Pharmacological Treatment Of Panic Disorder Research Articles

Efficacy of Aerobic Exercise Added to Alprazolam in Panic Disorder Treatment: Clinical Randomized Trial

Objective: The purpose of this study is to determine whether the combination of aerobic physical exercise and alprazolam in patients with panic disorder has a better therapeutic response than treatment with alprazolam alone. Description: We have observed in our clinical practice that patients who practiced aerobic physical exercise had faster remissions and better improvement in their treatments than those who did not. The objective is to compare the efficacy of a pharmacological monotherapy (alprazolam), which is one of the options for the pharmacological treatment of panic disorder, with another treatment such as the combination of aerobic physical exercise and alprazolam, and to determine if this combination results in a better therapeutic response. Methods: 150 outpatients with panic disorder were randomly assigned to 4 mg of alprazolam or 4 mg of alprazolam associated to a programmed aerobic exercise reaching a heart rate between 50% and 75% of their maximum. Both groups completed their treatments in 12 weeks and were scored using the Hamilton Anxiety Rating Scale (H.A.R.S./14) and the Clinical Global Impression (CGI) before the study and during weeks 1, 4, 8, and 12. Patients assigned to the pharmacological plan received 4 mg alprazolam daily for 12 weeks. Two weeks after the first interview they had their first baseline psychiatric control, where all the patients were evaluated. Then, at the same visit, all the patients were prescribed 4 mg of alprazolam. The dose was gradually increased from 1 to 4 mg throughout the first week of treatment. The test was repeated during weeks 2, 4, 8 and 12. Patients assigned to exercise had to pass an ergometric test to determine their functional capacity expressed in METs for future indication of exercise. Two weeks after the first interview they had their first baseline psychiatric control and at the same time a 4 mg dose of alprazolam was prescribed, gradually increased from 1 to 4 mg along the first week of treatment. The test was repeated during weeks 2, 4, 8 and 12. Then they followed a protocolized aerobic exercise plan for this study for 12 weeks. The type of exercise consisted of a brisk walk for 30 minutes divided into stages. After each stage, the patient must control his own heart frequency, which must be between 50 and 75% of its maximum to ensure an aerobic condition (according yo American Cardiological Association criteria) Results: 106 of the 150 selected patients managed to fulfill both treatments: 51 for the alprazolam + exercise group (dropout rate 32%) and 55 for the alprazolam group (dropout rate 27 %). The group treated with alprazolam + exercise experienced a significant improvement (p < 0.001) respect to the group treated only with alprazolam, reaching lower Hamilton Anxiety Scale scores (4,16 ± 1,06 and 8.57 ± 2,39 respectively) and Global Clinical Evaluation scores (Severity 1,86 ± 0,60 and 2.71 ± 0,62 ; Improvement 2,19 ± 0,49 and 2,87 ± 0,63 respectively for each group). Also, the remission rates were higher for the first group. Conclusion: Aerobic physical exercise in addition to pharmacological treatment (alprazolam) is more effective than the alprazolam treatment alone, and could be a useful alternative to treat this disorder.

Effects of the adjunctive treatment of antidepressants with opiorphin on a panic-like defensive response in rats

BackgroundAntidepressants are the first-choice for pharmacological treatment of panic disorder. However, they present disadvantages, such as delayed therapeutic effect, many side effects and a considerable rate of non-responders. These shortcomings prompt the development of new therapeutic strategies. Among these are the adjunctive use of enkephalinase inhibitors, such as opiorphin, which supposedly acts by increasing the availability of brain enkephalins and other endogenous opioids. AimsWe here evaluated whether opiorphin in the dorsal periaqueductal grey matter (dPAG), a key panic-related area, accelerates and/or facilitates the antipanic-like effect of fluoxetine or imipramine. We also verified whether the panicolytic effect of imipramine depends on activation of μ-opioid receptors (MORs). MethodsMale Wistar rats were submitted to the escape task of the elevated T-maze, an index of panic attack, after treatment with imipramine (3, 7 or 21 days) or fluoxetine (3, 7, 14 or 21 days), combined with an intra-dPAG injection of opiorphin. ResultsOpiorphin facilitated and accelerated the panicolytic-like effect caused by imipramine, but not with fluoxetine. The antipanic-like effect caused by chronic imipramine did not depend on MOR activation in the dPAG. ConclusionCombined treatment of antidepressant drugs with opiorphin for hastening or potentiating the effects of the former compounds may not be generally effective, with the results varying depending on the type/class of these panicolytic drugs.

