To the Editor: We were interested to learn from Drs. Ruini and Fava that a low prevalence of major depression has been found in a clinical study group of patients with panic disorder who were treated with cognitive behavior therapy. This observation is consistent with the association we reported of a lower incidence of major depression among individuals in an epidemiologic sample who received some form of treatment for panic. We are less impressed, however, with evidence linking the treatment of patients with panic disorder with antidepressants to a poorer outcome, specifically in terms of a greater risk of major depression. After a close reading of the literature, we have failed to find strong empirical support for the sensitizing effects of antidepressant medications. At least in the short term, there appears to be evidence that antidepressant medications are associated with a greater, rather than lower, incidence of depression among patients with panic disorder (1).

The work by Fava et al. (2001), suggesting that the combined use of antidepressants and benzodiazepines is associated with a worse prognosis among those with panic disorder, is based on a clinical study group and is open to selection bias. Specifically, patients with more severe or complex psychopathology may be at greater risk of developing comorbid depression and may also be more likely to be prescribed antidepressant medications.

We are in complete agreement with the sentiments expressed by Drs. Ruini and Fava that this is a topic of clinical and public health significance. Research is needed to evaluate the long-term outcome associated with the pharmacological and psychological treatment of broadly representative patient groups with panic disorder.