Stop Your Panic Attacks

In detail

Learn the attack before the next one. A rush of racing heart, tight chest, breathlessness, shaking, dizziness and the fear you are dying. It peaks and passes, most often within 5 to 20 minutes, and it does not harm you. Attacks can also wake you from sleep: that is the same wave, not a sign of danger. Chest pain you have not had checked goes to a doctor first.

Found

In a trial, a plain information booklet given at the start of treatment eased anxiety and panic more than treatment alone over the first weeks. Waking from sleep in panic is common with the disorder.

Why

The attack feeds on the belief that the body is failing: heart attack, stroke, going mad. Knowing the shape of it breaks the loop where fear of the symptoms makes the symptoms stronger.

Watch

First attack with chest pain, or chest pain that spreads to the arm, neck, jaw or back: call 911 first. Never assume it is only panic.

In detail

When an attack starts: stay where you are, breathe slowly, and tell yourself it will pass. Breathe in gently, low into the belly, and let it flow out slowly. Counting 1 to 5 each way helps some. Skip the paper bag, and skip big gulping breaths: over-breathing is fast, deep breathing.

Found

The guidance for the moment it starts: stay where you are, breathe slowly, and remind yourself the attack will pass and is not life threatening.

Why

Fast, shallow breathing blows off carbon dioxide and brings the tingling, dizziness and air hunger that feel like dying. A slow out-breath steadies it, and staying put teaches the brain the attack passes on its own.

Watch

Paper-bag rebreathing has killed when a heart or lung problem was mistaken for panic: never use it. Dizziness or tingling means you are blowing off too much carbon dioxide. Breathe lighter, not deeper.

In detail

Count the coffee, energy drinks, cola, tea and pre-workout for a week. Then cut well under 400 mg a day, and none after midday. If attacks started with a stimulant, stop it. Step down over a week or two.

Found

Above 400 mg, about four cups of coffee, caffeine set off panic attacks in half of those with the disorder in a challenge test. Across 14 studies, caffeine raised anxiety.

Why

Caffeine pushes adrenaline up and brings the racing heart, the shake and the jitter. Those are the exact body signals a panic attack starts from, so caffeine loads the trigger.

Watch

Cutting fast from a high intake brings headache and tiredness for a few days. Taper it.

The deep dive on this

In detail

Count the drinks for a week. Mark the ones you had to settle your nerves, and the mornings after. Then cut a level. If you drink every day and shake without it, see a doctor before you stop. For more, run Drinking less.

Found

Better mental health, one year. 1,383 people followed for a year: every step down the risk-drinking ladder came with fewer alcohol problems and better mental health. The bigger the cut, the bigger the gain.

Why

A drink settles the nerves for an hour, then the rebound comes: a racing heart, sweats and dread the next day, the same signals an attack runs on. Cutting the count breaks that loop.

Watch

If you drink every day and get shakes, sweats or a racing heart without it, stopping suddenly is a medical danger. Get medical help before you stop.

The deep dive on this

In detail

If you smoke or vape weed, stop, or cut hard while you work this page. Attacks that started with cannabis, or come on while high, are a reason to stop now. For the how, run Quit weed.

Found

In a large household survey, cannabis dependence came with a higher risk of panic attacks. Followed from the teens into the twenties, cannabis use and dependence came with higher odds of panic attacks and panic disorder.

Why

THC can set off a racing heart, a sense of unreality and sudden dread, which the brain can learn as an attack. Daily use also leaves a jumpy rebound between highs.

Watch

Stopping daily use can bring a few weeks of irritability, poor sleep and anxiety. It passes. Tell the doctor.

In detail

Run, row, cycle or swim three times a week, 30 minutes at a pace that makes you breathe hard. It raises the same heart rate and breathing panic does, on purpose, so the body learns those feelings are safe.

Found

Symptoms down against placebo. Ten weeks of regular running cut panic symptoms against placebo on every main measure in a trial. Added to CBT, 30 minutes of hard cardio three times a week kept the gains more than low-intensity exercise.

Why

A pounding heart and hard breathing are what a panic attack feels like. Making them on purpose, again and again, teaches the brain they are not a threat, and fitter hearts race less at rest.