Current pharmacological interventions in panic disorder.

The aim of this review was to summarize the recent evidences regarding the pharmacological treatment of panic disorder (PD). The authors performed a review of the literature regarding the pharmacological treatment of PD since the year 2000. The research done in the last decade brought strong evidences of effectiveness for paroxetine, venlafaxine, sertraline, fluvoxamine, citalopram, fluoxetine, clonazepam, and the relatively novel agent escitalopram. There are evidences indicating that the other new compounds inositol, duloxetine, mirtazapine, milnacipran, and nefazodone have antipanic properties and may be effective compounds in the treatment of PD. The effectiveness of reboxetine and anticonvulsants is a subject of controversy. In addition to selective serotonin reuptake inhibitors and serotonin and noradrenaline reuptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors, benzodiazepines and atypical antipsychotics may be valid alternatives in the treatment of PD. Recent data indicate that augmentation strategies with aripiprazole, olanzapine, pindolol or clonazepam may be effective. D-cycloserine is a promising agent in the augmentation of cognitive behavioral therapy.

Combination Psychological and Pharmacological Treatments for Panic Disorder

Several well-supported monotherapies exist for panic disorder; however, data are complex regarding the efficacy of combination treatment strategies for this disorder. Some meta-analytic evidence provides support for the implementation of combination psychotherapeutic and pharmacologic treatment for panic disorder. This review also considers several limitations to combination methods of treatments, such as long-term effects, treatment adherence, costs of combined treatments, treatment interference effects, and maintenance of treatment gains. Sequential approaches to combined treatments offer another viable option with stronger support in the literature, particularly when used to aid discontinuation of medications. Novel approaches to combined treatments, such as the use of cognitive enhancers, will also be considered. Finally, we will discuss clinical considerations and implementation of the combination form of therapy.

Pharmacological treatment of panic disorder.

A comprehensive database has developed and precise recommendations can be provided for treating patients with panic disorder. Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are standard treatments for panic disorder. Tricyclic antidepressants are as effective as modern antidepressants, but less well tolerated. For short-term treatment and in non-responsive cases, benzodiazepines such as alprazolam may be used when the patient does not have a history of dependency and tolerance. Combining drug treatment with cognitive behaviour therapy is the most successful treatment strategy for panic disorder. This chapter also includes treatment recommendations for pregnant or lactating women, children, adolescents, elderly patients, and patients who are non-responsive to standard treatments.

New treatment options for panic disorder: clinical trials from 2000 to 2010

Introduction: Panic disorder (PD) is a prevalent psychiatric disorder characterized by unexpected and recurrent panic attacks. PD patients present significant psychosocial impairment and a high risk of psychiatric comorbidities and suicide. PD should be treated effectively as soon as the symptoms emerge because the longer these patients remain without treatment, the worse the prognosis will be.Areas covered: The authors carried out a systematic review of the literature regarding the pharmacological treatment of PD in the last 10 years. Only open studies, placebo-controlled studies or comparative clinical trials were selected.Expert opinion: Compounds with reported effectiveness in the treatment of PD included tricyclic antidepressants, benzodiazepines, serotonin selective reuptake inhibitors (SSRIs), serotonin and noradrenaline reuptake inhibitors (SNRIs) and other drugs. SSRIs and SNRIs are the first-line compounds in the treatment of PD. These drugs were better tolerated than tricyclics and benzodiazepines as they had a low risk of dependence and overdosing complications. The serotonergic, noradrenergic and GABAergic pathways play a major role in the fear network and in the physiopathology of PD. A better understanding of the role of these neurotransmitter systems in PD will allow the development of more effective drugs for this psychiatric condition.

Selective serotonin-reuptake inhibitors in the treatment of panic disorder: a systematic review of placebo-controlled studies

The selective serotonin-reuptake inhibitors are widely used in clinical practice in the treatment of panic disorder (PD). This article undertakes an up-to-date, systematic review of the published double-blind, placebo-controlled, randomized, short-term studies with currently available selective serotonin-reuptake inhibitors in the treatment of PD. Sertraline, paroxetine, citalopram, escitalopram, fluoxetine and fluvoxamine have all been proven to be superior to pill-placebo, although the placebo effect has been shown to be extremely important in patients with PD. The authors also explore the anxiolytic mechanism of action of this antidepressant drug class and the preclinical studies that are being developed to clarify the etiopathogenic mechanisms of PD and, more precisely, the role of the serotoninergic system in this pathogenesis. These steps are considered fundamental for the improvement of pharmacological treatment of PD.

