To the Editor: Steven E. Bruce, Ph.D., et al. (1) suggested that despite current practice guidelines, benzodiazepines are being used more frequently than selective serotonin reuptake inhibitors (SSRIs) to treat panic disorder. One possible explanation for this discrepancy is that some physicians are prescribing benzodiazepines as needed for patients who experience infrequent panic attacks. (I can offer only anecdotal evidence drawn from working with dozens of physicians in emergency rooms and psychiatric and general/family medicine settings.) I would argue that this approach is reasonable because these patients only need to take a benzodiazepine periodically rather than having to take an SSRI every day for at least a year (according to APA recommendations [2]). The obvious advantages of this regimen are its lower cost and less frequent side effects. The disadvantage, many would argue, is that periodic use of benzodiazepines can escalate into physical dependence and abuse (2). However, this argument is based somewhat on myth because there are "no data to suggest that long-term therapeutic use of benzodiazepines by patients commonly leads to dose escalation or recreational abuse" (3).

Although I have suggested that there may be a place for the first-line use of benzodiazepines for the treatment of panic disorder, there are some circumstances in which I would argue that SSRIs should be the first-line treatment. For example, there is some evidence that patients with comorbid substance-related disorders are more inclined to abuse prescribed benzodiazepines; therefore, they may benefit from a treatment regimen that involves SSRIs (2). Another population that would clearly benefit from SSRIs are patients with comorbid major depression. Also, patients with frequent panic attacks may benefit from the prophylactic effect of regular use of SSRIs, rather than the symptom control that would be garnered by a benzodiazepine taken after the onset of panic symptoms.