Clonazepam and milnacipran in the treatment of patients with panic disorder and comorbid major depression

Background: Many patients suffering from panic disorder have comorbid major depression Although antidepressants treat both disorders they do so after a certain time. It is generally accepted that panic attacks, which characterise panic disorder, should be treated as rapidly as possible, and only once such attacks are under control switch to antidepressants. Aims: The objective of this study was to assess the efficacy, safety and tolerability of a treatment strategy of initial clonazepam monotherapy switching progressively to the serotonin and noradrenaline reuptake inhibitor, milnacipran. Patients and methods: Seventy-four outpatients, with a DSM-IV diagnosis of panic disorder, with or without agoraphobia, and comorbid unipolar major depression were recruited. Patients were administered clonazepam 0.5 mg to 2 mg per day for 28 days and then slowly tapered off over the next 2 weeks. From day 14 patients were administered milnacipran 50 mg per day (25 mg bid) increasing to 100 mg per day (50 mg bid) on day 21 and maintained at this dose for a further 7 weeks. Results: At endpoint, 85% of the 60 completer patients showed a good antidepressant response and 70% were free from full-symptom panic attacks. The treatment was well tolerated with only four patients discontinuing due to adverse events. Conclusions: This open study, suggests that the combined sequential treatment with clonazepam and milnacipran may be safe and effective in patients with comorbid panic disorder and major depressive disorder.