There are several options for treatment of panic disorder with antidepressant medications. Antidepressant medications are used in the treatment of panic disorder, as those antidepressants with effects on the serotonin neurotransmitter are effective. Serotonin is a neurotransmitter in your brain that is dysregulated when someone has panic disorder.
The antidepressants with effects on serotonin include first-generation antidepressants, which include tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs), and second-generation antidepressants, which include selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs). The first-generation antidepressants, TCAs and MAOIs, were previously used to treat panic disorder. However, with the introduction of the second-generation antidepressants in the late 1980’s, they have replaced the first-generation antidepressants as the treatment of choice for panic disorder.
Why did second-generation antidepressants, SSRIs and SNRIs, replace TCAs and MAOIs? Well, the SSRIs and SNRIs are associated with less side effects and are more tolerable than TCAs and MAOIs. With TCAs, there were the problems with side effects of dry mouth, sedation, and heart rhythm effects. Also, TCAs are potentially fatal when taken in overdose. With MAOIs, the problem is with the requirement to stick to a strict tyramine-free diet (no cheese, no wine, no fermented foods, etc.), and if tyramine were ingested, then there is the potential for increases in blood pressure which could lead to severe medical problems.
The SSRIs and the SNRIs do not have the problematic side effect profile of the TCAs and MAOIs. However, there are still some problems with SSRIs and SNRIs in terms of side effects. Among the second-generation antidepressants, the SNRIs, venlafaxine (Effexor) in particular, have the worst withdrawal symptoms when doses are missed or when trying to discontinue them. This is also known as Discontinuation Syndrome. For this reason, I prefer SSRIs for panic disorder, especially sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro). I find that fluoxetine (Prozac) is too activating (it causes worsening anxiety and agitation) when first starting it, and many patients with anxiety find this overwhelming. In addition, I would stay away from fluvoxamine (Luvox), as it interacts with many drugs.
In summary, the best antidepressants for panic disorder are sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro).