Treatment options for panic disorderSome patients with panic disorder do not respond to first-line treatment with an SSRI and, say US investigators, there is a lack of evidence on which to base subsequent treatment choices (J Clin Psychiatry 2009; October 6 doi:10.4088/JCP.08m04485blu).Their three-phase trial involved initial open-label treatment with sertraline (up to 100mg daily) or escitalopram (up to 15mg daily) for six weeks. Of 39 patients, 20 per cent achieved remission; the others were then randomised to continue with their initial treatment plus placebo or to receive an increased dose of SSRI (up to 200mg daily sertraline or up to 30mg daily escitalopram). After a further six weeks, symptom scores improved in both groups but there was no significant increase in remission rate with the increased dose versus placebo (9 per cent vs 15 per cent respectively). Those still not in remission were re-randomised to additional treatment with clonazepam plus SSRI dose adjustment or cognitive behavioural therapy for another 12 weeks. Again, symptom scores improved but only one patient in each group achieved remission.Acknowledging the small size of their study, the authors say all of the tested strategies are reasonable treatment options but better discriminators of treatment response are needed. Copyright © 2009 Wiley Interface Ltd