There is a dearth of research exploring the pharmacological treatment of co-occurring panic and AOD use disorders; however, there is a large body of evidence demonstrating the efficacy of SSRIs, SNRIs, TCAs, and benzodiazepines for the treatment of panic disorder as a single disorder [1158, 1182, 1183]. Although SSRIs, TCAs and benzodiazepines are considered to be equally effective, SSRIs and SNRIs (in particular, venlafaxine) are recommended by the RANZCP as first-line pharmacotherapies due to their superior safety and side-effect profiles relative to TCAs and benzodiazepines. As mentioned previously, TCAs are poorly tolerated, potentially lethal in overdose, and cause significant adverse effects when combined with other central nervous system depressants. Current evidence does not support the use of one SSRI over another [1158].
The RANZCP guidelines suggest that SSRIs or SNRIs may be considered as an alternative to CBT for cases in which the response to CBT has been inadequate or if the person has a preference for medication. Similarly, the combined use of CBT and an SSRI or SNRI may be considered in cases of severe panic disorder, or where the response to either CBT or pharmacotherapy alone has been insufficient. As mentioned previously, it is important that practitioners explain to clients who are prescribed SSRI or SNRI antidepressants, that they may experience an initial exacerbation of anxiety, particularly where there is a history of panic attacks [1158]. To reduce the likelihood of this occurring, it is recommended that clients start with a low dose and titrate slowly to a required therapeutic dose.
The RANZCP guidelines provide guidance on dose titration and switching within- and between- classes of anti-depressants and the other previously mentioned medications depending on treatment response. It is important to note however, that treatment response is typically slow (at least four weeks) and it is therefore important to allow time for appreciable effects to be discerned, which may be difficult for clients who are seeking immediate relief from their symptoms.