Watch

Early sessions can bring on the feelings you fear. Build up, and keep going through them. Chest pain on exertion goes to a doctor first.

The deep dive on this

In detail

Seven to eight hours, the same wake time seven days a week. A short night lowers the threshold for the next attack.

Found

g = 0.63 on depression. Sixty-five trials, 8,608 people: when a treatment improved sleep, depression fell by a medium effect. Anxiety and brooding fell with it. The more sleep improved, the more mood did.

Why

A short night raises the amygdala's reactivity and cuts the prefrontal brake on it the next day. Regular sleep is the one move here that every other move depends on.

Watch

Nine hours or more a night that does not refresh is a doctor's question, not a reason to sleep in.

The deep dive on this

In detail

Train the slow breath daily between attacks, so it is ready when one comes. Four weeks of short daily sessions, from a written guide or a breathing app. A device that shows your breath rate or carbon dioxide helps some.

Found

Effect sizes 1.34 and 1.53. A trial scored on the PDSS: four weeks of breathing training cut panic severity by large effects, and the gains held at six months. A second study with breath feedback: 83% responded and 54% went into remission.

Why

Panic runs on over-breathing and the fear of the sensations it brings. Daily training slows the resting breath and exposes you to the feelings in a safe dose, so they lose their charge.

Watch

Dizziness or tingling means you are breathing too hard. Breathe lighter.

In detail

Practice slow breathing every day between attacks, so the skill is there when one comes. About six breaths a minute: in for four, out for six, low into the belly. At least 5 minutes a day. A strap or wearable that shows your heart rate as you breathe gives the feedback the trials used.

Found

g = 0.83 against control. Twenty-four studies, 484 people: slow-breathing training with heart-rate feedback cut self-reported stress and anxiety by a large effect against control.

Why

At about six breaths a minute the heart rate swings widest with each breath, and every slow out-breath brakes the heart through the vagus nerve. Trained daily, the slow breath becomes the habit the body reaches for when the alarm goes off.

Watch

Dizziness or tingling means you are breathing too deep. Breathe lighter, not deeper.

The deep dive on this

In detail

Start the guided quest. It is built on the methods tested in trials, and you do it on your own. A lesson opens every five days or more. The lessons cover what an attack is, riding it out, and bringing on the feelings on purpose. Then come testing the scary thought, going back into the places you avoid, and the plan for a bad week. See your doctor every 4 to 8 weeks while you do it.

Found

g 1.22 against waiting. Nine trials of online self-help courses: panic fell by a large effect against waiting or information alone, and agoraphobia fell too. The gains held at 3 to 6 months, and courses with less doctor support matched those with more. A ten-week self-help book, worked through alone, improved every measure, and the gains held three months on.

Why

Panic runs on fear of the feelings and of what they seem to mean. The course takes each piece in turn. It covers what the attack is, the feelings brought on safely, the scary thought checked against the facts, and the places taken back.

Watch

Chest pain you have never had checked goes to a doctor before week 3.

The deep dive on this

In detail

Make the feelings your attacks start with, on purpose, at home, and stay with them until they fade. Pounding heart: sprint, or run hard on the spot. Dizzy: spin in a chair. Short of breath: breathe through a thin straw. Light-headed: breathe fast and hard for a short burst. Rate the fear before and after, and repeat daily until it barely rises. The trials ran it with support: supervised brisk walks with 30-second sprints for 12 weeks, or an online course with a coach. A training partner or a coach at the gym can play that part.

Found

Beat relaxation, held 24 weeks. Both trials ran it with support. In a trial, 12 weeks of supervised brisk walking with 30-second sprints, used to bring on the feared feelings, cut panic severity and attacks more than relaxation training, and the gains held at 24 weeks. An online course with a coach’s support that added these exercises cut panic by a large effect against a waiting list, and 43% no longer met the criteria for the disorder.

Why

The attack feeds on fear of a pounding heart, dizziness and air hunger. Making them yourself, again and again, with nothing bad happening, teaches the brain they are not a threat, and the attacks lose their fuel.

