Clinical Question

Is treatment with medication effective for patients with panic disorder?

Bottom Line

In a body of evidence plagued by poorly designed studies of short duration, selective serotonin reuptake inhibitors (SSRIs) show the best balance of effectiveness vs. risk. The analysis did not give a comparison of medication with psychotherapy, although a meta-analysis of limited research was unable to document a benefit of one over the other. (Level of Evidence = 1a−)

Synopsis

The researchers identified randomized controlled trials that evaluated medications to treat panic disorder (with or without agoraphobia) by searching three databases as well as reference lists of identified studies and meta-analyses. They included 87 studies published in any language that included a total of 12,800 participants and 12 drug classes, with two researchers independently selecting studies for inclusion and abstracting the data. Only one study was at low risk of bias, and all studies were of short duration (12 weeks or less). The other studies had problems with randomization and allocation concealment (which could affect outcomes) or were at risk of selectively reporting outcomes (many studies were conducted before registration of study protocols was a standard practice). The authors used network meta-analysis, a method of comparing different drug treatments when they were not studied in head-to-head trials. Evaluating the effect on remission, which was defined as no panic attacks for at least one week by the end of the study, all drug classes studied were more effective than placebo, with benzodiazepines, tricyclic antidepressants, and SSRIs, in that order, as the three best treatments for remission. All three drug classes were associated with an increased likelihood of adverse effects, with SSRIs having the least likelihood. Among the SSRIs, sertraline (Zoloft) and escitalopram (Lexapro) were associated with high remission and low risk of adverse events.