Skip to main page content
Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
, 8, 203-15

Optimal Treatment of Social Phobia: Systematic Review and Meta-Analysis

Affiliations

Optimal Treatment of Social Phobia: Systematic Review and Meta-Analysis

John Canton et al. Neuropsychiatr Dis Treat.

Abstract

This article proposes a number of recommendations for the treatment of generalized social phobia, based on a systematic literature review and meta-analysis. An optimal treatment regimen would include a combination of medication and psychotherapy, along with an assertive clinical management program. For medications, selective serotonin reuptake inhibitors and dual serotonin-norepinephrine reuptake inhibitors are first-line choices based on their efficacy and tolerability profiles. The nonselective monoamine oxidase inhibitor, phenelzine, may be more potent than these two drug classes, but because of its food and drug interaction liabilities, its use should be restricted to patients not responding to selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors. There are other medication classes with demonstrated efficacy in social phobia (benzodiazepines, antipsychotics, alpha-2-delta ligands), but due to limited published clinical trial data and the potential for dependence and withdrawal issues with benzodiazepines, it is unclear how best to incorporate these drugs into treatment regimens. There are very few clinical trials on the use of combined medications. Cognitive behavior therapy appears to be more effective than other evidence-based psychological techniques, and its effects appear to be more enduring than those of pharmacotherapy. There is some evidence, albeit limited to certain drug classes, that the combination of medication and cognitive behavior therapy may be more effective than either strategy used alone. Generalized social phobia is a chronic disorder, and many patients will require long-term support and treatment.

Keywords: antidepressant; cognitive behavior therapy; psychotherapy; social anxiety disorder; social phobia.

Figures

Figure 1
Figure 1
Odds ratios and 95% CI for treatment response in randomized placebo-controlled trials for SSRI. Response based on CGI for all studies except for Liebowitz Social Anxiety Scale in van Vliet et al. Only the highest ESC dose included for Lader et al. Abbreviations: CI, confidence interval; PAR, paroxetine; SERT, sertraline; ESC, escitalopram; FLX, fluoxetine; FLV, fluvoxamine; CGI, Clinical Global Impression; SSRI, selective serotonin reuptake inhibitor; M-H, Mantel-Haenszel odds ratio.
Figure 2
Figure 2
Odds ratios and 95% CI for treatment response in randomized placebo-controlled trials for the serotonin-norepinephrine reuptake inhibitor, venlafaxine. Response based on CGI for all studies. Abbreviations: CI, confidence interval; CGI, Clinical Global Impression; M-H, Mantel-Haenszel odds ratio; SNRIs, selective norepinephrine reuptake inhibitors.
Figure 3
Figure 3
Odds ratios and 95% CI for treatment response in randomized placebo-controlled trials for irreversible and reversible MAOIs. Response based on CGI for all studies except social phobia subscale of the Fear Questionnaire for Gelernter et al, and the Hamilton Anxiety Scale for van Vliet et al. Abbreviations: B, brofaromine; M, moclobemide; MAOIs, monoamine oxidase inhibitors; CI, confidence interval; M-H, Mantel-Haenszel odds ratio.
Figure 4
Figure 4
Odds ratios and 95% CI for treatment response in randomized placebo-controlled trials for the A2D ligands pregabalin (P) and gabapentin (G). Response based on CGI for all studies. Only the highest pregabalin doses are reported for Pande et al and Feltner et al. Abbreviations: A2D, alpha-2-delta; CI, confidence interval; M-H, Mantel-Haenszel odds ratio.
Figure 5
Figure 5
Odds ratios and 95% CI for treatment response in randomized placebo-controlled trials for five drug classes. Abbreviations: CI, confidence interval; SSRIs, selective serotonin reuptake inhibitors; SNRIs, serotonin-norepinephrine reuptake inhibitors; MAOIs, monoamine oxidase inhibitors; irrev, irreversible; RIMA, selective inhibitors of monoamine oxidase A; M-H, Mantel-Haenszel odds ratio.
Figure 6
Figure 6
Odds ratios and 95% CI for treatment response in randomized placebo-controlled trials for drug versus psychotherapy comparisons. Blomhoff et al used exposure therapy; all other trials used cognitive behavioral therapy as the psychotherapy intervention. Response based on Clinical Global Impression for all studies except social phobia subscale of the Fear Questionnaire for Gelernter et al, and the Social Anxiety Scale for Heimberg et al. Abbreviations: CI, confidence interval; SSRIs, selective serotonin reuptake inhibitors; MAOIs, monoamine oxidase inhibitors; M-H, Mantel-Haenszel odds ratio.
Figure 7
Figure 7
Odds ratios and 95% CI for treatment response in randomized placebo-controlled trials for medication compared with combined medication-psychological treatment. Blomhoff et al used exposure therapy; Knijnik et al used psychodynamic group therapy; all other trials used cognitive behavioral therapy as the psychotherapy intervention. Response based on Clinical Global Impression for all studies. Abbreviations: CI, confidence interval; SSRIs, selective serotonin reuptake inhibitors; MAOIs, monoamine oxidase inhibitors; BDZ, benzodiazepines; M-H, Mantel-Haenszel odds ratio.
Figure 8
Figure 8
Odds ratios and 95% CI for treatment response in randomized placebo-controlled trials for psychological therapy compared with combined medication-psychological treatment. Blomhoff et al used exposure therapy; all other trials used cognitive behavioral therapy as the psychotherapy intervention. Response based on Clinical Global Impression for all studies. Abbreviations: CI, confidence interval; SSRI, selective serotonin reuptake inhibitor; MAOI, monoamine oxidase inhibitor; M-H, Mantel-Haenszel odds ratio.

