Imipramine versus propranolol for the treatment of panic attacks: a pilot study

Beta-blockers for the treatment of anxiety disorders: A systematic review and meta-analysis

BACKGROUND

Beta-blocker prescriptions for patients with anxiety increased substantially between 2003 and 2018, yet there is no clinical guidance concerning their use. A previous review of propranolol - a beta-blocker - in the treatment of anxiety concluded there was insufficient evidence to support its use. Additional data have been published in the eight years since that review including some evidence for other beta-blockers. We aimed to synthesise all available data on the effectiveness of beta-blockers in the treatment of anxiety disorders in adults.

METHODS

We searched Medline, Embase, PsycINFO, Web of Science, and Trial Registries (September 2023), including randomised controlled trials (RCT), non-randomised control group comparative studies and cross-over trials reporting self- or clinician-reported anxiety symptoms. Study quality was assessed using Cochrane's Risk of Bias tool, with meta-analyses conducted by comparator group using random-effects models.

RESULTS

Searches produced 3068 records, with 10 studies included, of which five were included in meta-analyses (n = 179). There was no evidence for a beneficial effect of beta-blockers compared with either placebo or benzodiazepines in patients with social phobia or panic disorder with/without agoraphobia (p-value for all meta-analyses ≥0.54).

LIMITATIONS

Many of the included studies had small sample sizes, missing data and high or unclear risk of bias.

CONCLUSION

Beta-blockers are increasingly prescribed for anxiety, yet there is a lack of robust evidence of effectiveness. There is a need to understand when and why practitioners are using these drugs, and to undertake a large RCT to provide definitive evidence of whether beta-blockers are an effective and safe treatment for anxiety.

Propranolol for the treatment of anxiety disorders: Systematic review and meta-analysis

The effects of propranolol in the treatment of anxiety disorders have not been systematically evaluated previously. The aim was to conduct a systematic review and meta-analysis of randomised controlled trials, addressing the efficacy of oral propranolol versus placebo or other medication as a treatment for alleviating either state or trait anxiety in patients suffering from anxiety disorders. Eight studies met the inclusion criteria. These studies concerned panic disorder with or without agoraphobia (four studies, total n = 130), specific phobia (two studies, total n = 37), social phobia (one study, n = 16), and posttraumatic stress disorder (PTSD) (one study, n = 19). Three out of four panic disorder trials qualified for pooled analyses. These meta-analyses found no statistically significant differences between the efficacy of propranolol and benzodiazepines regarding the short-term treatment of panic disorder with or without agoraphobia. Also, no evidence was found for effects of propranolol on PTSD symptom severity through inhibition of memory reconsolidation. In conclusion, the quality of evidence for the efficacy of propranolol at present is insufficient to support the routine use of propranolol in the treatment of any of the anxiety disorders.

Power spectrum analysis and cardiovascular morbidity in anxiety disorders

Spectral analysis of heart rate variability (HRV) and related measures has been shown to be a reliable noninvasive technique enabling quantitative assessment of cardiovascular autonomic regulatory responses to autonomic regulatory mechanisms; it provides a dynamic probe of sympathetic and parasympathetic tone, reflecting the interactions between the two. Over 20 studies reported abnormalities of HRV in anxiety, and patients with heart disease and anxiety are at increased risk for morbidity and mortality. Psychiatric drugs partly correct abnormalities of HRV and, recently, autonomic drugs (beta-blockers) have been studied in anxiety disorders. The authors call for further studies, especially in patients with co-existing anxiety disorders and heart disease, incorporating assessment of HRV.

SSRIs vs. TCAs in the treatment of panic disorder: a meta-analysis

OBJECTIVE

To compare the short-term efficacy of selective serotonin reuptake inhibitors (SSRIs) vs. tricyclic antidepressants (TCAs) in the treatment of panic disorder (PD) a meta-analysis was conducted.

METHOD

Included were 43 studies (34 randomized, nine open), pertaining to 53 treatment conditions, 2367 patients at pretest and 1804 at post-test. Outcome was measured with the proportion of patients becoming panic-free, and with pre/post Cohen's d effect sizes, calculated for four clinical variables: panic, agoraphobia, depression, and general anxiety.

