Panic disorder: propranolol and behavioural therapy

EDITOR—Barr Taylor clearly shows that selective serotonin reuptake inhibitors (SSRIs) are well accepted as first line treatment for panic disorder.1 However, many patients are still prescribed propranolol along with diazepam as first line treatment in primary care trusts to treat the adrenergic symptoms of panic disorder—such as palpitations, etc—although β blockers have no proved efficacy in the treatment of panic disorder.

Considering patients' choice of treatments, many patients are generally quite keen on non-pharmacological methods such as cognitive behaviour therapy, especially after they consider the side effect profile of SSRIs. But if we consider the cost implications, one year's treatment with an SSRI—for example, paroxetine 20 mg—costs an estimated £289, including direct and indirect prescribing and including follow-up costs, which is around £10 more or less than other generic drugs. However, 16 one hour sessions of cognitive behaviour therapy delivered by a clinical psychologist cost an estimated £1056. That is more than £300 extra expenditure per patient per year.2 In addition, the waiting lists of psychology departments are sometimes long.

Thus it is yet to be answered which is the most cost effective treatment for panic disorder, and only more thorough randomised controlled trials with patients receiving SSRIs and cognitive behaviour therapy can answer that.