Deteriorating mental health has been widely reported as an outcome of the COVID-19 pandemic—not only through the death and losses caused by the virus, but also commonly as a result of the restrictions and lockdowns placed on people's lives. The latest research in the British Medical Journal reports on panic disorder and agoraphobia, exploring drug treatment for these disorders.
What happens during a panic attack?
When a person has a panic disorder, it is useful to be able to spot it when they first mention their symptoms. Not only is there a role for prescribing but there may be other options to keep the patient from deteriorating into a full-blown panic disorder in the first place. First, it is important to know there are many symptoms of panic attacks. Not everyone appears panicked in an immediately obvious way – their breathing may increase but while effects may feel debilitating to the person, this may not be noticeable to others as it is often portrayed in popular media. However, the experience for the person suffering the panic attack will be frightening and distressing nonetheless.
During a panic attack, NHS (2020) describes a ‘rush’ of intense mental and physical symptoms, that come on very fast and without reason. The person would likely experience multiple symptoms such as a racing heartbeat (palpitations), feeling faint, sweating, nausea, chest pain, shortness of breath, tremulous, hot flushes, chills, a feeling of choking as though breathing fully becomes difficult, dizziness, numbness or pins and needles, needing to go to the toilet, ringing in the ears, feeling of dread, fear of death, feeling of imminent danger, a churning stomach, dissociation or depersonalisation as though not connected with the body, which last from anywhere between 5 and 20 minutes, usually (NHS, 2020).
A generally more severe condition would involve more panic episodes. A person having one may mistake it for a heart attack, but a panic attack is not life-threatening and hospitalisation is not needed. Sometimes, low blood pressure causes palpitations, whereby similar feelings are produced, but the experience is not the result of panic but because of a physiological issue with blood pressure – in this case if a patient is known to be taking beta blockers and ACE inhibitors, or any other blood pressure medications, it would be important to review the medications with their GP to ensure they are not taking a dose that is too high.
Treating panic disorder
The drug treatments available for panic disorder include tricyclic antidepressants, benzodiazepines, SSRIs, monoamine oxidase inhibitors, and serotonin-noradrenaline reuptake inhibitors (SNRIs). Despite the proven effectiveness for symptoms of panic, Chawla et al (2022) report that tricyclic antidepressants and benzodiazepines are linked with a higher risk of adverse events. They highlight guidelines often recommending SSRIs as the treatment of choice as a result of having what appears in research to be a higher chance of long-term safety when compared with benzodiazepines and tricyclic antidepressants. The question of which SSRI remains to be answered, as the choice is varied and there is no one SSRI that has been singled out as being the most suitable for panic disorder as well as being low risk for adverse events.
Medications other than SSRIs – which the NHS (2020) also recommend – include pregabalin and clonazepam in more severe cases. Self-referral to psychological therapies or through a prescriber or GP is a good idea so that the patient can learn how to manage their illness and its effects on their lives. A multidisciplinary team approach is best, especially in complex cases, so that all medications are safely managed, and so that the patient has the help they need for symptom management.
The study
The primary objective of the study by Chawla et al (2022) was to identify drug classes and individual SSRIs that have a high rate of remission, with a low risk of adverse events for the treatment of panic disorder with or without agoraphobia. The authors noted the lifetime prevalence of panic disorder to be between 1 and 5%. The debilitating disorder causes recurrent and unexpected panic attacks linked to several comorbid conditions relating to mental health or otherwise, such as depression, anxiety and cardiovascular disease. The repercussions of panic disorder and its related illness cause significant disruption to the life of an individual by interfering with social functioning, work and relationships. The most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5) contains various descriptions of agoraphobia, but it is mainly centred around a strong fear or anxiety caused by real or anticipated exposure to a wide range of situations, often being linked to panic disorder.
In their systematic review and network meta-analysis, Chawla et al (2022) explore which drug classes – tricyclic antidepressants, benzodiazepines, beta blockers, monoamine oxidase inhibitors, noradrenaline and dopamine reuptake inhibitor (eg buspirone), SSRIs, SNRIs, noradrenaline reuptake inhibitors, and noradrenergic and specific serotonergic antidepressants – provided high benefits (remission) and low risk (adverse events) for the treatment of panic disorder. Additionally, the researchers analysed the data to compare individual SSRIs (eg fluoxetine, fluvoxamine, paroxetine, sertraline, escitalopram, and citalopram).
The studies selected for the analysis included randomised controlled trials where the participants were adults aged ≥18 years with a diagnosis of panic disorder, and where the studies compared drugs used to treat the panic disorder and measured the outcomes of interest, including remissions, dropouts, and adverse events. The researchers found 87 studies that matched their criteria, involving a total of 12 800 participants and 12 drug classes all being eligible for inclusion. However, Chawla et al (2022) found that almost all the studies (86/87) had some concern or were at high risk of bias. Their network meta-analysis of remission with consistent results indicated that tricyclic antidepressants, benzodiazepines, monoamine oxidase inhibitors, SSRIs and SNRIs were associated with significantly higher remission rates than placebo. The best treatments for the panic disorder found from analysing all the studies together were found to be benzodiazepines (84.5%) tricyclic antidepressants (68.7%), and SSRIs (66.4%). However, despite this, tricyclic antidepressants, benzodiazepines and SSRIs were also found to be significantly associated with an increased risk of adverse events compared with the placebo.
When analysing for both for remissions and adverse events, Chawla et al (2022) determined that SSRIs were linked to high remission and low risk of adverse events, and that when comparing individual SSRIs, sertraline and escitalopram were found to provide high remission with an acceptable risk of adverse events in comparison to the other SSRIs.
Chawla et al (2022) concluded that SSRIs provide high rates of remission with low risk of adverse events for the treatment of panic disorder. Sertraline and escitalopram were highlighted as the preferred SSRI choices, with high remission and low risk of adverse events observed in the meta-analysis. However, the studies compared, although significant in quantity, were not of the highest quality, with bias, inconsistency and imprecision of the findings being evident.