Cochrane Database Syst Rev

Panic therapy: What’s the evidence on pharmacologic treatments?

January 1, 2024

All medication classes studied were more effective than placebo, including TCAs, BDZs, SSRIs, SNRIs, and MAOIs, with little difference seen between drug classes. As a class, TCAs were ranked most effective, followed by BDZs and MAOIs. However, the evidence quality was generally low, and studies were short in duration. In terms of tolerability, BDZs ranked first, with a small but significantly reduced dropout rate compared with placebo; TCAs were second, followed by SNRIs, then SSRIs, and finally MAOIs.

• This network meta-analysis of 70 trials explored effectiveness and tolerability of tricyclic antidepressants (TCAs), benzodiazepines (BDZs), selective serotonin reuptake inhibitors (SSRIs), serotonin‐norepinephrine reuptake inhibitors (SNRIs), and monoamine oxidase inhibitors (MAOIs).
• Effectiveness. Strongest effects were seen with diazepam, alprazolam, clonazepam, paroxetine, venlafaxine, clomipramine, fluoxetine, and adinazolam. Among SSRIs, fluoxetine and paroxetine appeared to have stronger evidence for efficacy than did sertraline.
• Agoraphobia: Data from 26 RCTs (N=7044) showed strongest symptom reduction with citalopram, clomipramine, diazepam, escitalopram, and reboxetine.
• Remission rates. Most of the medications examined were more effective than placebo, and had clinically meaningful effects, specifically clonazepam, diazepam, desipramine, fluoxetine, fluvoxamine, imipramine, paroxetine, venlafaxine. Of these, alprazolam and desipramine ranked highest.
• Drop-out rates. Most of the medications studied were associated with similar dropout rates compared with placebo. Diazepam and alprazolam were associated with reduced dropout rates compared with placebo, ranking as most tolerated of the medications studied.
• Panic scale scores. Although brofaromine, clonazepam, and reboxetine had largest reductions compared with placebo, these results were based on either a single trial or very small trials.
• Attack frequency. Only alprazolam and clonazepam showed strong reductions in frequency compared to placebo.
• Evidence quality. Placebo-controlled studies on antidepressants were moderate of moderate quality; studies comparing BDZs with placebo and antidepressants were of low quality.
• Other treatments. Comparisons between pharmacotherapy and cognitive behavioral therapies are warranted.

Source:

Guiana, G. (2023, Nov. 28). Cochrane Database Syst. Rev. Cochrane Pharmacological treatments in panic disorder in adults: a network meta‐analysis. https://pubmed.ncbi.nlm.nih.gov/38014714/