Watch

Check with a doctor first if you have a heart or lung condition, asthma or epilepsy, or have ever fainted. The feelings are meant to be uncomfortable for a few minutes. Stop at any chest pain.

The deep dive on this

In detail

List the places and things you now avoid: the highway, the train, the gym, the crowd, the coffee. Rank them. Go back to them in steps, easiest first, and stay until the fear drops. Leave the safety habits at home.

Found

The strongest effects on avoidance. Pooled across 34 treatment studies, graded exposure to the avoided places had the most consistently strong effects. In an experiment, dropping safety habits during exposure cut catastrophic beliefs and anxiety more than keeping them.

Why

Avoiding the place, or going only with the water bottle, the pills in the pocket or the exit in sight, stops the brain learning that nothing bad happens. Going back without them lets the fear be tested and fade.

Watch

Expect the fear to rise before it falls. Stay put until it drops, then repeat. Chest pain on exertion goes to a doctor first.

In detail

Early research. Myo-inositol powder, 12 g a day in the first trial, stirred into a drink and split through the day, for four weeks before you judge it. Beside the rest of the page, never in place of it.

Found

4.0 fewer attacks a week. A four-week trial of 12 g a day: panic attacks came less often and were less severe than on placebo, with few side effects. Against an SSRI, it cut weekly attacks by 4.0, against 2.4.

Why

Inositol feeds the second-messenger system that serotonin receptors signal through, so it may work a step downstream of the SSRIs.

Watch

Side effects were minimal in the trials. It is a large dose of powder. Tell the doctor if you take it beside a prescription.

In detail

Early research. A yoga class with postures, breathing and a quiet end, beside the rest of the page. The larger trial ran an hour, five days a week, for twelve weeks.

Found

Anxiety down more. A trial of 64 people on usual care: adding yoga cut anxiety more and lifted quality of life across the board. A smaller trial: yoga eased panic symptoms, beliefs and body sensations.

Why

Yoga raises the heart rate and the breath and then brings them down, a gentle rehearsal of the rise and fall of an attack, with slow breathing built in.

The deep dive on this

In detail

Early research. A mindfulness course you follow on your own, online or from a book with recordings: a short guided sitting each day. It trains you to notice the first body signals without reacting to them.

Found

g 0.22 on anxiety. Fifteen trials of online mindfulness courses: small gains on anxiety, depression and wellbeing, and a moderate one on stress. More sessions went with bigger gains on stress.

Why

Panic runs on fear of the fear. Mindfulness trains you to watch a racing heart as a sensation that rises and passes, not a signal of disaster.

Watch

Keep the sittings short and daily. Long silent retreats can stir distress.

In detail

Early research. Teach yourself to relax the whole body in seconds, in stages, from a self-help course. First tense and let go of each muscle group. Then let go without tensing, then on a cue word, then in a few seconds, anywhere. Practice twice a day, then use it at the first sign of an attack.

Found

d 0.71, self-taught. Taught as an online self-help course with brief email contact, applied relaxation brought a medium to large drop in panic, d 0.71. In the first trial of the method, 82% were free of attacks at follow-up.

Why

An attack builds from small body signals. Catching the first one and letting the tension go stops the build before it becomes a full wave.

In detail

The oral lavender oil capsule, 80 mg once a day, for ten weeks before you judge it. Not the diffuser oil or the pillow spray. It calms without making you drowsy.

Found

g 0.72 on anxiety. Across trials of lavender, anxiety fell by a moderate to large effect against placebo or no treatment. The oral capsule trials ran 80 mg a day for ten weeks.

Why

Its main constituents damp calcium entry at the nerve ending, so less excitatory signal is released. That is a similar target to pregabalin, at a gentler strength.

Watch

Burping, stomach upset and a lavender aftertaste. It may add to the effect of sedatives and sleeping pills.

The deep dive on this

In detail

The pharmaceutical-grade extract, 500 mg three times a day, for four weeks before you judge it. Strong chamomile tea is the kitchen version; the trials used the extract.

