Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. A variety of drugs are used for people with panic disorder and the effects of these were brought together in November 2023 in a Cochrane review and network meta-analysis by Giuseppe Guaiana from Western University in St Thomas Canada and a large group of international authors. Here's Giuseppe to tell us about the problem, and whether these drug treatments are helpful.

Giuseppe: Panic disorder is common in the general population, affecting up to four people in every hundred. It leads to panic attacks, which are discrete periods of fear or anxiety with a rapid onset that reach a peak within 10 minutes.
The treatment of panic disorder includes psychological and pharmacological interventions, such as antidepressants and benzodiazepines. Our focus is on the pharmacological interventions, and, in our network meta‐analysis, we evaluated individual drugs and placebo for efficacy and acceptability in the acute treatment of panic disorder. We included people aged 18 and over, with or without agoraphobia, which is frequently associated with panic disorder. We ranked individual active drugs according to their effectiveness and acceptability, and also looked at antidepressants as a whole and by class, benzodiazepines and placebo.
Seventy randomized trials were eligible for the review, providing evidence that most medications are more effective for the response outcome than placebo. There is heterogeneity in most of the comparisons, but our threshold analyses suggest that this is unlikely to impact the findings of the network meta‐analysis. Results also suggest that most medications are associated with either a reduced or similar risk of dropout to placebo.
In regard to other outcomes, most medications were more effective than placebo on remission, and we found that some medications were more effective than placebo for agoraphobia.
When we analyzed medications by class, all classes examined were more effective than placebo for the two primary outcomes of response and dropout. Tricyclic antidepressants ranked as the most effective, followed by benzodiazepines and mono‐amine oxidase inhibitors. Selective serotonin reuptake inhibitors as a class ranked fifth on average, while serotonin‐norepinephrine reuptake inhibitors were ranked lowest. When we compared classes of medication with each other for the response outcome, we found no difference between classes.
For dropouts, benzodiazepines were the only class associated with lower dropout than placebo and this class was ranked first in terms of tolerability. The other classes did not show any difference in dropouts compared to placebo.
In summary, for efficacy, selective serotonin reuptake inhibitors, serotonin‐norepinephrine reuptake inhibitors (specifically, the drug venlafaxine), tricyclic antidepressants, mono‐amine oxidase inhibitors and benzodiazepines may be effective, with little difference between classes but some differences within classes. However, it is important to note that the reliability of these findings may be limited due to the overall low quality of the studies, with all having unclear or high risk of bias across multiple domains. In regard to tolerability, benzodiazepines appear to have a small but significant advantage over other classes.

Mike: Thanks Giuseppe. If you would like to read the full Cochrane review and look in detail at the network meta-analysis, it's available at Cochrane Library dot com. If you go online and search 'pharmacological treatments for panic disorder' you'll see a link to it.