Selective Serotonin Reuptake Inhibitors safe and effective for treating panic disorders: BMJ

The findings suggest that Selective Serotonin Reuptake Inhibitors (SSRIs) provide high rates of remission with a low risk of adverse events for the treatment of panic disorder, according to the latest research published in the BMJ.

The lifetime prevalence of the common psychological problem known as panic disorder lies between 1% and 5%. Panic disorder is characterized by recurrent and unexpected panic attacks associated with several comorbid psychiatric and non-psychiatric conditions like depression, anxiety, cardiovascular diseases, impaired social work, and family functioning.

Agoraphobia is a significant dread or anxiety that is triggered by actual or anticipated exposure to a wide range of events. It is frequently linked to panic disorder.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-III, DSM-III-R, and DSM-IV) have all provided comparable definitions of panic disorder, which have been updated with each subsequent edition; however, panic disorder and agoraphobia have been classified separately in the fifth revision (DSM-5).

SSRIs are preferred over benzodiazepines and tricyclic antidepressants in terms of long-term safety, according to various standards.

However, it remains unclear which SSRI is most effective and is associated with the risk of the least adverse event owing to the limited availability of direct comparisons between SSRIs and other drug classes.

The authors Natasha Chawla et. al tried to identify drug classes and individual selective serotonin reuptake inhibitors (SSRIs) with high rates of remission and low risk of adverse events in the treatment of panic disorder with or without agoraphobia.

The risk of bias in the included studies was assessed using the revised Cochrane risk of bias tool for randomized trials.

Direct meta-analyses were performed using random-effects models.

A two-stage network meta-analysis with a surface under the cumulative ranking curve (SUCRA) was used to estimate the comparative efficacy of drug classes and individual SSRIs.

87 studies including a total of 12 800 participants and 12 drug classes were eligible for inclusion.

Almost all the studies (86/87) had some concern or were at high risk of bias.

Network meta-analysis of remission with consistent results indicated that tricyclic antidepressants, benzodiazepines, monoamine oxidase inhibitors, SSRIs, and serotonin-noradrenaline reuptake inhibitors (SNRIs) were associated with significantly higher remission rates than placebo, with risk ratios of 1.39, 1.47 , 1.30, 1., and 1.27, respectively.

SUCRAs identified benzodiazepines, tricyclic antidepressants, and SSRIs as the top three best treatments for remission.

However, tricyclic antidepressants, benzodiazepines, and SSRIs were also significantly associated with an increased risk of adverse events compared with placebo, with risk ratios of 1.79, 1.76, and 1.19, respectively.

Consistency assumption of adverse events was upheld but could still be present on the removal of studies with high percentages of women participants and those with agoraphobia.

A SUCRA cluster ranking plot considering both remission and adverse events among all drug classes indicated that SSRIs were associated with high remission and low risk of adverse events.

Among individual SSRIs, sertraline and escitalopram provided high remission with an acceptable risk of adverse events.

"Among SSRIs, sertraline and escitalopram were associated with high remission and low risk of adverse events. The findings were, however, based on studies of moderate to very low certainty levels of evidence, mostly as a result of within study bias, inconsistency, and imprecision of the findings reported," the authors concluded.

Reference:

Chawla N., Anothaisintawee T., Charoenrungrueangchai K., et. al, Drug treatment for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials, BMJ 2022; 376 doi: https://doi.org/10.1136/bmj-2021-066084 (Published 19 January 2022)