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Social Anxiety Help
CBT Trumps Medications
When looking at individual medications, the SSRIs citalopram (multiple brands), escitalopram (Lexapro, Forest Laboratories, Inc) fluoxetine (multiple brands), fluvoxamine (Luvox, ANI Pharmaceuticals, Inc, and Jazz Pharmaceuticals, Inc) paroxetine (multiple brands), and sertraline (Zoloft, Pfizer Inc), as well as the SNRI venlafaxine (mutiple brands), all showed greater outcome effects than the wait-list reference. With the exception of citalopram, all of these drugs, as well as clonazepam (Klonapin, Roche), moclobemide (multiple brands), and phenelzine (Nardil, Parke-Davis), were more effective than pill placebo.
There was no evidence that combining medication and talk therapy was better than talk therapy alone.
Because there was little evidence of differential efficacy within or between classes of drugs, differences in tolerability and side effects are especially important when choosing treatment, note the investigators.
"SSRIs and SNRIs with a short half-life...are associated with the greatest risk of discontinuation effects," they write. "Some side effects such as increased agitation and sexual dysfunction can be especially distressing for people with social anxiety disorder."
The authors add that these issues should be discussed with patients before starting treatment. In addition, they note that most patients who respond to an SSRI will relapse within a few months if the drug is discontinued after acute treatment ― and 25% of those who continue treatment will still relapse within 6 months.
On the other hand, effects from psychological interventions are generally well maintained. "For this reason, and because of the lower risk of side-effects, psychological interventions should be preferred over pharmacological interventions for initial treatment," they write.
However, if a patient declines talk therapy, the investigators recommend treatment with an SSRI. "Other drugs are recommended only for people who do not respond to initial treatment."
[The research found that a combination of individual CBT and group CBT was by far the most effective treatment for social anxiety, surpassing all medication treatment, as well as other forms of psychotherapy and support. The research found that individual CBT alone is more effective than group CBT alone, and that individual CBT alone is more effective than medication and other forms of psychotherapy and support. Nonetheless, group CBT alone was found to be about as effective as medications, and is more effective than other non-CBT forms of psychotherapy and support.]
Dr Mayo-Wilson noted that his investigative team examined cost-effectiveness of the therapies, the results of which will be reported in a separate article, and found that group therapy "was not worth the money" vs. individual therapy. "The conclusion we reached was that individual CBT was the most cost-effective thing you could do for patients with social anxiety disorder in the long term, and it doesn't have the side effects you have from taking medication," he said.
Good News for Patients
Pim Cuijpers, PhD, from the Department of Clinical Psychology at the VU University Amsterdam, the Netherlands, and Prof Dr Annemieke van Straten, from the EMGO Institute for Health and Care Research in Amsterdam, write in an accompanying editorial that the meta -analysis is "an important next step in improving our knowledge" about social anxiety disorder treatments.
"The findings confirm that both psychological and pharmacological treatments are effective, and that the effects of these treatments are large," they write. "The message that social anxiety disorder can often be treated successfully is important from a public health perspective, and would certainly be a good subject for an educational public campaign."
The editorialists note that although the investigators write that individual CBT is better than SSRIs/SNRIs because of the latter group's high relapse rates, "the long-term effects of treatment could not be included in this meta-analysis because the number of studies examining this was too small."
"To really help patients and reduce their distress, long-term trials on drugs and psychotherapy are urgently needed," the editorialists write.
Still, they conclude that the promising findings from the current analysis are "good news for our patients!"
Dr Mayo-Wilson, five of the other study authors, and the editorialists have reported no relevant financial relationships. The remaining study author reports being the developer of one of the versions of individual CBT examined.
Lancet Psychiatry. Published online September 26, 2014.
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