Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis

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Summary

Background

Social anxiety disorder—a chronic and naturally unremitting disease that causes substantial impairment—can be treated with pharmacological, psychological, and self-help interventions. We aimed to compare these interventions and to identify which are most effective for the acute treatment of social anxiety disorder in adults.

Methods

We did a systematic review and network meta-analysis of interventions for adults with social anxiety disorder, identified from published and unpublished sources between 1988 and Sept 13, 2013. We analysed interventions by class and individually. Outcomes were validated measures of social anxiety, reported as standardised mean differences (SMDs) compared with a waitlist reference. This study is registered with PROSPERO, number CRD42012003146.

Findings

We included 101 trials (13 164 participants) of 41 interventions or control conditions (17 classes) in the analyses. Classes of pharmacological interventions that had greater effects on outcomes compared with waitlist were monoamine oxidase inhibitors (SMD −1·01, 95% credible interval [CrI] −1·56 to −0·45), benzodiazepines (−0·96, −1·56 to −0·36), selective serotonin-reuptake inhibitors and serotonin–norepinephrine reuptake inhibitors (SSRIs and SNRIs; −0·91, −1·23 to −0·60), and anticonvulsants (−0·81, −1·36 to −0·28). Compared with waitlist, efficacious classes of psychological interventions were individual cognitive–behavioural therapy (CBT; SMD −1·19, 95% CrI −1·56 to −0·81), group CBT (−0·92, −1·33 to −0·51), exposure and social skills (−0·86, −1·42 to −0·29), self-help with support (−0·86, −1·36 to −0·36), self-help without support (−0·75, −1·25 to −0·26), and psychodynamic psychotherapy (−0·62, −0·93 to −0·31). Individual CBT compared with psychological placebo (SMD −0·56, 95% CrI −1·00 to −0·11), and SSRIs and SNRIs compared with pill placebo (−0·44, −0·67 to −0·22) were the only classes of interventions that had greater effects on outcomes than appropriate placebo. Individual CBT also had a greater effect than psychodynamic psychotherapy (SMD −0·56, 95% CrI −1·03 to −0·11) and interpersonal psychotherapy, mindfulness, and supportive therapy (−0·82, −1·41 to −0·24).

Interpretation

Individual CBT (which other studies have shown to have a lower risk of side-effects than pharmacotherapy) is associated with large effect sizes. Thus, it should be regarded as the best intervention for the initial treatment of social anxiety disorder. For individuals who decline psychological intervention, SSRIs show the most consistent evidence of benefit.

Funding

National Institute for Health and Care Excellence.

Related collections

Most cited references 23

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Evidence Synthesis for Decision Making 4

Sofia Dias, Nicky Welton, Alex J Sutton … (2013)

Inconsistency can be thought of as a conflict between “direct” evidence on a comparison between treatments B and C and “indirect” evidence gained from AC and AB trials. Like heterogeneity, inconsistency is caused by effect modifiers and specifically by an imbalance in the distribution of effect modifiers in the direct and indirect evidence. Defining inconsistency as a property of loops of evidence, the relation between inconsistency and heterogeneity and the difficulties created by multiarm trials are described. We set out an approach to assessing consistency in 3-treatment triangular networks and in larger circuit structures, its extension to certain special structures in which independent tests for inconsistencies can be created, and describe methods suitable for more complex networks. Sample WinBUGS code is given in an appendix. Steps that can be taken to minimize the risk of drawing incorrect conclusions from indirect comparisons and network meta-analysis are the same steps that will minimize heterogeneity in pairwise meta-analysis. Empirical indicators that can provide reassurance and the question of how to respond to inconsistency are also discussed.

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Selective serotonin reuptake inhibitor discontinuation syndrome: a randomized clinical trial.

Jerrold Rosenbaum, Maurizio Fava, Sharon L Hoog … (1998)

Recent reports describe discontinuation-emergent adverse events upon cessation of selective serotonin reuptake inhibitors including dizziness, insomnia, nervousness, nausea, and agitation. We hypothesized that interruption of fluoxetine treatment would be associated with fewer discontinuation-emergent adverse events than interruption of sertraline or paroxetine treatment, based on fluoxetine's longer half-life. In this 4-week study, 242 patients with remitted depression receiving maintenance therapy with open-label fluoxetine, sertraline, or paroxetine for 4-24 months had their maintenance therapy interrupted with double-blind placebo substitution for 5-8 days. The Symptom Questionnaire (SQ), the Discontinuation-Emergent Signs and Symptoms checklist, the 28-item Hamilton Depression Rating Scale, and the Montgomery-Asberg Depression Rating Scale were used to assess somatic distress and stability of antidepressant response. Two hundred twenty patients (91%) completed the study. Following interruption of therapy, fluoxetine-treated patients experienced fewer discontinuation-emergent events than either sertraline-treated or paroxetine-treated patients (p < .001). The mean SQ somatic symptom scale score in fluoxetine-treated patients was significantly lower than that in sertraline-treated and paroxetine-treated patients (p < .001). Fluoxetine-treated patients also experienced less reemergence of depressive symptoms than sertraline-treated or paroxetine-treated patients (p < .001). Abrupt interruption of antidepressant therapy for 5-8 days was associated with the emergence of new somatic and psychological symptoms in patients treated with paroxetine and to a lesser degree sertraline, with few symptoms seen with fluoxetine.

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The treatment of social anxiety disorder.

Robert Holaway, Thomas Rodebaugh, Richard Heimberg (2004)

We review the available treatments for social anxiety disorder, focusing primarily on psychotherapeutic interventions for adults, but also giving briefer summaries of pharmacological treatments and treatments for children and adolescents. The most well-researched psychosocial treatments for social anxiety disorder are cognitive-behavioral therapies (CBTs), and meta-analyses indicate that all forms of CBT appear likely to provide some benefit for adults. In addition, there are several pharmacological treatments with demonstrated efficacy, and cognitive-behavioral interventions have some demonstrated efficacy for children and adolescents. We outline a number of concerns regarding this literature, including the questions of what influences treatment response and what role combinations of CBT and medication might have. Clearly, although a number of treatments appear well-established in regard to their effects on social anxiety disorder, a number of opportunities for future research remain, including the search for predictors of who will benefit from which treatment.

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Author and article information

Contributors

Evan Mayo-Wilson

Journal

Journal ID (nlm-ta): Lancet Psychiatry

Journal ID (iso-abbrev): Lancet Psychiatry

Title: The Lancet. Psychiatry

Publisher: Elsevier

ISSN (Print): 2215-0366

ISSN (Electronic): 2215-0374

Publication date PMC-release: 26 September 2014

Publication date (Print): 26 September 2014

Volume: 1

Issue: 5

Pages: 368-376

Affiliations

[a ]Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational, and Health Psychology, University College London, London, UK

[b ]School of Social and Community Medicine, University of Bristol, Bristol, UK

[c ]Population Health Research Institute, St George's, University of London, London, UK

[d ]Department of Experimental Psychology, University of Oxford, Oxford, UK

Author notes

[* ]Correspondence to: Dr Evan Mayo-Wilson, Center for Clinical Trials and Evidence Synthesis, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA evan.mayo-wilson@ 123456jhu.edu

Article

Publisher ID: S2215-0366(14)70329-3

DOI: 10.1016/S2215-0366(14)70329-3

PMC ID: 4287862

PubMed ID: 26361000

SO-VID: f615a0d0-97bf-4417-ae7e-644473945e48

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This document may be redistributed and reused, subject to certain conditions.

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