A large variety of anti-depressant and minor tranquilizers have been reported to help social anxiety disorder as has cognitive behavioral psychotherapy. In fact, for many counseling may be better than medication, especially gentle but prolonged exposure therapy.
I favor avoiding the addictive minor tranquilizers and first trying counseling followed by lower cost anti-depressants. Hydroxyzine pamoate is probably the most mild, effective medication. Imipramine, nortriptyline, fluoxetine, 5-HTP, and St. John's wort are low cost alternatives.
An SSRI Helped Social Anxiety Disorder Slightly: In a 12 week DB PC trial of 300 patients with generalized social anxiety disorder, the half given fluvoxamine had a 37% decrease in anxiety vs. a 28% decrease with placebo. Univ Hosp Utrecht. A double-blind placebo-controlled study of controlled release fluvoxamine for the treatment of generalized social anxiety disorder. Westenberg HG, Stein DJ, Yang H, Li D, Barbato LM. J Clin Psychopharmacol. 2004 Feb; 24(1): 83-6. This minimal benefit suggests that counseling and non-medication alternatives should be tried first.
Pregabalin for Social Anxiety: In a 11-week, 135 patient DB PC study of social anxiety using pregabalin 150 mg/d, pregabalin 600 mg/d, or placebo, significant differences (P < or = 0.05) between pregabalin 600 mg/d and placebo were seen on several secondary measures including the LSAS subscales of total fear, total avoidance, social fear, and social avoidance, and the Brief Social Phobia Scale fear subscale. Efficacy of the novel anxiolytic pregabalin in social anxiety disorder: a placebo-controlled, multicenter study. Pande AC, Feltner DE, Jefferson JW, Davidson JR, Pollack M, Stein MB, Lydiard RB, Futterer R, Robinson P, Slomkowski M, DuBoff E, Phelps M, Janney CA, Werth JL. Pfizer Drug Company. J Clin Psychopharmacol. 2004 Apr;24(2):141-9. Ed: This seems like a minor benefit for a condition with numerous effective low cost generic medications already available.
Lexapro Said to Help Social Anxiety Disorder in Bogus Study: In a poorly designed DB PC study, intentionally designed to make Lexapro look good, 371 patients with a primary diagnosis of social anxiety disorder who had received 12 weeks of Lexapro in an open-label trial, were then assigned to either stay of Lexapro 10-20 mg/day or to have the medicine abruptly withdrawn and given look-alike placebos. The risk of relapse was 180% higher for placebo than for Lexapro (p < .001), resulting in fewer Lexapro relapses (22% vs. 50%). A 24-week randomized, double-blind, placebo-controlled study of escitalopram for the prevention of generalized social anxiety disorder. Montgomery SA, et al. Imperial College , London , U.K. and others. J Clin Psychiatry. 2005 Oct;66(10):1270-8. Ed: This study must have been designed by the manufacturer. Lexapro has a 26% side-effect discontinuation rate according to the manufacturer’s insert in the PDR . This study avoids those cases. It also avoids those who didn’t improve while on Lexapro. These two groups totaled 34% in this study which started with 517 patients, 149 of whom had side-effects or failed to improve while on Lexapro. It also subjects patients to abrupt withdrawal, which is known to have a harmful effect with many antidepressants. Thus, an additional unknown percentage of the placebo relapses is almost certainly due to drug withdrawal. Only a drug dealer and his accomplices could like this study design.
Escitalopram (Lexapro), Other SSRI Help Social Anxiety: In a 24-week DB PC study of 839 adults with social anxiety disorder funded by the manufacturer of escitalopram, 5 mg/day, 10 mg/day, and 20 mg/day of escitalopram and 20 mg/day of paroxetine all did better than placebo, and 20 mg escitalopram was significantly superior to 20 mg paroxetine. Efficacy and tolerability of escitalopram in 12- and 24-week treatment of social anxiety disorder: Randomised, double-blind, placebo-controlled, fixed-dose study. Lader M, Stender K, Burger V, Nil R. University of London, UK. Depress Anxiety. 2004;19(4):241-8. Ed: While the psychiatrists working for the manufacturer claim that SSRIs are superior for social anxiety disorder, this has definitely not been proven. They also picked out the worst SSRI, short-acting paroxetine, as a comparison. Fluoxetine (generic Prozac) would almost certainly done as well for $2 per month vs. $80 per month wholesale cost for Lexapro. Many other inexpensive alternatives also help social anxiety. Based on currently available research, it does not appear ethically responsible to prescribe Lexapro as a first line treatment.