Similar articles

  • Evidence-based Treatment of Anxiety Disorders
    DJ Stein. Int J Psychiatry Clin Pract 10 Suppl 1, 16-21. PMID 24931539.
    Evidence-based medicine combines the best currently available evidence from systematic medical research, together with clinical expertise, in order to provide the best av …
  • Medication Therapy for Social Phobia
    RD Marshall et al. J Clin Psychiatry 55 Suppl, 33-7. PMID 8077172. - Review
    Social phobia, though the third most common psychiatric disorder in the United States, has received little systematic attention until recently. Chronic and disabling symp …
  • Using Antipsychotic Agents in Older Patients
    GS Alexopoulos et al. J Clin Psychiatry 65 Suppl 2, 5-99; discussion 100-102; quiz 103-4. PMID 14994733. - Review
    The experts reached a high level of consensus on many of the key treatment questions. Within the limits of expert opinion and with the expectation that future research da …
  • Anxiety Disorders: A Comprehensive Review of Pharmacotherapies
    EJ Hoffman et al. Mt Sinai J Med 75 (3), 248-62. PMID 18704983. - Review
    This article reviews the evidence from randomized, placebo-controlled trials and meta-analyses of pharmacological treatments of the following anxiety disorders: generaliz …
  • Social Phobia: A Pharmacologic Treatment Overview
    JW Jefferson. J Clin Psychiatry 56 Suppl 5, 18-24. PMID 7782272. - Review
    Generalized and specific social phobias are common, chronic, and potentially debilitating conditions. In recent years, there have been major advances in the pharmacothera …
See all similar articles

Cited by 11 PubMed Central articles

See all "Cited by" articles

References

    1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Health Disorders. 4th ed. Washington DC: American Psychiatric Association; 2000.
    1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Health Disorders. 3rd ed. Washington, DC: American Psychiatric Association; 1980.
    1. Magee WJ, Eaton WW, Wittchen H-U, McGonagle KA, Kessler RC. Agoraphobia, simple phobia, and social phobia in the National Comorbidity Survey. Arch Gen Psychiatry. 1996;53(2):159–168. - PubMed
    1. Ruscio A, Brown T, Chiu W, Sareen J, Stein M, Kessler R. Social fears and social phobia in the USA: results from the National Comorbidity Survey Replication. Psychol Med. 2008;38(1):15–28. - PMC - PubMed
    1. Stein MB, Kean YM. Disability and quality of life in social phobia: epidemiologic findings. Am J Psychiatry. 2000;157(10):1606–1613. - PubMed

LinkOut - more resources

Feedback