80 These older agents appear as effective as more recent antidepressant agents.83 However, the widespread use of these agents is limited by their relatively unfavorable side-effect profile, including problematic anticholinergic and PF2341066 antiadrenergic effects,84 and they are not recommended as first-line agents.8-11 Similarly, while classic monoamine oxidase inhibitors (MAOIs) may be

effective for panic disorder, they are not commonly prescribed for this indication. These agents exert their antidepressant effect by inhibiting the MAO enzyme, so decreasing the breakdown Inhibitors,research,lifescience,medical of serotonin and noradrenaline and increasing the net level of these neurotransmitters in the CNS.15 However, Inhibitors,research,lifescience,medical as is the case with TCAs, the widespread use of MAOIs is generally limited by their associated adverse effects (including the risk of hypertensive crisis when taken with tyramine-containing foods) and their numerous potential drug interactions. Alprazolam, a short-acting agent, is the best studied benzodiazepine in panic disorder.80 It has shown efficacy compared with placebo in short and longer-term studies, and it has been found comparable in effect to the tricyclics

and to the Inhibitors,research,lifescience,medical SSRIs.85 Alprazolam as well as a number of other benzodiazepines (clonazepam, diazepam, and lorazepam) are FDA-approved for PD.15 Nevertheless, once again, given their relatively unfavorable Inhibitors,research,lifescience,medical side-effect profile, most treatment guidelines do not list these agents as a first-line option.8-11 Fluoxetine, paroxetine, and sertraline have all been rigorously investigated in clinical trials and have received

FDA approval for use in PD.15 They are as effective, but better tolerated, than the older TCAs.83 There seems to be little difference in efficacy within this group of agents.80 Current guidelines recommend that active medication be continued for at least a year, in order to prevent relapse and optimize outcome.8-11 There is partial evidence that SNRIs Inhibitors,research,lifescience,medical and other newer antidepressants are effective in PD.80 On the one hand, relatively few of these agents have been well studied in PD, not all findings have been consistently positive, and concerns have also been raised about the safety profile of certain agents (eg, venlafaxine) in comparison with the SSRIs.85 Org 27569 On the other hand, there is some evidence that more noradrenergic antidepressants may be of benefit in PD patients who have failed to respond to serotonergic antidepressants.86 Thus SNRIs and some other newer antidepressants (for example, mirtazapine and reboxetine) can be considered as a treatment option in the pharmacotherapy of PD:87 There is also some evidence of the efficacy of other classes of agent in panic disorder. In particular, anticonvulsant agents have been investigated for use.