International study of expert judgment on therapeutic use of benzodiazepines and other psychotherapeutic medications: V. Treatment strategies in panic disorder, 1992-1997

The objective of this study was to assemble expert clinical experience and judgment regarding the treatment of panic disorder in a systematic, quantit ative manner, particularly with respect to changes during the past 5 years. A panel of 73 internationally recognized experts in the field of pharmacot herapy of anxiety and depression was constituted by multistage peer nominat ion. Sixty-six experts completed a questionnaire in 1992, and 51 of those c ompleted a follow-up questionnaire in 1997. This report focuses on the expe rts' responses to questions about therapeutic options as they relate to a v ignette describing a typical case of panic disorder. The preferred initial treatment strategy in 1992 (59%) and in 1997 (55%) was a combination of med ication with cognitive behavioral therapy. The vast majority of the expert panel included a medication in their recommendations-91% in 1992 and 90% in 1997. Experts recommending a medication for panic in 1992 chose as first-l ine treatment a benzodiazepine (35%), a selective serotonin reuptake inhibi tor (SSRI, 7%), an older antidepressant (33%), or a combination of medicati ons (25%), principally a benzodiazepine plus an older antidepressant (19%). In 1997, fewer chose a benzodiazepine (15%) or an older antidepressant (11 %) alone, whereas 33% chose an SSRI alone. More experts chose a combination of medications in 1997 (39%), and the increase was attributable mainly to the choice of a benzodiazepine plus an SSRI (17%). Overall, there was only a small decline in recommendations for benzodiazepines, whereas the increas ed choice of SSRIs came largely at the expense of the older antidepressants . As second-line medications for panic should their first-line choice fail, the experts in 1997 recommended a benzodiazepine (7%), an SSRI (15%), an o lder antidepressant (28%), or a combination of medications (50%), most ofte n a benzodiazepine plus an older antidepressant (21%) or a benzodiazepine p lus an SSRI (17%). (Experts were not asked to recommend second-line treatme nt in 1992.) Thus, in case of unsatisfactory response, the experts' choices shifted from benzodiazepines and SSRIs alone toward the older antidepressa nts alone or combinations of an antidepressant plus a benzodiazepine. This report concluded that combined cognitive behavioral therapy plus medication was highly favored by the experts as the initial treatment strategy for pa nic disorder. Over the past 5 years, SSRIs displaced older antidepressants as the experts' choice for first-line pharmacotherapy of panic disorder. In case of an unsatisfactory response, the experts more often recommended an older antidepressant or a combination of an antidepressant plus a benzodiaz epine. According to the experts' judgments, the benzodiazepines, especially combined with an antidepressant, remain mainstays of pharmacotherapy for p anic disorder.