Combining escitalopram and cognitive-behavioural therapy for social anxiety disorder: randomised controlled fMRI trial

Malin Gingnell; Andreas Frick; Jonas Engman; Iman Alaie; Johannes Björkstrand; Vanda Faria; Per Carlbring; Gerhard Andersson; Margareta Reis; Elna-Marie Larsson; Kurt Wahlstedt; Mats Fredrikson; Tomas Furmark

doi:10.1192/bjp.bp.115.175794

Combining escitalopram and cognitive-behavioural therapy for social anxiety disorder: randomised controlled fMRI trial

Br J Psychiatry. 2016 Sep;209(3):229-35. doi: 10.1192/bjp.bp.115.175794. Epub 2016 Jun 23.

Affiliations

¹ Malin Gingnell, MD, PhD, Andreas Frick, PhD, Jonas Engman, MSc, Iman Alaie, MSc, Johannes Björkstrand, MSc, Department of Psychology, Uppsala University, Uppsala, Sweden; Vanda Faria, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden, and Center for Pain and the Brain, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Per Carlbring, PhD, Department of Psychology, Stockholm University, Stockholm, Sweden; Gerhard Andersson, PhD, Department of Behavioural Sciences and Learning, Psychology, Linköping University, Linköping, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Margareta Reis, PhD, Division of Drug Research/Clinical Pharmacology, Department of Health Sciences, Linköping University, Linköping, Sweden; Elna-Marie Larsson, MD, PhD, Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden; Kurt Wahlstedt, MD, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden; Mats Fredrikson, DMSc, PhD, Department of Psychology, Uppsala University, Uppsala, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Tomas Furmark, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden malin.gingnell@psyk.uu.se.
² Malin Gingnell, MD, PhD, Andreas Frick, PhD, Jonas Engman, MSc, Iman Alaie, MSc, Johannes Björkstrand, MSc, Department of Psychology, Uppsala University, Uppsala, Sweden; Vanda Faria, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden, and Center for Pain and the Brain, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Per Carlbring, PhD, Department of Psychology, Stockholm University, Stockholm, Sweden; Gerhard Andersson, PhD, Department of Behavioural Sciences and Learning, Psychology, Linköping University, Linköping, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Margareta Reis, PhD, Division of Drug Research/Clinical Pharmacology, Department of Health Sciences, Linköping University, Linköping, Sweden; Elna-Marie Larsson, MD, PhD, Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden; Kurt Wahlstedt, MD, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden; Mats Fredrikson, DMSc, PhD, Department of Psychology, Uppsala University, Uppsala, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Tomas Furmark, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden.

PMID: 27340112
DOI: 10.1192/bjp.bp.115.175794

Abstract

Background: Selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioural therapy (CBT) are often used concomitantly to treat social anxiety disorder (SAD), but few studies have examined the effect of this combination.

Aims: To evaluate whether adding escitalopram to internet-delivered CBT (ICBT) improves clinical outcome and alters brain reactivity and connectivity in SAD.

Method: Double-blind, randomised, placebo-controlled neuroimaging trial of ICBT combined either with escitalopram (n = 24) or placebo (n = 24), including a 15-month clinical follow-up (trial registration: ISRCTN24929928).

Results: Escitalopram+ICBT, relative to placebo+ICBT, resulted in significantly more clinical responders, larger reductions in anticipatory speech state anxiety at post-treatment and larger reductions in social anxiety symptom severity at 15-month follow-up and at a trend-level (P = 0.09) at post-treatment. Right amygdala reactivity to emotional faces also decreased more in the escitalopram+ICBT combination relative to placebo+ICBT, and in treatment responders relative to non-responders.

Conclusions: Adding escitalopram improves the outcome of ICBT for SAD and decreased amygdala reactivity is important for anxiolytic treatment response.

Publication types

Randomized Controlled Trial

MeSH terms

Adult
Amygdala / physiology*
Anxiety Disorders / drug therapy*
Anxiety Disorders / physiopathology*
Anxiety Disorders / therapy*
Citalopram / therapeutic use*
Cognitive Behavioral Therapy*
Combined Modality Therapy
Double-Blind Method
Facial Recognition / physiology
Female
Functional Neuroimaging
Humans
Internet
Magnetic Resonance Imaging
Male
Selective Serotonin Reuptake Inhibitors / therapeutic use
Therapy, Computer-Assisted
Treatment Outcome
Young Adult

Substances

Serotonin Uptake Inhibitors
Citalopram