Relapse Following Combined Treatment Discontinuation in a Placebo-Controlled Trial for Panic Disorder

A recent double-blind, placebo-controlled trial (Barlow et al., 2000 JAMA. 283:2529-2536) examined separate and synergistic effects of psychological and pharmacological treatments for panic disorder. One finding warranting further investigation involved relatively high relapse rates of participants who received cognitive-behavioral therapy (CBT) + imipramine when compared with those receiving CBT + placebo. In this article, we investigate why CBT was less effective in protecting against relapse for individuals in the active drug condition. We hypothesized that participants correctly deduced treatment assignments and, for those taking imipramine, this was associated with the belief that they were no longer taking active drug after discontinuation, accounting for increased relapse rates. Contrary to hypothesis, there were no group differences in frequencies of guessing drug or placebo, nor were specific beliefs about taking drug or placebo differentially associated with relapse. Other possible reasons for differential relapse rates and treatment implications are discussed.

Do Medications Matter in the Context of Cognitive Behavior Therapy for Panic Disorder?

Patients with panic disorder are frequently medicated when they participate in psychotherapy such as cognitive behavioral therapy (CBT). The present study examined the effects of overall medication status, medication type (benzodiazepine versus antidepressant), and medication dose in a large sample of patients with panic disorder (N=178) participating in CBT. Overall, medications exhibited very little effect on outcome. After controlling for the effects of CBT, however, taking higher doses of antidepressants was associated with poorer end-state functioning. Results are discussed in relation to better understanding the role of combining psychopharmacological and psychosocial treatments for panic disorder. Keywords: panic disorder; medication; cognitive behavioral therapy, treatment Epidemological evidence suggests that panic disorder (PD) afflicts millions (Kessler et al., 1994). Individuals with PD experience marked impairment (Simon et al., 2002) and are at an increased risk for alcohol use disorders (Otto, Pollack, Sachs, O'Neil, & Rosenbaum, 1992), smoking (see Zvolensky, Schmidt, & Stewart, 2003, for review), and suicide attempts (Schmidt, Woolaway-Bickel, & Bates, 2001). Fortunately, efficacious treatments for PD are available including several types of pharmacotherapies as well as cognitive behavioral therapy (CBT) (Schmidt, Koselka, & Woolaway-Bickel, 2001). Antidepressants such as monoamine oxidase inhibitors (MAOIs), tricydic antidepressants (TCAs), and serotonin selective reuptake inhibitors (SSRIs) are among the psychotropics that have demonstrated the highest levels of efficacy in the treatment of PD (see Schmidt, 1999, for review). Antidepressants have become the medication of choice in the pharmacological treatment of PD, reducing panic-related symptoms without causing the withdrawal and dependency that can occur with benzodiazepines. Yet, benzodiazepines are appealing hi that they provide more rapid anxiolytic effects and therefore continue to also serve as a common treatment for PD. In terms of psychotherapy, research has consistently demonstrated that CBT is one of the most efficacious treatments for PD (see Barlow, Raffa, & Cohen, 2002, for a review). CBT for PD is a highly structured, skill-based treatment in which the therapist works with patients to modify thinking and behaviors that maintain PD. Techniques utilized in CBT include education, cognitive reappraisal, interoceptive exposure (i.e., repeated exposure to bodily sensations associated with the fear response), in vivo exposure (i.e., repeated exposure to external situations connected to the fear response), and breathing control techniques. The efficacy of both psychopharmacology and psychosocial treatments for mental disorders has led some to assume that combined treatments, in which psychotherapy is coupled with pharmacotherapy, may be superior to singular ones. In fact, over half of patients receiving mental health services have been found to receive a combination of psychotherapy and medication (Pincus et al., 1999). In the case of PD, the majority of patients presenting for psychosocial treatments are medicated. It is therefore critical to determine the effects of medication use on psychosocial treatment for PD. Overall, there is little work on the combined effects of medication and CBT for PD. Among the antidepressants, there is some support for the short-term superiority of the combination of CBT plus fluvoxamine (de Beurs, van Balkom, Lange, Koele, & van Dyck, 1995) and CBT plus paroxetine (Stein, Norton, Walker, Chartier, & Graham, 2000) relative to CBT alone or CBT plus placebo. However, evidence suggests that the preliminary benefits of combining antidepressants with psychosocial treatments are often lost during follow-up and that combined treatment may actually result in poorer long-term outcome. In the case of CBT plus imipramine, Barlow, German, Shear, and Woods (2000) found that the combined treatment resulted in better initial outcome, but CBT alone predicted the best outcome at 6-month follow-up. …

