Fig. 19.5 Schematic representation of the time course of panic treatments.

Antidepressants (both SSRIs and TCAs) have a slower onset of action and, indeed, may induce an initial increase in both anxiety and panic frequency, such that a patient may discontinue medication, even after a single dose. This provoking reaction usually lasts for only 2-3 weeks after which panic frequency and severity improve but patients need help to stay on treatment over this period. The doctor needs to give a clear explanation of the likely course of events and the antidepressant should be started at half the usual initial dose to reduce the likelihood of exacerbation. Where the exacerbation is particularly of anxiety, a short course of a long-acting benzodiazepine can provide benefit. The dose of antidepressant required to treat panic disorder is generally as high or higher than that for depression and maximal benefit may not emerge for 8-12 weeks. Patients should therefore receive as high a dose as can be tolerated for this length of time.

If there is no response to adequate trial of an SSRI, followed by a TCA, the MAOI, phenelzine should be used at doses of up to 90 mg/d. MAOIs tend to produce less exacerbation at the beginning of treatment than the other antidepressants but can increase anxiety and panics in more sensitive individuals.

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