Non sedating ssris

Anecdotally, self-help groups like Agoraphobics in Motion, 1719 Crooks Rd., Royal Oak, MI 48067; telephone: 248-547-0400, can be inexpensive and helpful.22 Patients with panic disorder commonly have other comorbidities including mood and anxiety disorders, and substance use.23 Because these disorders may be associated with panic attacks and anticipatory anxiety23 and may require distinct treatments,4 the diagnosis of panic disorder should consistently trigger a systematic search for other anxiety disorders.22 Because the common comorbidities of panic disorder respond differentially to antipanic treatments, knowledge of these comorbidities also helps in treatment selection. I.),24 which takes less than 20 minutes to complete, is a more effective screening tool.Unfortunately, most commonly used diagnostic and screening tools for mental health disorders in the primary care setting are not sufficiently comprehensive; the less familiar Mini-International Neuropsychiatric Interview (M. Finally, it is important to assess the risk of suicide in all patients who have panic disorder.18Because panic disorder is a chronic condition that often manifests early in adult life,25 comorbid mood disorders, substance use, and anxiety disorders can develop over time.

CBT, a form of psychotherapy that is usually short-term and focused on symptom resolution through the observation and change of cognitive distortions and their subsequent behaviors, should be encouraged in patients with panic disorder.

The basic premise of CBT is that internal cognitive distortions (e.g., “My heart is beating too fast,” or “I’m going to die.”) are linked with maladaptive behaviors (e.g., fleeing a crowded room), which are then reinforced because this behavior usually temporarily reduces anxiety.19The gains made with CBT tend to be maintained after the treatment is discontinued, which is generally not the case for pharmacotherapy.10 The high initial cost for the treatment may be offset by savings in the cost of long-term medications.

Unfortunately, there are no controlled trials to guide the next therapeutic selection.18 The recommendations of these groups and the authors’ clinical experience are synthesized in the algorithm presented in View/Print Figure FIGURE 1.

Algorithm for sequencing treatment for panic disorder.

In contrast to antidepressants, benzodiazepines relieve anxiety within hours,7 can prevent panic attacks within a few days to a few weeks,5 and are free of troublesome activating effects.7 Nevertheless, benzodiazepine use in treating panic disorder can be complicated by abuse, physiologic and psychologic dependence, and sedative and neurocognitive side effects.7Beta blockers, once widely touted as effective antipanic medications, have proven disappointing as monotherapy in subsequent placebo-controlled trials.5 Buspirone (Bu Spar) is ineffective as monotherapy for panic disorder, as is the antidepressant bupropion (Wellbutrin).5 Traditional forms of psychotherapy (psychodynamic, insight-oriented, and supportive) have little proven benefit in treating panic disorder, but they may be efficacious in treating comorbidities or to help patients adapt to their condition.10When directly questioned by a physician, about 60 percent of patients who take SSRIs report experiencing sexual dysfunction, including delayed orgasm, anorgasmia, loss of libido, decreased lubrication, and erectile dysfunction11; that number drops to 14 percent when patients spontaneously report the information.12 Only 25 percent of these patients with sexual dysfunction report being able to tolerate this side effect—presenting a major challenge because of the long-term nature of the treatment.12In general, the sexual dysfunction is dose-related and responds to reductions in the total amount of antidepressant medication used.1112 Occasionally, patients can successfully alter the time of dosing or skip doses prior to sexual activity.

This strategy would presumably work best with short half-life agents such as paroxetine (Paxil) or sertraline (Zoloft).11 Because sexual dysfunction is ordinarily a class effect, switching SSRIs is usually not beneficial.

Strategies to improve management of such patients include optimizing SSRI dosing (starting at a low dose and slowly increasing the dose to reach the target dose) and ensuring an adequate trial before switching to a different drug.

Benzodiazepines should be avoided but, when necessary, may be used for a short duration or may be used long-term in patients for whom other treatments have failed.

Slower-onset, longer-acting benzodiazepines are preferred. All patients should be encouraged to try cognitive behavior therapy.

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