The pharmacotherapy of panic disorder.

Panic disorder is common and associated with significant morbidity and dysfunction. The pharmacologic treatment of panic disorder is aimed at reducing or eliminating panic attacks, avoidance behavior, anticipatory anxiety, and comorbid conditions--and substantially improving and normalizing overall function and quality of life. Antidepressants and benzodiazepines remain the current mainstays of pharmacotherapy for panic disorder, although other novel agents and strategies are becoming available and may add effective alternatives to the therapeutic armamentarium.

Physical, Mental, and Social Catastrophic Cognitions as Prognostic Factors in Cognitive-Behavioral and Pharmacological Treatments for Panic Disorder.

The authors explored the prognostic value of 3 different types of catastrophic cognitions in the treatment of panic disorder with and without mild-to-moderate agoraphobia using a sample of 143 participants who received either cognitive-behavioral therapy (CBT) or imipramine in a randomized controlled trial. Stronger fears of social catastrophes both prior to and following treatment with CBT or imipramine were associated with a poorer outcome. In contrast, cognitions involving physical or mental catastrophes were unrelated to outcome, regardless of whether these thoughts were measured prior to or following treatment. These findings are consistent with the notion that although the intensity of physical catastrophe cognitions may best discriminate between panic disorder and other anxiety disorders, it is the intensity of social catastrophe cognitions that is most closely tied to success in treating this disorder.

Use of Psychotropic Medications for Patients With Office Visits Who Receive a Diagnosis of Panic Disorder

We sought to examine trends in the medication management of panic disorder from a nationally representative sample of visits to psychiatrists and primary care physicians in office-based practice. We analyzed physician-reported data from the 1992-1995 and 1996-1999 National Ambulatory Medical Care Survey, focusing on medication management of panic disorder by primary care physicians and psychiatrists. Rates for which doctors prescribed medication for patients with a diagnosis of panic disorder were compared over the course of time to identify changes in medication management between physician groups. We used logistic regression models to identify predictors of medication prescription, adjusting for the presence of other covariates. Both physician groups prescribed a psychotropic medication to a majority of patients for panic disorder in each time period. In 1992-1995, primary care physicians were less likely than psychiatrists to prescribe psychotropic medications. This difference was not evident in 1996-1999. The prescribing of benzodiazepines was common in both physician groups and time periods. Overall rates of psychotropic prescriptions by physician groups converged over time, although no single drug class accounted individually for the convergence. In recent years, changes in the medication management of patients with panic disorder by primary care physicians have resulted in greater similarity with the pharmacologic treatment of panic disorder provided in psychiatric practice.

Changes in anxiety sensitivity with pharmacotherapy for panic disorder

Fear of anxiety symptoms (anxiety sensitivity) has been implicated in the etiology and maintenance of panic disorder, and has been shown to improve with cognitive-behavioral treatment. The impact of pharmacotherapy on anxiety sensitivity is less clear. We administered the Anxiety Sensitivity Index (ASI) during a 12-week randomized controlled trial investigating the relative efficacy of paroxetine, paroxetine plus sustained clonazepam, and paroxetine plus brief clonazepam for patients with panic disorder. We found a mean reduction in ASI scores of 9.6 points, which correlated with symptomatic improvement, and did not differ significantly between groups. Our data provides further evidence that pharmacotherapy leads to significant acute reductions in fears of anxiety symptoms in patients with panic disorder, albeit at levels that may be somewhat less than the changes associated with CBT. Implications of these findings are discussed relative to optimizing pharmacologic treatment of panic disorder.

Pharmacological treatment of panic disorder

In the early 1960s, a pivotal study showed that imipramine was effective in reducing panic attacks (Klein and Fink, 1962). This discovery was instrumental in the subsequent delineation and nosological differentiation of panic disorder from the old concept of anxiety neurosis, and ushered the treatment of the condition into the modern era of psychopharmacology.

