Optimal treatment of social phobia: systematic review and meta-analysis

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.

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

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

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

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

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

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

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

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.