Social anxiety disorders best treated by therapy

Today it may seem like there’s a pill to treat everything. But is turning to medication always the best answer? A researcher at the Bloomberg School of Public Health (JHSPH) conducted a meta-analysis of studies from between 1988 to 2013 and found that individual Cognitive Behavior Therapy (CBT) is more effective at treating social anxiety disorder than any pharmacological or psychological treatment options. This analysis could help treat the 15 million people in the U.S. with social anxiety disorder.

Evan Mayo-Wilson, a researcher at the JHSPH, conducted the study. His analysis concludes that among all treatments studied, only individual CBT and the class of antidepressants known as selective serotonin-reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs) perform better at reducing levels of anxiety than their respective placebos. He also found that individual CBT performed better than SSRIs or SNRIs.

The analysis was published Sept. 26 in The Lancet Psychiatry. Several mass media outlets, including CNN, Time and Forbes, ran articles on the study.

Over the course of three years, from 2011 to 2014, the analysis identified 101 studies of both pharmacological and psychological treatments for social anxiety disorder, then compiled the data from those studies to draw conclusions about which treatments were most effective.

Mayo-Wilson began the analysis at Oxford University and continued it while working at the National Collaborating Centre for Mental Health (NCCMH), a division of the National Institute for Health and Clinical Excellence (NICE), which develops clinical guidelines for healthcare in England and Wales. He then finished the analysis after moving to the JHSPH.

The analysis was funded by NICE as part of its efforts to determine optimized clinical guidelines for mental and physical ailments.

“Because [the UK] is a single payer system, there’s an interest there in comparing everything that you can do for a problem and figuring out which is best. The goal of the project was to come up with a clinical guideline about how to treat social anxiety disorder,” Mayo-Wilson said.

Among the treatments studied, although only individual CBT and SSRI/SNRIs performed better than the placebo, several other treatments performed better than the waitlist (patients receiving no treatment, placebo or otherwise) but not better than placebo. Among pharmacological treatments, those who performed better than the waitlist were monoamine oxidase inhibitors, benzodiazepines and anticonvulsants. Among psychological treatments, those who performed better than the waitlist were group CBT, exposure and social skills, self-help with support, self-help without support and psychodynamic psychotherapy.

Mayo-Wilson hopes that the findings that individual CBT performs better than other psychological treatments will encourage further research into those treatments.

“One of the things that we found is that there’s very little evidence that combination therapy is better than any individual therapy. I think that there’s a belief among a lot of practitioners that combination therapy is going to have the greatest benefit for people with common mental health problems, and there’s some evidence that might be true in depression. I don’t know that it’s likely to be true in anxiety disorders. So I think that that’s one area where people might do some more research on the back of this. I think that the finding that individual therapy is much more effective than group therapy will be a bit controversial, and then we’re likely to see more trials comparing things like individual CBT versus group CBT,” Mayo-Wilson said.

Mayo-Wilson also hopes that the same will be true for the pharmacological treatments, but doubts that industry will be willing to invest in research.

“The antidepressants that we looked at are all off patent. It may be that academics decide to do comparisons of drugs versus psychological therapies, but I don’t see industry having much interest in continuing to put money into things that are not profitable,” he said.

In the published analysis, Mayo-Wilson writes that the results may be affected by reporting bias, which tends to skew published studies towards positive results. However, recent requirements within the past five to 10 years that trials be registered before they are conducted have reduced bias. Full data sets for studies conducted before these requirements are also sometimes released after litigation. Mayo-Wilson says that these data sets suggest that reporting bias in the studies analyzed is likely not severe.

“It’s common now in studies of drugs and devices that you register trials in advance, he said. “So then we know what outcomes will be measured... For the drugs where we do have more complete data sets, for instance ones where they’ve been sued and forced to release more of the data, the outcomes don’t look too different from many of the other ones. So I think that we’re probably in the right ballpark for most of the important [treatments].”

Though NICE is internationally recognized for its work with clinical guidelines, Mayo-Wilson is hopeful that such work will become more common in the U.S. in the near future even without a single-payer system through independent organizations like the American Psychological Association (APA).

“I’ve met with some folks at the American Psychological Association, which is getting into developing treatment guidelines,” Mayo-Wilson said. “I hope that we start doing this kind of work more in America, because I think that having a systematic way of comparing treatments and trying to make recommendations about what the clinicians and patient should do is really important, and it’s good to see the APA starting to do that.”

Ultimately, Mayo-Wilson thinks that the analysis should encourage people to seek psychological treatment.

“The main clinical message is that there’s something to be done about this. People should be going in and getting therapy,” he said.