Found

1.8 points off HAM-A at 4 weeks. Twelve trials reviewed: on the doctor-rated anxiety scale, generalized anxiety scores fell at two and four weeks. Long-term trial, 179 people at 1,500 mg a day: symptoms stayed lower than placebo through 26 weeks, with blood pressure down alongside.

Why

Apigenin sits on the benzodiazepine site of the GABA-A receptor at a fraction of the affinity, which is a brake without the dependence.

Watch

Allergic reactions in some, more with a ragweed or daisy allergy. It can add to the effect of blood thinners and sedatives.

The deep dive on this

In detail

300 to 600 mg a day of root extract, for eight weeks before you judge it. Take it at night: it sedates a little. Stop at any yellowing of the eyes.

Found

Large effect on anxiety. Twelve trials, 1,002 people: anxiety and stress both fell against placebo, by large effects, with the stress effect sitting between 300 and 600 mg a day. Five trials on sleep: sharper mornings and less anxiety on top.

Why

Withanolides damp the stress-hormone system. The most repeated human finding is lower cortisol under load. A GABA-side action carries the sleep half. It is the one daily move here that works on both the wired and the flat.

Watch

Gut upset and daytime drowsiness. Liver injury case reports cluster around some extracts, so stop at any yellowing of the eyes or dark urine. It can raise thyroid hormone levels: on thyroid pills, ask the doctor first. It may add to sedatives.

The deep dive on this

In detail

Early research. Fish oil with food, working up to about 2 g of omega-3 a day, for at least eight weeks before you judge it. Or fatty fish several times a week as the food version.

Found

Medium effect per gram a day. Twenty-three trials, 2,189 people: each gram a day of omega-3 lowered anxiety symptoms by a moderate effect, with the greatest gain at 2 g a day. Nineteen trials: omega-3 might help reduce clinical anxiety.

Why

Omega-3 fats are built into brain cell membranes and shift the body toward less inflammatory signaling, which is raised in some anxiety.

Watch

Above 1 g a day, heart trials found a higher risk of an irregular heartbeat, atrial fibrillation, rising with the dose. On a blood thinner, ask the doctor first. Fishy burps and loose stools.

The deep dive on this

In detail

Early research. A standardized saffron stigma extract, 30 mg a day as 15 mg twice a day, for six weeks before you judge it. A standardized extract only: saffron is often faked.

Found

5.1 points off BAI. Thirty-four trials, 1,769 people: on the self-rated anxiety scale, six trials and 339 people, anxiety fell 5.1 points against placebo. Self-rated low mood fell too.

Why

Crocin and crocetin carry it, and crocetin is small enough to cross into the brain, where it acts on serotonin and stress signaling.

Watch

Mild stomach upset or headache in some. High doses of the spice itself are unsafe; stay at the trial dose. It may add to antidepressants and to blood thinners: on either, ask the doctor first. With bipolar disorder, ask first: it can lift mood too far.

The deep dive on this

In detail

Early research. Passionflower extract as drops, 45 drops a day in the trial, for four weeks. Beside the rest of the page, not in place of it. Not with sedatives or alcohol.

Found

Matched oxazepam. A trial of 36 people with the worry disorder: passionflower extract matched oxazepam, a benzodiazepine, over four weeks, with less trouble at work. Across nine trials, most reported lower anxiety.

Why

Its flavonoids act on the GABA system, the brain’s main brake, more gently than a sedative drug.

Watch

Drowsiness and dizziness in some: care driving. Do not combine with sedatives, sleeping pills or alcohol.

In detail

Early research. 200 mg, thirty to sixty minutes before a place or moment that sets you off, or 200 to 400 mg a day through a stressful stretch. It calms without dulling you.

Found

Small effect on acute stress. Thirty-one trials, 1,168 people: a single dose took a modest amount off acute stress, with no serious side effects, and 200 mg sharpened reaction time. Nine trials: 200 to 400 mg a day eased stress and anxiety under load.

Why

It resembles glutamate closely enough to sit on its receptors and slow its transport, which damps excitatory signaling without sedation, and it raises GABA alongside.

Watch

Mild headache, drowsiness or nausea in some. It may add to sedatives, and it can lower blood pressure a little: on blood pressure pills, ask first.

