Pharmacotherapy for social phobia

D J Stein, J C Ipser, A J Balkom
Cochrane Database of Systematic Reviews 2004 October 18, (4): CD001206

BACKGROUND: Social phobia (SP), or social anxiety disorder, is a prevalent and disabling disorder. There is growing evidence that SP is mediated by specific neurobiological factors, and increased interest in the use of medication in its treatment.

OBJECTIVES: To assess the effects of pharmacotherapy for Social Phobia, and to determine whether particular classes of medication are more effective and/or acceptable than others in its treatment.

SEARCH STRATEGY: Studies of the pharmacotherapy of SP were identified using literature searches of the Cochrane Depression, Anxiety & Neurosis Group (CCDAN) specialised register, the Cochrane Central Register of Controlled Trials (The Cochrane Library issue 1, 2004), MEDLINE (1966 to 2003) and PsycLit (1966 to 2003). In addition, published and unpublished RCTs were requested from SP researchers and pharmaceutical companies and additional studies of any language were sought in reference lists of retrieved articles.

SELECTION CRITERIA: All RCTs of the pharmacotherapy of SP were considered for the review.

DATA COLLECTION AND ANALYSIS: The quality of selected RCTs was independently assessed by 2 raters on the CCDAN Quality Rating Scale, with the same raters collating data on treatment response and SP symptom ratings. Investigators were contacted to obtain missing data. Summary statistics were stratified by medication class (SSRIs - selective serotonin reuptake inhibitors; MAOIs - Monoamine oxidase inhibitors; RIMAs - reversible inhibitors of monoamine oxidase A), from which dichotomous and continuous measures were calculated, heterogeneity was assessed, and subgroup/sensitivity analyses undertaken.

MAIN RESULTS: 36 RCTs of a range of medications were included in the analysis (4268 participants), of which 26 were short-term (14 weeks or less). A funnel plot provided evidence of publication bias. Summary statistics for responder status (assessed using the Clinical Global Impressions scale change item (CGI-C)) from 25 short-term comparisons demonstrated superiority of various medication agents over placebo (relative risk of non-response (RR) = 0.63; 95% CI = 0.55, 0.72; random effects model). Response to treatment by serotonin reuptake inhibitors (N = 11; RR = 0.67; 95% CI = 0.59, 0.76), MAOIs (N = 3; RR = 0.43; 95% CI = 0.24, 0.76) and RIMAs (N = 6; RR = 0.74; 95% CI = 0.59, 0.91) supported the value of these agents. However, the SSRIs were significantly more effective than the RIMAs (Deeks' stratified test of heterogeneity (Deeks 2001): Qb = 29.82; p < 0.00001). Summary statistics for SP symptoms from 16 comparisons using the Liebowitz Social Anxiety Scale (LSAS) showed a statistically significant difference between medication and placebo (weighed mean difference = -15.56, 95%CI = -17.95, -13.16), with this effect once again most evident for the SSRIs. Medication was also significantly superior to placebo in reducing SP symptom clusters, comorbid depressive symptoms, and associated disability. The value of long-term medication treatment in treatment responders was supported by 3 comparisons from maintenance studies (relative risk of non-response = 0.58; 95% CI = 0.39, 0.85) and 5 comparisons from relapse prevention studies (relative risk of relapse = 0.33; 95% CI = 0.22, 0.49).

REVIEWERS' CONCLUSIONS: This review provides evidence that medication can be effective in treating SP over the short term, with the strongest evidence of treatment efficacy observed amongst the SSRIs. Furthermore, the data support continued pharmacotherapy in medication responders over the longer-term. Nevertheless, the possibility of publication has to be acknowledged. Additional issues for future research include the use of medication in children and adolescents with SP, and in SP with comorbid psychiatric disorders.

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