How should I approach the management of a patient experiencing recurrent panic attacks in primary care?

Approach to managing a patient with recurrent panic attacks in primary care:

• Step 1: Recognition and diagnosis – Use high-standard consultation skills to take a structured history, including personal history, symptom timeline, and comorbidities such as depression or substance misuse. Confirm diagnosis of panic disorder versus isolated panic attacks, noting that a panic attack does not necessarily mean panic disorder. Exclude acute physical causes with minimal necessary investigations, especially if chest pain is present.
• Step 2: Treatment in primary care – Offer evidence-based treatments promptly, including psychological therapies (e.g., cognitive behavioural therapy), medication (typically SSRIs), and self-help interventions. For mild to moderate panic disorder, low-intensity interventions such as individual non-facilitated or facilitated self-help should be offered or referred. Provide written information about panic attacks and sources of support, including local and national voluntary groups.
• Step 3: Review and alternative treatment – Monitor response to initial treatment and consider alternative or additional treatments if symptoms persist.
• Step 4: Referral – If two interventions (any combination of psychological, medication, or bibliotherapy) have been tried without sufficient improvement, refer to specialist mental health services for comprehensive reassessment and management.
• Additional considerations – Discuss the benefits of exercise as part of general health. Be alert to drug interactions and contraindications, especially when prescribing SSRIs. Ensure clear communication between primary and secondary care providers. Provide ongoing monitoring and support, including managing withdrawal symptoms if medication is discontinued.

This stepped-care approach ensures tailored, effective management of recurrent panic attacks in primary care, with escalation to specialist services as needed ¹.