RESULTS

There were no differences between SSRIs and TCAs on any of the effect sizes, indicating that both groups of antidepressants are equally effective in reducing panic symptoms, agoraphobic avoidance, depressive symptomatology and general anxiety. Also the percentage of patients free of panic attacks at post-test did not differ. The number of drop-outs, however, was significantly lower in the group of patients treated with SSRIs (18%) vs. TCAs (31%).

CONCLUSION

SSRIs and TCAs are equal in efficacy in the treatment of panic disorder, but SSRIs are tolerated better.

Comparative effects of low and high doses of clomipramine and placebo in panic disorder: a double-blind controlled study. French University Antidepressant Group

This study was designed to explore the dose-response relationship for clomipramine in patients with panic disorder, with or without agoraphobia. After 1 week of single-blind placebo pretreatment, 180 such patients were assigned to a multicentre placebo-controlled comparison of the effects of high and low doses of clomipramine, and were followed up for 8 weeks. In alleviating anxiety and panic disorder, both clomipramine doses were more efficacious than placebo for panic disorder and, to a lesser degree, for phobia. The lower dose was better tolerated and at least as effective as the higher dose, sometimes more so. These results indicate the clinically important possibility that low-dose clomipramine is effective and well tolerated.

Description of antipanic therapy in a prospective longitudinal study

The authors present a summary scale for assessing the percentage of patients in a large longitudinal study of panic disorder who received proven effective psychopharmacologic treatment. Such a scale provides a means for assessing and comparing somatic treatments of panic disorder across medication classes. The antipanic therapy levels were applied to data on medication treatment received by 492 patients participating in a naturalistic study and reflect psychopharmacologic treatment prescribed in 11 academic centers. Results show that among patients treated by psychiatrists at major teaching hospitals only 54% of the most symptomatic groups received optimal pharmacologic treatment. Among less symptomatic patients, who nonetheless met full criteria for panic disorder with or without agoraphobia, only 43% received maximal therapy.

Panic disorder. Pathophysiology and drug treatment

Advances over the past 2 decades in our understanding of the biology of panic disorder have paralleled a remarkable increase in the development of new pharmacological agents with antipanic effects. Although we can not presently use biological tests to help with our choice of therapeutic agent for individual patients, we can use this biological understanding in the development of overall pharmaco-therapeutic strategies. Current evidence does not support the hypothesis that panic disorder is associated with a primary disorder in one neurotransmitter system. Rather, the data suggest that the biological aetiology of panic disorder is related to abnormalities in the function of a variety of neurotransmitters including serotonin (5-hydroxytyrptamine; 5-HT), noradrenaline (norepinephrine), gamma-aminobutyric acid (GABA), dopamine, and cholecystokinin. It is likely, however, that panic disorder is a biologically heterogeneous condition and that biological subtypes may exist in which the primary abnormality may involve one or a few neurotransmitter systems. Currently, the data best support the hypothesis that pharmacotherapeutic agents with primary action at sites within the GABA and serotonin systems are the most effective in the treatment of panic disorder. Nevertheless, some patients will respond well to drugs with predominant activity in other systems, or may require pharmacotherapy designed to affect the function of more than 1 neurotransmitter. As our understanding of the biological aetiology of panic disorder evolves, the pharmacotherapeutic agents and strategies used in the treatment of this disorder will continue to evolve as well.

The utility of the panic disorder concept

In this paper we discuss the theory that agoraphobic avoidances are central and spontaneous panics an epiphenomenon to the development of agoraphobia. Moreover we discuss the theory that posits a fixed cognitive-catastrophizing set as causal for panic. We conclude these theories do not fit the facts. We argue that it is important to distinguish between spontaneous panic and chronic or anticipatory anxiety and avoidance. Such a distinction allows for an understanding of the roles of anti-spontaneous panic medications such as tricyclics and MAOI's as well as exposure therapy, in the treatment of panic disorder with agoraphobia. The former serves the purpose of blocking panic attacks while the latter undermines phobic avoidance, but only after the panic attacks have ceased through proper medication. We conclude that recognizing the key role of spontaneous panic and its variants in anxiety nosology is a necessary guide for etiological, psychophysiological and therapeutic research in this rapidly developing area.

