Management of Treatment-Resistant Panic Disorder

Abstract

Purpose of Review Purpose of Review Management of treatment-resistant (TR) panic disorder (PD) is an unresolved issue. In this paper, we provide a brief summary of previous findings, an updated (2015–2017) systematic review of pharmacological/non-pharmacological studies, and our personal perspective on this topic.Recent Findings Recent Findings We found a very limited number of recent findings. Quetiapine extended-release augmentation has not been found to be beneficial, in comparison to placebo, in non-responders to previously recommended pharmacotherapy. In non-responders to cognitive behavioral therapy (CBT), switching to paroxetine/citalopram has been found to be more effective than continuing CBT. Acceptance and commitment therapy (ACT) has shown some improvement in patients’ resistance to previous psychological/pharmacological interventions compared with a waiting-list condition.Summary Summary Previous and recent findings regarding the treatment of TR PD suffer from several methodological limitations. Available studies provide insufficient evidence to support the use of medications alternative to the recommended medications; the efficacy of ACT needs confirmation with more rigorous methodology. Prolonged pharmacotherapy may produce significant improvement in patients with unsatisfactory response to short-term pharmacotherapy, while switching to pharmacotherapy may help non-responders to CBT. We discuss our personal perspective on the definition of “treatment resistance” as it relates to PD and provide personalized intervention strategies to increase favorable clinical outcomes based on our clinical expertise and review of experimental studies on the pathophysiology of PD.

The role of acid-sensitive ion channels in panic disorder: a systematic review of animal studies and meta-analysis of human studies

“…While there is a clear need for more studies in primates addressing the issues discussed above, our findings that pharmacological blockade of acid channels in animal models of PD implies that these channels may contribute to PD treatment. PD has been treated primarily with drugs that have anxiolytic properties, including benzodiazepines and selective serotonin reuptake inhibitors 65 . Nevertheless, 20–40% of patients do not achieve full remission with the recommended medicine 65 .…”

“…PD has been treated primarily with drugs that have anxiolytic properties, including benzodiazepines and selective serotonin reuptake inhibitors 65 . Nevertheless, 20–40% of patients do not achieve full remission with the recommended medicine 65 . Thus, new therapeutic targets and drug development for PD patients should be further investigated.…”

Is panic disorder a disorder of physical fitness? A heuristic proposal

“…If our hypothesis is correct, the aim of antipanic treatments should be not only the disappearance of PAs but also, most importantly, the achievement of a full sense of physical wellbeing 118 . Hence, the doses of drug treatments with antipanic agents should be titrated until these subtle physical abnormalities disappear.…”

Aligning the many definitions of treatment resistance in anxiety disorders: A systematic review

“…In other psychiatric disorders the term "treatment resistance" (TR) is preferred to describe a subgroup of patients who have a prior history of unfavorable treatment effects (Conway, George, & Sackeim, 2017;Fekadu et al, 2009;Fogelson & Leuchter, 2017;Howes et al, 2016), which also implies having less favorable future treatment effects (Conway et al, 2017;Fekadu et al, 2009;Fogelson & Leuchter, 2017;Howes et al, 2016). The varying terminology reflects the absence of consensus regarding the criteria for TR (Barton et al, 2014;Cirillo, Freire, & Freire, 2016;Perna & Caldirola, 2017;Stein & Seedat, 2004;Yoshinaga et al, 2016). This lack of consensus on criteria for TR-AD was first recognized in 2004; however, 14 years later still no consensus exists (Barton et al, 2014;Chen & Tsai, 2016;Roy-Byrne, 2015;Starcevic, 2008;Stein & Seedat, 2004;Van Ameringen & Mancini, 2001).…”