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

Abstract

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and network meta-analysis of interventions for adults with social anxiety disorder, identified from published and unpublished sources between 1988 and Sept 13, 2013.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.

Copyright © 2014 Mayo-Wilson et al. Open Access article distributed under the terms of CC BY. Published by Elsevier Ltd.. All rights reserved.

Figures

Figure 1

PRISMA flowchart PRISMA=Preferred Reporting Items for Systematic reviews and Meta-Analyses.

Figure 2

Network diagram representing direct comparisons among classes The width of lines represents the number of trials in which each direct comparison is made. The size of each circle represents the number of people who received each treatment. CBT=cognitive–behavioural therapy. SNRI=serotonin–norepinephrine reuptake inhibitor. SSRI=selective serotonin-reuptake inhibitor.

Figure 3

Effect of each class of intervention compared with waitlist Data are standardised mean difference and 95% credible intervals compared with waitlist as a reference. CBT=cognitive–behavioural therapy. SNRI=serotonin–norepinephrine reuptake inhibitor. SSRI=selective serotonin-reuptake inhibitor.

Figure 4

Efficacy of classes of interventions Classes of interventions are ordered according to efficacy ranking from largest mean effect (top, left) to smallest mean effect (bottom, right). Data in blue represent the effects on symptoms of social anxiety (SMD [95% CrI]); SMD less than 0 favours the intervention in the row. Data in green represent the effects on recovery (RR [95% CrI]); RR greater than 1 favours the intervention in the column. Significant results are shaded dark blue and dark green. CBT=cognitive–behavioural therapy. CrI=credible interval. EXER=promotion of exercise. EXPO=exposure and social skills. MAOI=monoamine oxidase inhibitors. NSSA=noradrenergic and specific serotonergic antidepressants. OTHER=other psychological therapy. PDPT=psychodynamic psychotherapy. PSYP=psychological placebo. RR=risk ratio. SHNS=self-help without support. SHWS=self-help with support. SMD=standardised mean difference. SNRI=serotonin–norepinephrine reuptake inhibitors. SSRI=selective serotonin-reuptake inhibitor.