The deep dive on this

In detail

Early research. Magnesium, 248 mg of elemental magnesium a day, the trial dose, for six weeks before you judge it. Split it through the day if it loosens the gut.

Found

GAD-7 down 4.5 points. In a six-week trial of 248 mg a day, anxiety scores fell 4.5 points more than on no supplement, and it was well tolerated. A review of 18 studies found the evidence pointing toward less anxiety.

Why

Magnesium damps the NMDA glutamate receptor and the stress-hormone response, two parts of the body’s alarm.

Watch

Loose stools, the most common. With kidney disease, ask first: it can build up. It cuts the absorption of some antibiotics and thyroid tablets, so take them hours apart.

The deep dive on this

In detail

Early research. A standardized lemon balm leaf extract, 300 to 600 mg, the doses tested in a stress trial, daily for a few weeks. Not with sedatives or alcohol.

Found

Large effect on anxiety. Trials pooled: lemon balm lowered anxiety scores against placebo by a large effect, without serious side effects. In a stress test, a single 600 mg dose raised calmness.

Why

Its rosmarinic acid slows the breakdown of GABA, the brain’s main brake, which is where the calm comes from.

Watch

Drowsiness in some: care driving. Not with sedatives, sleeping pills or alcohol. On thyroid medicine, ask first.

In detail

Early research. A multi-strain probiotic capsule with lactobacillus and bifidobacterium strains, once a day, for eight weeks. Beside the rest of the page, not in place of it.

Found

d 0.10 on anxiety. Thirty-four controlled trials: probiotics lowered anxiety and depression by small effects. In an eight-week trial of a three-strain capsule, depression scores fell 5.7 points against 1.5 on placebo.

Why

Gut bacteria signal to the brain through immune, hormone and nerve pathways, and may turn down the body’s alarm a notch.

Watch

Wind and bloating for the first week or two. With a weakened immune system, ask the doctor first.

In detail

Book your doctor. Bring the PDSS scores, the attack diary, the caffeine, drinks and any drugs or supplements. Ask for the checks: a heart trace (ECG) if the heart races or skips, and a thyroid blood test if you run hot, shaky or are losing weight.

Found

odds 0.54 of a diagnosis. In a national survey, men were about half as likely as women to hold a professional diagnosis for the same symptoms. The treatments that got men in used role models, plain information about symptoms and services signposted.

Why

The appointment clears the heart and thyroid, so you can stop scanning your body for them, and it opens the door to the medicines if you want one.

The deep dive on this

In detail

If you choose a medicine, the UK’s NICE guideline offers an SSRI licensed for panic. Sertraline is labeled for panic in the UK and the US, on a prescription. The label starts at 25 mg a day for a week, then 50 mg. It rises weekly if needed, up to 200 mg.

Found

A 12-week trial of 178 people: sertraline cut panic attacks, unexpected ones included, and time spent worrying more than placebo, and it was safe. Across 30 trials pooling all antidepressants, for every seven treated, one more got better than on a dummy pill.

Why

SSRIs block the pump that clears serotonin, so more of it stays working on the brain’s alarm circuits. The calm builds over weeks as the brain adapts, which is why it is judged at twelve.

Watch

Boxed warning: antidepressants raised suicidal thoughts and behavior at younger ages in short trials, 5 more per 1,000 at ages 18 to 24. Watch closely in the first months and after any dose change. Never with an MAOI, or within 14 days of one, and never with pimozide. Serotonin syndrome with other serotonin drugs, triptans and tramadol among them; tell the doctor about any cocaine use. Bleeding risk with aspirin, NSAIDs or blood thinners. It raises the level of some drugs, warfarin and CYP2D6 drugs among them. Can trigger mania: tell the doctor about any highs. Seizures. Angle-closure glaucoma in narrow-angle eyes. Low blood sodium: headache, confusion, unsteadiness. A heart-rhythm change (QTc) with other risk factors. Anxiety can rise for the first weeks, which is why the dose starts low. Sexual side effects: delayed or failed ejaculation, lower drive, erectile trouble. Never stop suddenly.

