobia, and GAD) in adults in primary, secondary and community care 2007.

13. Bandelow B, Zohar J, Hollander E, Kasper S, Möller HJ. WFSBP Task Force on Treatment Guidelines for Anxiety, Obsessive-Compulsive and Post-Traumatic Stress Disoders. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders-first revision. World J Biol Psychiatry 2008;9:248-312.

14. Mavissakalian M, Perel JM. Protective effects of imipramine maintenance treatment in panic disorder with agoraphobia. Am J Psychiatry 1992;149:1053-1057.

15. Pollack MH, Allgulander C, Bandelow B, Cassano GB, Greist JH, Hollander E, Nutt DJ, Okasha A, Swinson RP. World Council of Anxiety. WCA recommendations for the long-term treatment of panic disorder. CNS Spectrums 2003;8:17-30.

16. Hirschmann S, Dannon PN, Iancu I, Dolberg OT, Zohar J, Grunhaus L. Pindolol augmentation in patients with treatment-resistant panic disorder: A double-blind, placebo-controlled trial. J Clin Psychopharmacol 2000;20:556-559.

17. Tiffon L, Coplan JD, Papp LA, Gorman JM. Augmentation strategies with tricyclic or fluoxetine treatment in seven partially responsive panic disorder patients. J Clin Psychiatry 1994;55:66-69.

18. Etxebeste M, Arags E, Malo P, Pacheco L. Olanzapine and panic attacks. Am J Psychiatry 2000;157:659-660.

19. Sepede G, De Berardis D, Gambi F, Campanella D, La Rovere R, D'Amico M, Cicconetti A, Penna L, Peca S, Carano A, Mancini E, Salerno RM, Ferro FM. Olanzapine augmentation in treatment-resistant panic disorder: a 12-week, fixed-dose, open-label trial. J Clin Psychopharmacol 2006;26:45-49.

20. Hollifield M, Thompson PM, Ruiz JE, Uhlenhuth EH. Potential effectiveness and safety of olanzapine in refractory panic disorder. Depress Anxiety 2005;21:33-40.

21. Bandelow B, Rüther E. Treatment-resistant panic disorder. CNS Spectr 2004;9:725-739.

22. Heldt E, Manfro GG, Kipper L, Blaya C, Maltz S, Isolan L, Hirakata VN, Otto MW. Treating medication-resistant panic disorder: predictors and outcome of cognitive-behavior therapy in a Brazilian public hospital. Psychother Psychosom 2003;72:43-48.

23. Pollack MH, Otto MW, Kaspi SP, Hammerness PG, Rosenbaum JF. Cognitive behavior therapy for treatment-refractory panic disorder. J Clin Psychiatry 1994;55:200-205.

24. Hoffart A, Due Madsen J, Lande B, Gude T, Bille H, Torgersen S. Clomipramine in the treatment of agoraphobic inpatients resistant to behavioral therapy. J Clin Psychiatry 1993;54:481-487.

25. Kampman M, Keijsers GP, Hoogduin CA, Hendriks GJ. A randomized, double-blind, placebo-controlled study of the effects of adjunctive paroxetine in panic disorder patients unsuccessfully treated with cognitive-behavioral therapy alone. J Clin Psychiatry 2002;63:772-777.

26. Gilbert DA, Altshuler KZ, Rago WV, Shon SP, Crismon ML, Toprac MG, Rush AJ. Texas medication algorithm project: definitions, rationale, and methods to develop medication algorithms. J Clin Psychiatry 1998;59:345-351.

27. Woolf SH. Practice guidelines, a new reality in medicine. II. Methods of developing guidelines. Arch Intern Med 1992;152:946-952.

28. Lee SH, Yu BH, Kim CH, Yoon SC. Development of the treatment algorithm for panic disorder(1)-background, organization, principles, future plan and methods of algorithm development. Anxiety Mood 2007;3:77-90.

29. Yang JC, Kim MS, Yu BH, Yoon SC, Lee SH, Suh HS, Kim CH. Study Group for Korean Medication Algorithm Project for Panic Disorder 2008. Korean medication algorithm for panic disorder 2008: initial treatment strategies. Korean J Psychopharmacol 2009;20:32-39.

30. Suh HS, Lee SH, Kim MS, Yang JC, Kim CH, Yoon SC, Yu BH. Study Group for Korean Medication Algorithm Project for Panic Disorder 2008. Korean medication algorithm for panic disorder 2008: consensus regarding treatment strategies in cases of non-responsive and co-morbid conditions. Korean J Psychopharmacol 2009;20:40-51.

31. Kim MS, Yu BH, Kim CH, Yoon SC, Lee SH, Suh HS, Yang JC. Study Group of Korean Medication Algorithm Project for Panic Disorder 2008. Korean Medication Algorithm for Panic Disorder 2008:diagnosis, treatment response and remission of panic disorder in Korea. Anxiety Mood 2008;4:49-54.

Figure 1

Korean medication algorithm flow for panic disorder. This figure was adapted from [11].

Abbreviations: SSRI, selective serotonin reuptake inhibitor; SNRI, serotonin and norepinephrine reuptake inhibitor; BZD, benzodiazepine; TCA, tricyclic antidepressant; NaSSA, noradrenergic and specific serotonergic antidepressant.

Table 1

Categories of evidence and recommendation grades

This table was adapted from [13].

Table 2

Recommendations for the drug treatment of panic disorder

Abbreviations: SSRIs, selective serotonin reuptake inhibitor; SNRI, serotonin norepinephrine reuptake inhibitor; TCA, tricyclic antidepressant; MAOI, monoamine oxidase inhibitor.

This table was adapted from [13].

^a)Categories of evidence are only based on efficacy without regard to other properties (e.g., side effects).