Escitalopram (Lexapro) Small Benefit for Generalized Anxiety: In a 12-week DB PC study of 358 adults with generalised social anxiety disorder, 10-20 mg escitalopram resulted in slightly more responders than placebo (54% v. 39%; P<0.01). Escitalopram in the treatment of social anxiety disorder: Randomised, placebo-controlled, flexible-dosage study. Kasper S, Stein DJ, Loft H, Nil R. University of Vienna. Br J Psychiatry. 2005 Mar;186:222-6. Ed: This means seven need to be treated for every one who responds. That's not very impressive. Many older medications do just as well or better without the high cost of Lexapro.
Fluoxetine or Cognitive Behavioral Therapy Helped Social Phobia; but Cognitive Behavioral Therapy No Added Benefit: In a 14-week DB PC study of 295 adults with social phobia, those given fluoxetine 10-60 mg/d did as well whether they received weekly cognitive behavioral therapy or not. Those receiving cognitine behavior therapy for 14 weeks did as well as those on fluoxetine. Notwithstanding the benefits of treatment, many patients remained symptomatic after 14 weeks. Fluoxetine, comprehensive cognitive behavioral therapy, and placebo in generalized social phobia. Davidson JR, Foa EB, et al. Duke University. Arch Gen Psychiatry. 2004 Oct;61(10):1005-13.
Shyness Usually Outgrown: In the US National Comorbidity, Survey of 5877 adults, 26% of women and 19% of men described themselves as 'very shy' when they were growing up. Of these shy individuals, 53% of women and 40% of men met criteria for a lifetime diagnosis of one or more anxiety or mood disorders [this is about twice as high as the national average suggesting that the shyness is the cause for only half in the disorders]. Shyness in childhood was linked to the complex subtype of social phobia in adulthood with lesser links to posttraumatic stress disorder in women and for major depressive disorder in men. Excessive shyness does not appear to be strongly associated with other anxiety and mood disorders when related psychosocial and developmental dimensions are statistically controlled. Finally, many individuals who report excessive childhood shyness do not meet criteria for any anxiety or mood disorder. Also, 50% of individuals with a lifetime history of complex social phobia did not view themselves as very shy when growing up. Psychiatric correlates of childhood shyness in a nationally representative sample. Cox BJ, et al. University of Manitoba. . Behav Res Ther. 2005 Aug;43(8):1019-27
Venlafaxine and SSRI Equally Effective for Social Anxiety: In a 12-week DB PC study of 440 adults with social anxiety disorder, venlafaxine hydrochloride ER (75-225 mg/d) did as well as paroxetine (20-50 mg/d) and better than placebo at 26 centers in the United States on the Liebowitz Social Anxiety Scale. Mean daily doses were 201.7 mg of venlafaxine hydrochloride ER and 46.0 mg of paroxetine. Week 12 response rates were significantly greater for the venlafaxine ER and paroxetine groups (58.6% and 62.5%) vs the placebo group (36.1%) (P < .001). Liebowitz MR, Gelenberg AJ, Munjack D. New York State Psychiatric Institute. Arch Gen Psychiatry. 2005 Feb;62(2):190-8. Ed: Both of these drugs have frequent bad withdrawal reactions. Other SSRIs, tricyclics, hydroxyzine, or anti-depressants seem more desirable.
Venlafaxine (Effexor) No Better Than SSRI for Social Anxiety: In 434 social anxiety disorder patients in a DB PC study of venlafaxine ER 75 mg to 225 mg/day, paroxetine 20 mg to 50 mg/day, or placebo for 12 weeks, there was no difference between venlafaxine and paroxetine with response rates of 69%, 66% and 36%, respectively. Efficacy of Venlafaxine ER in patients with social anxiety disorder: a double-blind, placebo-controlled, parallel-group comparison with paroxetine. Allgulander C, Mangano R, Zhang J, Dahl AA, Lepola U, Sjodin I, Emilien G. Karolinska Institutet, Sweden. Hum Psychopharmacol. 2004 Aug;19(6):387-96
Venlafaxine Helped Social Anxiety: In a 12-week DB PC study of 271 adults with generalized social anxiety disorder, Improvement was significantly greater with venlafaxine ER (75-225 mg/d) than with placebo at weeks 6 through 12 (p < .05, week 6, and p < .001, week 12). The response rate was 44% vs. 30%, and the remission rate: 20% vs. 7%, respectively, p < .01). A Randomized Controlled Trial of Venlafaxine Extended Release in Generalized Social Anxiety Disorder. Liebowitz MR, Mangano RM, et al. New York State Psychiatric Institute. J Clin Psychiatry. 2005 Feb;66(2):238-247. Ed: Many less expensive anti-depressants do just as well, but venlafaxine-XR is still patent-protected so can get large profits by financing such studies.
Thomas E. Radecki, M.D., J.D.