Alternative treatments
For patients who do not respond to any of the treatments described above, data from uncontrolled studies support mirtazapine, levetiracetam, and the serotonin-norepinephrine reuptake inhibitors duloxetine and milnacipran as monotherapy for PD.17 Pindolol—a beta blocker and 5-HT1A receptor antagonist—proved superior to placebo as an adjunctive agent to SSRIs in treatment-resistant PD in 1 of 2 trials.17 Minimal evidence supports the atypical antipsychotics risperidone and olanzapine in treatment-resistant PD, although a placebo-controlled trial of quetiapine SR coadministered with SSRIs recently was completed (NCT00619892; results pending). Atypical antipsychotics are best reserved for patients with a primary psychotic disorder or bipolar disorder who experience panic attacks.5
Panic-focused psychodynamic psychotherapy, a 12-week (approximately 24 sessions) form of psychotherapy, has demonstrated superiority vs applied relaxation therapy.18 This treatment could be considered for patients who do not respond to standard first-line treatments, but few community therapists are familiar with this method.
For many patients with PD, complementary and alternative medicine (CAM) approaches are appealing. See this article at CurrentPsychiatry.com for a Box that discusses CAM for PD.
Complementary and alternative medicine for panic disorder
Although no complementary and alternative medicine treatments have strong evidence of efficacy as monotherapy for panic disorder (PD), several have data that suggest benefit with little evidence of risk. These include bibliotherapy, yoga, aerobic exercise, and the dietary supplements kava and inositol.a Exercise as a treatment poses a challenge because it can induce symptoms that the patient fears, such as tachycardia and shortness of breath. In addition to any direct physiologic benefit from aerobic exercise, there is also an exposure component that can be harnessed by gradually increasing the exertion level.
Another approach undergoing extensive evaluation is Internet-provided cognitive-behavioral therapy (CBT). Using guided CBT modules with or without therapist support, Internet-provided CBT provides an option for motivated patients unable to complete in-person CBT because of logistical factors.b A helpful resource that reviews Internet self-help and psychotherapy guided programs for PD and other psychiatric conditions is http://beacon.anu.edu.au.
References
a. Antonacci DJ, Davis E, Bloch RM, et al. CAM for your anxious patient: what the evidence says. Current Psychiatry. 2010;9(10):42-52.
b. Johnston L, Titov N, Andrews G, et al. A RCT of a transdiagnostic internet-delivered treatment for three anxiety disorders: examination of support roles and disorder-specific outcomes. PLoS One. 2011;6(11):e28079.
Maintenance treatment
Patients who complete a course of CBT for PD often follow up with several “booster sessions” at monthly or longer intervals that focus on relapse prevention techniques. Few controlled trials have evaluated pharmacotherapy discontinuation in PD. Most guidelines recommend continuing treatment for ≥1 year after achieving remission to minimize the risk of relapse.3 Researchers are focusing on whether medication dosage can be reduced during maintenance without loss of efficacy.
Treatment discontinuation
In the absence of urgent medical need, taper medications for PD gradually over several months. PD patients are highly sensitive to unusual physical sensations, which can occur while discontinuing antidepressants or benzodiazepines. If a benzodiazepine is used in conjunction with an antidepressant, the benzodiazepine should be discontinued first, so that the antidepressant can help ease benzodiazepine-associated discontinuation symptoms. A brief course of CBT during pharmacotherapy discontinuation may increase the likelihood of successful tapering.19
CASE CONTINUED: A successful switch
Ms. K has to discontinue sequential trials of fluoxetine, 40 mg/d, and venlafaxine XR, 225 mg/d because of side effects, and she does not reduce the frequency of her alprazolam use. She agrees to switch from alprazolam to clonazepam, 0.5 mg every morning and 1 mg at bedtime, and to start CBT. Clonazepam reduces her anxiety sufficiently so she can address her symptoms in therapy. Through CBT she becomes motivated to monitor her thoughts and treat them as guesses rather than facts, reviewing the evidence for her thoughts and generating rational responses. She participates in exposure exercises, which she practices between sessions, and grows to tolerate uncomfortable sensations until they no longer signal danger. After 12 CBT sessions, she is panic-free. Despite some trepidation, she agrees to a slow taper off clonazepam, reducing the dose by 0.25 mg every 2 weeks. She continues booster sessions with her therapist to manage any re-emerging anxiety. After an additional 12 weeks, she successfully discontinues clonazepam and remains panic-free.
Related Resources
- American Psychiatric Association. Panic disorder. http://healthyminds.org/Main-Topic/Panic-Disorder.aspx.
- Anxiety and Depression Association of America. Panic disorder & agoraphobia. http://adaa.org/understanding-anxiety/panic-disorder-agoraphobia.
- Mayo Clinic. Panic attacks and panic disorder. www.mayoclinic.com/health/panic-attacks/DS00338.
- National Health Service Self-Help Guides. www.ntw.nhs.uk/pic/selfhelp.
- National Institute of Mental Health. Panic disorder. www.nimh.nih.gov/health/topics/panic-disorder/index.shtml.
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