Selective serotonin reuptake inhibitors (SSRIs) were associated with high remission in adults with panic disorder, according to the findings of a systematic review and network meta-analysis recently published in The BMJ.

The study aimed to identify medication classes and specific SSRIs that provide high rates of remission as well as a low risk of adverse events when used in the treatment of panic disorder with or without agoraphobia. The study authors searched Embase, Medline, and for randomized controlled trials that compared panic disorder treatment options in adults by analyzing remissions, dropouts, and adverse events.

The revised Cochrane risk of bias tool for randomized trials was used to assess the risk of bias in the studies included in the analysis and random effects models were used to perform direct meta-analyses. Additionally, the comparative efficacy of medication classes and specific SSRIs were estimated using a 2-stage network meta-analysis with surface under the cumulative ranking curve (SUCRA).

The analysis included 87 studies with a total of 12,800 patients receiving 12 different medication classes. The majority of the studies (86/87) included in the analysis were at some risk of bias.

Findings showed that when compared with placebo, significantly higher remission rates were observed in patients receiving tricyclic antidepressants (risk ratio [RR], 1.39; 95% CI, 1.26-1.54), benzodiazepines (RR, 1.47; 95% CI, 1.36-1.60), monoamine oxidase inhibitors (RR, 1.30; 95% CI, 1.00-1.69), SSRIs (RR, 1.38; 95% CI, 1.26-1.50), and serotonin-noradrenaline reuptake inhibitors (RR, 1.27; 95% CI, 1.12-1.45).

Based on SUCRA score, the best treatments for remission were benzodiazepines (84.5%; mean rank, 2.4), tricyclic antidepressants (68.7%; mean rank, 3.8), and SSRIs (66.4%; mean rank, 4.0); beta-blockers and buspirone were ranked worst.

As for safety, the risk of adverse events was found to be significantly greater with tricyclic antidepressants, benzodiazepines, and SSRIs when compared with placebo. However, the authors noted that “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.”

When individual SSRIs were assessed, sertraline and escitalopram were found to be the most safe and effective.

“Our findings suggest that SSRIs offer important benefit with low risk for drug treatment of panic disorder,” the study authors concluded. “The findings should be interpreted with caution, however, as the results were based on evidence with moderate to very low levels of certainty.”


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. Published online January 19, 2022. doi: 10.1136/bmj-2021-066084.