Relapse prevention in panic disorder with pharmacotherapy: where are we now?

ABSTRACT

Introduction: A substantial number of patients with PD experience relapse after the discontinuation of effective pharmacotherapy, leading to detrimental effects on the individuals and considerable societal costs. This suggests the need to optimize pharmacotherapy to minimize relapse risk.

Area covered: The present systematic review examines randomized, double-blind, placebo-controlled relapse prevention studies published over the last 20 years involving recommended medications. The authors aim to provide an overview of this topic and evaluate whether recent advances were achieved. Only seven studies were included, providing limited results. One-year maintenance pharmacotherapy with constant doses had protective effects against relapse in patients who had previously exhibited satisfactory responses to the same medication at the same doses. The duration of maintenance treatment did not influence relapse risk. No data were available concerning the use of lower doses or the predictors of relapse.

Expert opinion: Relapse prevention in PD has received limited attention. Recent progress and conclusive indications are lacking. Rethinking pharmacological research in PD may be productive. Collecting a wide range of clinical and individual features/biomarkers in large-scale, multicenter long-term naturalistic studies, and implementing recent technological innovations (e.g., electronic medical records/‘big data’ platforms, wearable devices, and machine learning techniques) may help identify reliable predictive models.

KEYWORDS:

• Panic disorder
• relapse
• personalized medicine
• pharmacotherapy
• antidepressants
• selective serotonin reuptake inhibitors
• treatment outcome
• tricyclic antidepressive agents
• venlafaxine

Article highlights

• Although several medications are effective for treating panic disorder (PD), a substantial proportion of patients relapse after discontinuation.

• Optimizing pharmacological treatment to minimize relapse risk is a medical need, because PD exhibits detrimental effects on the affected individuals and considerable societal costs.

• Disappointingly, a limited number of relapse prevention studies is available and neither advances nor conclusive results were achieved in recent years.

• Provisional indications suggested that one-year maintenance pharmacotherapy with constant doses had significant protective effects against relapse in patients who had previously exhibited satisfactory responses to the same medication at the same doses. Duration of maintenance treatment did not influence relapse risk.

• No reliable predictors or early signs of relapse were identified.

• Future studies should expand a personalized approach to pharmacotherapy for PD. The use of clinical/psychophysiological profiles and biomarkers, and the application of technological advances, such as wearable devices and machine learning techniques, may provide reliable predictions for individual patients with PD.

This box summarizes key points contained in the article.

Acknowledgments

The authors would like to thank E Sangiorgio for her assistance with the preparation of the manuscript. The authors would like to thank Enago (www.enago.com) for the English language review.

Declaration of interest

D Caldirola, A Alciati, S Daccò, and G Perna are scientific consultants for Medibio Ltd. G Perna has also served as a consultant for Lundbeck and Pfizer Inc. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript was not funded.