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History of the present illness and current symptoms
Past psychiatric history
General medical history
History of substance use, including illicit drugs,
prescribed and over-the-counter medications, and other substances
(e.g., caffeine) that may produce physiological effects that can
trigger or exacerbate panic symptoms
Personal history (e.g., major life events)
Social, occupational (including military), and family
Review of the patient's medications
Review of systems
Mental status examination
Appropriate diagnostic tests (to rule out possible
causes of panic symptoms)
Mitral valve prolapse
Irritable bowel syndrome
Identification of specific psychiatric symptoms known
to be associated with suicide attempts or suicide
Assessment of past suicidal behavior, family history
of suicide and mental illness, and current stressors
Assessment of potential protective factors such as
positive reasons for living
Specific inquiry about suicidal thoughts, intent, plans,
means, and behaviors
Avoidance that is a manifestation of panic disorder
Logistical barriers (e.g., economic factors, transportation,
Cultural or language barriers
Problems in the therapeutic relationship
Short-term intensification of anxiety associated with
treatment (e.g., due to medication side effects or exposure to fear
Risks and benefits of the treatment, including risk
of medication side effects
The patient's treatment history
Presence of co-occurring general medical and psychiatric
Cost for the patient
Availability of the treatment
Factors Favoring Psychosocial Treatment
Patient prefers nonmedication treatment.
Patient can invest the time and effort needed for this
Patient is pregnant, nursing, or planning to become
Patient has co-occurring personality disorder.
Factors Favoring Pharmacotherapy
Patient prefers this modality.
Patient does not have time or other resources needed
for psychosocial treatment.
Factors Favoring Combined Treatment
Patient has failed to respond to standard monotherapies.
Patient prefers immediate control of distressing symptoms
Patient prefers to reduce future need for medications.
Side effects (including any applicable warnings of
the U.S. Food and Drug Administration)
Potential drug interactions
Co-occurring general medical and psychiatric conditions
Strength of the evidence base for the particular medication
Cost and availability
Strength of the evidence base for the particular psychotherapy
Presence of co-occurring personality disorder
doses are sometimes used for patients who do not respond to the
usual therapeutic dose.
into three or four doses given throughout the day.
split into two doses given morning and evening.
Suicidal ideation and behavior
Carefully monitor for self-harming or suicidal thoughts
or behaviors and for side effects (e.g., anxiety, agitation, insomnia,
irritability) that may influence such behaviors.
Upper gastrointestinal bleeding
Consider possible increase in risk, particularly when an
SSRI is prescribed in combination with a nonsteroidal anti-inflammatory
drug or with aspirin.
Falls and fractures
Prescribe carefully to elderly patients.
See above for SSRIs.
Venlafaxine, extended release
Sustained hypertension in a small proportion of patients
Assess blood pressure during treatment, particularly
when venlafaxine is titrated to higher doses.
Do not prescribe TCAs for patients who have acute narrow-angle
glaucoma or clinically significant prostatic hypertrophy.
Significant or fatal arrhythmia
Consider obtaining a baseline ECG for patients with preexisting
cardiac conduction abnormalities.
Significant cardiac toxicity and fatality on overdose
Prescribe TCAs judiciously in suicidal patients.
Sedation, fatigue, ataxia, slurred speech, memory impairment,
Increased risk of motor vehicle accidents
Warn patients about driving or operating heavy machinery.
Additive effects of benzodiazepines and alcohol
Advise patients about these effects, particularly about
combined sedative and respiratory effects.
Potential misuse of the benzodiazepine or relapse of a
substance use disorder
Prescribe cautiously to patients with a history of substance
use disorders and monitor carefully, e.g., dispense in limited quantities,
supervise medication administration, assess nonadherence, increase
office visit frequency.
Monitor the patient for development of cognitive impairment,
which may be more problematic at higher doses and in patients performing
complex information-processing tasks at work. Prescribe with caution
to elderly patients or those with preexisting cognitive impairment.
Underlying untreated medical illness
Interference by co-occurring general medical or psychiatric
conditions (including depression and substance use)
Inadequate treatment adherence
Problems in the therapeutic alliance
Presence of psychosocial stressors
Inability to tolerate treatment
The patient's level of motivation
Duration of the patient's symptom stability
Stability of co-occurring conditions
Current or impending psychosocial stressors in the
Availability of alternative treatments