In detail

Another SSRI labeled for panic in the UK and the US, on a prescription. The label starts at 10 mg a day and goes up to 60 mg. In the fixed-dose trial, 40 mg did best. It needs a slow, planned stop.

Found

A 10-week trial of 278 people at fixed doses: 86% on 40 mg were free of full attacks by the end, against 50% on placebo. A 12-week trial of 664 people: paroxetine and venlafaxine both worked and were well tolerated.

Why

It blocks the serotonin pump like the others. It also blocks a second receptor, which brings drowsiness and a strong withdrawal, so the stop is planned from the start.

Watch

Boxed warning: antidepressants raised suicidal thoughts and behavior at younger ages, 5 more per 1,000 at 18 to 24. Watch closely early and after dose changes. Never with an MAOI or within 14 days of one, linezolid or intravenous methylene blue among them; never with thioridazine or pimozide, which can upset the heart rhythm. Serotonin syndrome with other serotonin drugs. Bleeding risk with aspirin, NSAIDs, warfarin or other blood thinners. Can trigger mania: screened for bipolar first. Seizures. Angle-closure glaucoma in narrow-angle eyes. Low blood sodium: headache, confusion, unsteadiness. Sexual side effects, drowsiness and sweating are common. The withdrawal syndrome is among the strongest of these drugs: stop slowly, never suddenly.

In detail

An SSRI licensed for panic in the UK, on a prescription; in the US it is labeled for low mood and constant worry, and used off-label for panic. The UK label starts at 5 mg a day for the first week, then 10 mg, up to 20 mg.

Found

Symptoms down against placebo. A 10-week trial of 366 people: escitalopram cut panic symptoms and severity and lifted quality of life against placebo, and it was well tolerated.

Why

It blocks the serotonin pump like the others and is the most selective of them. The low first week softens the early jitter that panic is prone to.

Watch

Boxed warning: antidepressants raised suicidal thoughts and behavior at younger ages, 5 more per 1,000 at 18 to 24. Watch closely in the first months and after dose changes. Never with an MAOI, within 14 days of one, or with linezolid or intravenous methylene blue; never with pimozide. Ruled out with a known long QT, a long QT from birth, or other drugs that lengthen the QT. Serotonin syndrome with other serotonin drugs. Bleeding risk with aspirin, NSAIDs, warfarin or other blood thinners. Low blood sodium. Seizures. Can trigger mania: screened for bipolar first. Can slow thinking and reactions: care with driving and machinery until you know how it hits. Angle-closure glaucoma in narrow-angle eyes. Sexual side effects. Stop slowly, never suddenly.

In detail

An SSRI licensed for panic in the UK, on a prescription; in the US it is labeled for low mood only, so panic use is off-label. The UK label starts at 10 mg a day for a week, then 20 mg, up to 40 mg. Its heart-rhythm limit keeps the dose capped.

Found

A one-year trial: citalopram at 20 to 60 mg a day was effective, well tolerated and safe for long-term panic treatment. In a 10-week trial, it cut panic symptoms and severity against placebo.

Why

It is the parent drug of escitalopram and blocks the serotonin pump the same way. The dose cap comes from its effect on the heart’s rhythm at higher doses.

Watch

Boxed warning: antidepressants raised suicidal thoughts and behavior at younger ages. Watch closely early and after dose changes. Never with an MAOI or within 14 days of one, linezolid and intravenous methylene blue among them, and never with pimozide. Ruled out with a known long QT or a long QT from birth, and with other drugs that lengthen the QT. The heart-rhythm risk rises with dose: avoided with a slow heart rate, low potassium or magnesium, a recent heart attack or heart failure, and never above 40 mg. Capped at 20 mg for slow CYP2C19 metabolizers and with cimetidine or another CYP2C19 blocker. Serotonin syndrome with other serotonin drugs. Bleeding risk with aspirin, NSAIDs, warfarin or other blood thinners. Can trigger mania: screened for bipolar first. Seizures. Angle-closure glaucoma. Low blood sodium. Sexual side effects. Stop slowly, never suddenly.

In detail

An SSRI labeled for panic in the US, on a prescription; in the UK it is not licensed for panic, so use is off-label. The US label starts at 10 mg a day, then 20 mg after a week. Trials ran 10 to 60 mg.

