Panic disorder: A review of treatment options

BACKGROUND

Panic disorder (PD) is a devastating illness, with numerous patients experiencing significant functional disability and many not achieving full remission with first-line pharmacologic and psychotherapeutic treatments.

METHODS

A search of PubMed, Cochrane Library, and PsychINFO databases was used to identify publications focused on evidence-based treatment of PD.

RESULTS

Selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines are standard first-line pharmacologic treatments for PD. Many other antidepressants can be considered as alternatives to SSRIs, including serotonin-norepinephrine reuptake inhibitors, serotonin multimodal agents, tricyclic antidepressants, monoamine oxidase inhibitors, and mirtazapine. Certain anticonvulsants and antipsychotics may be helpful; however, the evidence base is limited. Buspirone, beta blockers, and hydroxyzine can be considered third-line agents. Currently, there is minimal data supporting the use of electroconvulsive therapy or repetitive transcranial magnetic stimulation (rTMS). There is very little evidence justifying the use of medical cannabis or over-the-counter supplements for PD, and these treatments have risk for adverse effects. Research strongly supports the use of cognitive-behavioral therapy (CBT) for PD.

CONCLUSIONS

Many options exist for the management of PD. Treatments with the strongest evidence include SSRIs, other antidepressants, and CBT. Newer interventions approved for the treatment of depression, such as serotonin multimodal agents, esketamine, and rTMS, merit further investigation for use in PD.

A 6 week randomized double-blind placebo-controlled trial of ziprasidone for the acute depressive mixed state

Objective

To examine the efficacy of ziprasidone vs. placebo for the depressive mixed state in patients with bipolar disorder type II or major depressive disorder (MDD).

Methods

73 patients were randomized in a double-blinded, placebo-controlled study to ziprasidone (40-160 mg/d) or placebo for 6 weeks. They met DSM-IV criteria for a major depressive episode (MDE), while also meeting 2 or 3 (but not more nor less) DSM-IV manic criteria. They did not meet DSM-IV criteria for a mixed or manic episode. Baseline psychotropic drugs were continued unchanged. The primary endpoint measured was Montgomery- Åsberg Depression Rating Scale (MADRS) scores over time. The mean dose of ziprasidone was 129.7±45.3 mg/day and 126.1±47.1 mg/day for placebo.

Results

The primary outcome analysis indicated efficacy of ziprasidone versus placebo (p = 0.0038). Efficacy was more pronounced in type II bipolar disorder than in MDD (p = 0.036). Overall ziprasidone was well tolerated, without notable worsening of weight or extrapyramidal symptoms.

Conclusions

There was a statistically significant benefit with ziprasidone versus placebo in this first RCT of any medication for the provisional diagnostic concept of the depressive mixed state.

Trial Registration

Clinicaltrials.gov NCT00490542