In terms of drug treatment NICE make the following recommendations:
Panic disorder:
Antidepressants should be the only pharmacological intervention used in the longer term management of panic disorder. The two classes of antidepressants that have an evidence base for effectiveness are the selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants.

The following must be taken into account when deciding which medication to offer:

· the age of the patient

· previous treatment response

· risks

- the likelihood of accidental overdose by the person being treated and by other family members if appropriate

- the likelihood of deliberate self-harm, by overdose or otherwise

· tolerability

· the preference of the person being treated

· cost, where equal effectiveness is demonstrated.

Unless otherwise indicated, an SSRI licensed for panic disorder should be offered.

If an SSRI is not suitable or there is no improvement after a 12-week course and if a further medication is appropriate, imipramine or clomipramine may be considered.

For generalised anxiety disorder
If immediate management of generalised anxiety disorder is necessary, any or all of the following should be considered:

· support and information

· problem solving · benzodiazepines · sedating antihistamines · self-help.

Benzodiazepines should not usually be used beyond 2–4 weeks
In the longer-term care of individuals with generalised anxiety disorder, any of the following types of intervention should be offered and the preference of the person with generalised anxiety disorder should be taken into account. The interventions which have evidence for the longest duration of effect, in descending order, are:

· psychological therapy · pharmacological therapy (antidepressant medication)

· self-help
Advice on pharmacotherapy is as follows:
Antidepressants should be the only pharmacological intervention used in the longer-term management of generalised anxiety disorder. There is an evidence base for the effectiveness of the SSRIs. Paroxetine has a licence for the treatment of generalised anxiety disorder.

The following must be taken into account when deciding which medication to offer:

· the age of the patient

· previous treatment response

· risks

- the likelihood of accidental overdose by the person being treated and by other family members if appropriate

- the likelihood of deliberate self-harm, by overdose or otherwise

· tolerability

· the preference of the person being treated

· cost, where equal effectiveness is demonstrated.

All patients who are prescribed antidepressants should be informed, at the time that treatment is initiated, of potential side effects (including transient increase in anxiety at the start of treatment) and of the risk of discontinuation/withdrawal symptoms if the treatment is stopped abruptly or in some instances if a dose is missed or, occasionally, on reducing the dose of the drug.


Patients started on antidepressants should be informed about the delay in onset of effect, the time course of treatment and the need to take medication as prescribed, and possible discontinuation/withdrawal symptoms. Written information appropriate to the patient’s needs should be made available.


Unless otherwise indicated, an SSRI should be offered.

If one SSRI is not suitable or there is no improvement after a 12-week course, and if a further medication is appropriate, another SSRI should be offered.

When prescribing an antidepressant, the healthcare professional should consider the following.

· Side effects on the initiation of antidepressants may be minimised by starting at a low dose and increasing the dose slowly until a satisfactory therapeutic response is achieved.

· In some instances, doses at the upper end of the indicated dose range may be necessary and should be offered if needed.

· Long-term treatment may be necessary for some people and should be offered if needed.

· If the patient is showing improvement on treatment with an antidepressant, the drug should be continued for at least 6 months after the optimal dose is reached, after which the dose can be tapered.

If there is no improvement after a 12-week course, another SSRI (if another medication is appropriate) or another form of therapy (see above) should be offered.