Regarding the choice of pharmacological treatment, empirical evidence suggests that the SSRIs are an appropriate first consideration. Benzodiazepines, at minimum therapeutic dosage, may be a useful adjunct to an SSRI (or CBT), if prompt relief is indicated. If a benzodiazepine is used initially, the treatment plan should include its discontinuation when the effects of the SSRI are expected (ie, approximately 4 to 6 weeks). This approach will help minimize the risks of discontinuation difficulties. Although benzodiazepines are an appropriate intervention after SSRIs and other medications have failed, they should not be prescribed if comorbid substance abuse or a history of such abuse is suspected. Benzodiazepines should not be prescribed as monotherapy if the patient has comorbid depression.

When treatment consists of medication only, it is advisable to continue it for at least 12 months. Earlier discontinuation may result in symptom rebound and relapse. Many patients respond to acute treatment and maintain those gains over the long term; those who do not may need some form of continuation pharmacotherapy and/or CBT to restore or maintain gains. While not empirically tested, one possible strategy to help increase the response to maintenance therapy may be to ini­ti­ate treatment with medication and provide CBT subsequently.

As mentioned above, b-blockers are currently used on an as-needed basis for circumscribed SAD (eg, 10 to 40 mg of propranolol taken an hour before the situation that is the focus of anxiety). Exposure-based CBT, with or without initial as-needed b-blockers, is also an appropriate first-line treatment for those with circumscribed SAD.

Once treatment is selected, the patient should be monitored approximately weekly. When stabilized, patients should be encouraged to reenter previously avoided situations gradually—regardless of the treatment approach being used. Alternatives should be considered if the treatment response is inadequate after approximately 8 weeks.

Treatment of SAD with comorbidity
As noted, SAD is commonly associated with other psychiatric disorders.5-12 Clearly, comorbidity has implications for treatment selection. An important question is whether the first-line treatments for SAD with comorbidity are still safe and effective in this patient population.

We are beginning to see an emerging literature on treating SAD comorbid with alcohol use disorders and depression. Unfortunately, evidence on how to treat SAD in the context of a current comorbid psychiatric condition still remains scarce. One reason is that clinical trials usually exclude persons with comorbid disorders.

The scarcity of evidence on how to treat SAD with comorbidities was highlighted in a relatively recent review of pharmacotherapy for SAD and in another recent review of treatment recommendations for persons with a co-occurring affective or anxiety and substance use disorder.14,69 Both these reviews called for more research on comorbid samples.

SAD comorbid with depression tends to be associated with more impairment and more severe social anxiety symptoms than SAD alone.70 Higher rates of attempted suicide have been reported in this comorbid group.71 The treatment of comorbid depression or anxiety is challenging, and unfortunately there is a scarcity of data to inform treatment.

An open-label study of citalopram in a group of 21 patients with generalized SAD comorbid with major depression demonstrated improvement in both mood and anxiety symptoms after 12 weeks of treatment. Improvement in depressive symptoms occurred earlier than improvement in SAD symptoms.72 In another placebo-controlled study, moclobemide was both effective and well tolerated in the short- and long-term treatment of a sample of 390 patients with comorbid anxiety.73

A robust literature indicates that alcohol use disorders are commonly comorbid with SAD.9-12 While there is compelling evidence that supports the first-line use of SSRIs in the treatment of SAD, the efficacy of SSRIs has been determined in studies that typically excluded persons with alcohol use disorder.

To investigate whether an SSRI is safe and effective treatment for social anxiety in patients with alcohol use disorders, Randall and colleagues74 undertook a small 8-week pilot study. Findings from this study indicate that paroxetine is an effective treatment for SAD in persons with comorbid alcohol problems. However, the investigators recommend that further study is warranted. Book and colleagues75 subsequently conducted a 16-week, double-blind, placebo-controlled clinical trial of paroxetine that included 42 patients with SAD and comorbid alcohol use disorder. Paroxetine was superior to placebo in reducing social anxiety.75

The same group of investigators studied whether effective treatment of social anxiety will also reduce drinking in patients with a dual diagnosis who report using alcohol to cope with their anxiety symptoms.76 All of the 42 participants who sought treatment for social anxiety and not for the alcohol problem met DSM-IV diagnostic criteria for SAD and alcohol abuse or dependence. Paroxetine reduced self-reported reliance on alcohol for self-medication purposes but did not effect a change relative to placebo in the quantity and frequency of drinking or the proportion of drinking days that were identified as coping-related.76

rugs Mentioned in This Article
Alprazolam (Xanax)
Bupropion (Wellbutrin, Zyban)
Buspirone (BuSpar)
Citalopram (Celexa)
Clomipramine (Anafranil)
Clonazepam (Klonopin, Rivotril)
Clonidine (Catapres)
Duloxetine (Cymbalta)
Fluoxetine (Prozac, Sarafem, Symbyax)
Gabapentin (Neurontin, Gabarone)
Imipramine (Tofranil)
Mirtazapine (Remeron)
Moclobemide (Manerix)
Nefazodone (Serzone)
Olanzapine (Zyprexa)
Paroxetine (Paxil)
Phenelzine (Nardil)
Pregabalin (Lyrica)
Propranolol (Inderal)
Sertraline (Zoloft)
Venlafaxine (Effexor)
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