Network meta-analysis is used to indirectly synthesise evidence on all possible treatments using direct comparisons with common comparators. 6 9 10 Nevertheless, it remains unclear which SSRI is most efficacious and is associated with the lowest risk of adverse events given the limited availability of direct comparisons between SSRIs and other drug classes. 7 8 As a result several guidelines recommend SSRIs as the primary treatment owing to their preferable long term safety over benzodiazepines and tricyclic antidepressants. 6 Findings from previous systematic reviews and direct meta-analyses suggest these treatments are more effective in reducing panic symptoms than placebo, but tricyclic antidepressants and benzodiazepines are linked with a significantly higher risk of adverse events. Several drug treatments are available for panic disorder, including tricyclic antidepressants, benzodiazepines, selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors, and serotonin-noradrenaline reuptake inhibitors (SNRIs).
IPANIC REVIEWS MANUAL
Successive revisions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, DSM-III-R, and DSM-IV) provide similar definitions of panic disorder, refined with each new edition but in the fifth revision (DSM-5) panic disorder and agoraphobia have been defined individually. 5 Agoraphobia is a strong fear or anxiety provoked by real or anticipated exposure to a wide range of situations and is often associated with panic disorder. 1 2 Panic disorder is characterised by recurrent and unexpected panic attacks associated with several comorbid psychiatric and non-psychiatric conditions 2 such as anxiety, depression, and cardiovascular diseases 3 4 and impairment of social, work, and family functioning. The lifetime prevalence of the common psychological problem known as panic disorder is between 1% and 5%. Among individual SSRIs, sertraline and escitalopram provided high remission with an acceptable risk of adverse events. 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. Consistency assumption of adverse events was upheld but could still be present on removal of studies with high percentages of women participants and those with agoraphobia. However, tricyclic antidepressants, benzodiazepines, and SSRIs were also significantly associated with increased risk of adverse events compared with placebo, with risk ratios of 1.79 (1.47 to 2.19), 1.76 (1.50 to 2.06), and 1.19 (1.01 to 1.41), respectively. SUCRAs identified benzodiazepines (84.5%, mean rank=2.4), tricyclic antidepressants (68.7%, 3.8), and SSRIs (66.4%, 4.0) as the top three best treatments for remission.
Network meta-analysis of remission with consistent results indicated that tricyclic antidepressants, benzodiazepines, monoamine oxidase inhibitors, SSRIs, and serotonin-noradrenaline reuptake inhibitors (SNRIs) were associated with significantly higher remission rates than placebo, with risk ratios of 1.39 (95% confidence interval 1.26 to 1.54), 1.47 (1.36 to 1.60), 1.30 (1.00 to 1.69), 1.38 (1.26 to 1.50), and 1.27 (1.12 to 1.45), respectively. Almost all the studies (86/87) had some concern or were at high risk of bias. Results 87 studies including a total of 12 800 participants and 12 drug classes were eligible for inclusion.
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