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SSRI usually preferred in cases of significant SSRI-responsive comorbidities, especially significant depression.

‡--This strategy makes the most sense when the patient has had at least a partial response to the first SSRI and the main problem has been side effects rather than lack of efficacy.

CBT, a form of psychotherapy that is usually short-term and focused on symptom resolution through the observation and change of cognitive distortions and their subsequent behaviors, should be encouraged in patients with panic disorder.

The basic premise of CBT is that internal cognitive distortions (e.g., “My heart is beating too fast,” or “I’m going to die.”) are linked with maladaptive behaviors (e.g., fleeing a crowded room), which are then reinforced because this behavior usually temporarily reduces anxiety.19The gains made with CBT tend to be maintained after the treatment is discontinued, which is generally not the case for pharmacotherapy.10 The high initial cost for the treatment may be offset by savings in the cost of long-term medications.

Following are several strategies to help patients overcome resistance to therapy.

Most patients should receive one half of the usual beginning dose of SSRIs and TCAs that would be prescribed for the treatment of depression.15 For patients who have had negative experiences with other medications or who seem unusually apprehensive, one fourth of the usual beginning dose can be used. Cost to the patient will be higher, depending on prescription filling fee Based on the lowest average wholesale price for a one-month supply (without splitting tablets) for the range of dosages typically used to treat panic disorder. Cost to the patient will be higher, depending on prescription filling fee Based on the lowest average wholesale price for a one-month supply (without splitting tablets) for the range of dosages typically used to treat panic disorder.

Accordingly, the development of panic that is refractory to treatment in a patient with previously well-controlled panic disorder should prompt rescreening for these disorders.

With increasing age, patients may develop medical comorbidities that can interact with panic phenomenology to produce refractory panic symptoms.2627 have proposed guidelines for treatment selection but, except for a general preference to begin with an SSRI or CBT, the recommendations differ.

Most patients have a favorable response to SSRI therapy; however, 30 percent will not be able to tolerate these drugs or will have an unfavorable or incomplete response.

Unfortunately, there are no controlled trials to guide the next therapeutic selection.18 The recommendations of these groups and the authors’ clinical experience are synthesized in the algorithm presented in View/Print Figure FIGURE 1.

Algorithm for sequencing treatment for panic disorder.

§--Augmentation is often preferred if the patient has had at least a partially favorable response to therapy.

//--Allow at least two weeks (five weeks for fluoxetine [Prozac]) between dosing with other antidepressants and MAOIs. Algorithm for sequencing treatment for panic disorder.

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Anecdotally, self-help groups like Agoraphobics in Motion, 1719 Crooks Rd., Royal Oak, MI 48067; telephone: 248-547-0400, can be inexpensive and helpful.22 Patients with panic disorder commonly have other comorbidities including mood and anxiety disorders, and substance use.23 Because these disorders may be associated with panic attacks and anticipatory anxiety23 and may require distinct treatments,4 the diagnosis of panic disorder should consistently trigger a systematic search for other anxiety disorders.22 Because the common comorbidities of panic disorder respond differentially to antipanic treatments, knowledge of these comorbidities also helps in treatment selection. I.),24 which takes less than 20 minutes to complete, is a more effective screening tool.

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