Found

More panic-free than placebo. A 12-week trial: more were panic-free on fluoxetine than on placebo at six weeks and at the end. Twenty mg a day was safe and effective.

Why

It blocks the serotonin pump like the others, with a very long half-life. That long tail makes a missed dose or a stop gentler, and makes dose changes slow to show.

Watch

Boxed warning: antidepressants raised suicidal thinking and behavior at younger ages. Watch closely early and after dose changes. Never with an MAOI, within 14 days of stopping one or within 5 weeks of stopping fluoxetine, and not started on linezolid or intravenous methylene blue. Never with pimozide or thioridazine. Serotonin syndrome with other serotonin drugs. Stop at a rash or allergic signs. Can trigger mania: screened for bipolar first. Seizures. Weight loss. Bleeding risk with NSAIDs, aspirin or warfarin. Angle-closure glaucoma. Low blood sodium. Anxiety and poor sleep can come early. QT lengthening and rhythm trouble. Can slow judgment and reactions: care with machinery. A long half-life: dose changes take weeks to show. Stopping, most of all suddenly, can bring low mood, irritability, agitation and dizziness: taper with the doctor. Sexual side effects.

In detail

If the SSRIs did not suit: venlafaxine extended-release, on a prescription, labeled for panic in the UK and the US. The label starts at 37.5 mg a day for 7 days, then 75 mg, up to 225 mg. Steps are at least 7 days apart in the US, 2 weeks in the UK.

Found

Up to 61% against 35% panic-free. A 12-week trial of 664 people: 54% to 61% were panic-free on venlafaxine or paroxetine, against 35% on placebo. About three in four responded, and nearly half went into remission.

Why

An SNRI blocks the pumps for both serotonin and norepinephrine. The second chemical adds a push on the brain’s alarm-control circuits that some respond to when an SSRI did not.

Watch

Boxed warning: antidepressants raised suicidal thoughts and behavior at younger ages, 5 more per 1,000 at 18 to 24. Watch closely early and after dose changes. Never with an MAOI or within 14 days of one, linezolid or intravenous methylene blue among them. Serotonin syndrome with other serotonin drugs. Raises blood pressure: it is controlled first and checked regularly. Bleeding risk with aspirin, NSAIDs or blood thinners. Angle-closure glaucoma. Can trigger mania: screened for bipolar first. Seizures. Low blood sodium. Rare lung inflammation: report a new cough or breathlessness. Sexual side effects. More dangerous than the SSRIs in an overdose. A strong withdrawal: taper, never stop suddenly.

In detail

If an SSRI did not suit, or there is no gain after a 12-week course: one of two older tricyclic antidepressants, on a prescription and off-label for panic in the UK and the US. Started low and raised slowly. The clomipramine label starts at 25 mg a day.

Found

In a 12-week trial against a placebo, both drugs markedly cut panic attacks and the anxiety between them, and clomipramine did more. In a 10-week trial, clomipramine cut symptoms against placebo on every main measure.

Why

Both block the serotonin and norepinephrine pumps, clomipramine leaning on serotonin. They also hit other receptors, which brings the dry mouth, drowsiness and heart effects.

Watch

Boxed warning: antidepressants raised suicidal thinking and behavior at younger ages. Watch closely early. Never with an MAOI or within 14 days of one. Clomipramine is not started on linezolid or on methylene blue given into a vein. Ruled out in the recovery weeks after a heart attack. With any heart disease, the heart is watched at every dose for rhythm and conduction trouble. Far more dangerous than the SSRIs in an overdose. It makes seizures more likely. On clomipramine, seizures are the biggest risk. Dry mouth, constipation, trouble passing urine, blurred vision, and angle-closure glaucoma in narrow-angle eyes. Extra care with an overactive thyroid or thyroid pills, and with methylphenidate. It adds to the sedation of alcohol. Low blood sodium. Serotonin syndrome with other serotonin drugs. Sexual side effects: lower or raised drive, erection trouble, and on clomipramine often failed ejaculation. Stop slowly.