Panic Disorder: Cognitive Behavioral and Pharmacological Treatment Strategies

The past decade has seen significant advances in both psychosocial, notably cognitive behavioral (CBT), and pharmacological treatments for panic disorder. Given the widely acknowledged efficacy of both forms of treatment, it is reasonable to consider that the combination of approaches should yield an extremely potent strategy to treating panic disorder. The present report summarizes scientific evidence for the singular and combined treatment approaches to panic disorder. Data across studies indicate that combined treatments yield immediate and short-term benefits above those provided by either pharmacologic treatment or CBT alone. In the long-term, however, these benefits disappear. In fact, the combination of benzodiazepines and CBT appears to produce poorer end-state functioning than CBT alone. Other data indicate that the sequencing of pharmacotherapy and CBT may be useful for benzodiazepine fading. Although these data are preliminary, combined treatments do not appear to be the treatment of choice for patients with panic disorder. Treatment algorithms are suggested based on existing data.

Psychopharmacological Treatment of Panic Disorder

Social workers can use pharmacological knowledge in collaboration with physicians to treat individuals who suffer from panic disorder and panic disorder with agoraphobia. An overview of research and clinical findings is provided on the pharmacological treatment of panic disorder, including information about types of appropriate medication and their dosages, efficacy, side effects, and assessment of medication effects. Recent developments in the treatment of panic disorder are presented that favor the use of selective serotonin reuptake inhibitors (SSRIs) over other medications because of their efficacy and less adverse side effects. Further controlled research is required to determine the long-term effects of SSRIs and to confirm their superiority over benzodiazepines (BZDs), tricyclic antidepressants (TCAs), and monoamine oxidase inhibi tors (MAOIs) The use of alternative treatments, including cognitive behavior therapy, alone or m conjunction with psychotropic medications in treating panic disorder, is also discussed.

A risk-benefit assessment of pharmacological treatments for panic disorder.

Panic disorder, a psychiatric disorder characterised by frequent panic attacks, is the most common anxiety disorder, affecting 2 to 6% of the general population. No one line of treatment has been found to be superior, making a risk-benefit assessment of the treatments available useful for treating patients. Choice of treatment depends on a number of issues, including the adverse effect profile, efficacy and the presence of concomitant syndromes. Tricyclic antidepressants (TCAs) are beneficial in the treatment of panic disorder. They have a proven efficacy, are affordable and are conveniently administered. Adverse effects, including jitteriness syndrome, bodyweight gain, anticholinergic effects and orthostatic hypotension are commonly associated with TCAs, but can be managed successfully. Selective serotonin (5-hydroxytryptamine; 5HT) reuptake inhibitors are also potential first line agents and are well tolerated and effective, with a favourable adverse effects profile. There is little risk in overdose or of anticholinergic effects. Adverse effects include sedation, dyspepsia and headache early in treatment, and sexual dysfunction and increased anxiety, but these can be effectively managed with proper dosage escalation and management. Benzodiazepines are an effective treatment, providing short-term relief of panic-related symptoms. Patients respond to treatment quickly, providing rapid relief of symptoms. Adverse effects include ataxia and drowsiness, and cognitive and psycho-motor impairment. There are reservations over their first-line use because of concerns regarding abuse and dependence. Monoamine oxidase inhibitors, because of their adverse effects profile, potential drug interactions, dietary restrictions, gradual onset of effect and overdose risk, are not considered to be first-line agents. They are effective however, and should be considered for patients with refractory disease. Valproic acid (valproate sodium), while not intensively studied, shows potential for use in panic disorder. More studies are needed in this area before the available data can be confirmed. As a supplement to drug therapy, cognitive behavioural therapy is effective. It is well tolerated, and may be beneficial in certain clinical situations. Its main drawback is the time commitment and effort needed to be made by the patient.

New findings in the pharmacological treatment of panic disorder

New findings in the pharmacological treatment of panic disorder

Setting New Standards for the Pharmacological Treatment of Panic Disorder

Setting New Standards for the Pharmacological Treatment of Panic Disorder

Setting New Standards for the Pharmacological Treatment of Panic Disorder

Setting New Standards for the Pharmacological Treatment of Panic Disorder