Drugs and psychological treatments for agoraphobia/panic and obsessive-compulsive disorders: a review

In the short term, both antidepressants and exposure therapy usually improve agoraphobia/panic (AP) and obsessive-compulsive (OC) disorders and are accepted by most patients; psychological methods omitting exposure are not consistently helpful. Antidepressants have a broad-spectrum rather than specific anti-agoraphobia/panic or anti-obsessive-compulsive action. For long-term efficacy, there is good evidence for the value of exposure, but none for drugs. Because of relapse on ceasing drugs, and their side-effects, medication is less useful as the first line of treatment for chronic agoraphobia/panic or obsessive-compulsive disorder than is the lastingly helpful approach of exposure. Antidepressants are worth trying when patients refuse or fail with exposure therapy, or are dysphoric.

Tricyclic therapy of the DSM-III anxiety disorders: a review with implications for further research

Existing data suggests dramatic efficacy for all tested tricyclics in disorders involving spontaneous panic attacks; moderate efficacy for clomipramine but not other tricyclics in obsessive-compulsive patients; possible, but as yet not well established, tricyclic efficacy in generalized anxiety; and lack of efficacy in simple phobias. Further studies in all DSM-III Anxiety Disorders are both warranted and required to answer the nosological, pathophysiological and treatment questions raised by these findings.

Antidepressants in panic disorder and agoraphobia

A survey of the literature on the use of antidepressants for treating patients with panic disorder and agoraphobia with panic attacks suggests that both tricyclic antidepressants and monoamine oxidase inhibitors have efficacy in blocking panic attacks. While we have witnessed dramatic progress in the pharmacological treatment of panic-related disorders over the past 20 years, many unresolved questions remain. Further understanding of dose-response relationships, optimal duration of treatment and predictors of relapse are needed to optimize pharmacological treatment of panic-related disorders. Studies comparing the relative efficacy and side effects spectrum of various effective medications are needed. It is not presently possible to specify which patients will require medication or behavioral treatment alone, and studies to date have incompletely examined this murky issue. Further prospective studies directly comparing the pharmacological and behavioral treatments will help further elucidate the relative contribution of each treatment and possibly clarify which patients require both treatments. Controlled studies in the future which standardize dosage and duration of treatment and use comparable, objective outcome variables promise to provide important theoretical and clinical information regarding the pharmacological treatment of panic-related disorders.

Beta-blockers in anxiety disorders

Studies evaluating the antianxiety and antipanic properties of beta-blockers do not support their routine use in treating either generalized anxiety disorder or panic disorder. The use of propranolol for anxiety disorders accompanied by physical symptoms, especially cardiovascular complaints, may be effective in some patients when combined with benzodiazepines or perhaps in some non-responders to conventional treatment. Better designed studies are needed to evaluate the exact role of beta-blocking agents in treating anxiety. The efficacy of propranolol in patients with panic disorder has not been widely researched, but preliminary results have not been encouraging. Propranolol may provide symptomatic relief in some patients with residual somatic complaints (i.e., palpitations and tachycardia), when combined with the patient's ongoing drug regimen. Because beta-blockers may induce depression, they should be used cautiously--if at all--in panic patients with concurrent depressive illness.

Antidepressant drugs in anxiety disorders

The efficacy of tricyclic antidepressants and monoamine oxidase inhibitors (MAOI) in the treatment of panic syndromes (panic disorder and agoraphobia with panic attacks) and obsessive-compulsive disorders is reviewed. Imipramine has been reported as significantly more effective against panic attacks than placebo or other psychoactive drugs in 12 of 16 studies. Clomipramine has been found superior to placebo or other psychoactive drugs in 5 controlled studies. The effectiveness of these drugs is also reflected in a large number of open trials. The MAOI phenelzine has been reported to be effective in 5 controlled studies. Clomipramine is the best documented drug in the treatment of obsessive-compulsive disorders. Its effectiveness has been documented in 7 controlled studies. Most investigators consider the effects in panic syndromes as well as in obsessive-compulsive disorders to be unrelated to the antidepressant effect.

Paruresis: overview and implications for treatment

Paruresis or psychogenic urinary retention is a functional disorder of micturition characterized by psychosomatic symptomatology that includes an inability to void urine in public facilities. Through largely non-experimental studies and case reports, clinical investigators have identified characteristics, behaviors, and etiological factors associated with the disorder. Although few reports about paruresis appear in the literature, a review is presented to describe the disorder and compare treatments used. As adjuncts to a multifaceted approach to treatment, the 1948 Kegel exercises and the use of beta-adrenergic blocking drugs are specific methods for alleviating the maladaptive symptomatology.