Prevention of relapse in generalized social phobia: results of a 24-week study in responders to 20 weeks of sertraline treatment

Approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults

BACKGROUND

Depression and anxiety are the most frequent indication for which antidepressants are prescribed. Long-term antidepressant use is driving much of the internationally observed rise in antidepressant consumption. Surveys of antidepressant users suggest that 30% to 50% of long-term antidepressant prescriptions had no evidence-based indication. Unnecessary use of antidepressants puts people at risk of adverse events. However, high-certainty evidence is lacking regarding the effectiveness and safety of approaches to discontinuing long-term antidepressants.

OBJECTIVES

To assess the effectiveness and safety of approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults.

SEARCH METHODS

We searched all databases for randomised controlled trials (RCTs) until January 2020.

SELECTION CRITERIA

We included RCTs comparing approaches to discontinuation with continuation of antidepressants (or usual care) for people with depression or anxiety who are prescribed antidepressants for at least six months. Interventions included discontinuation alone (abrupt or taper), discontinuation with psychological therapy support, and discontinuation with minimal intervention. Primary outcomes were successful discontinuation rate, relapse (as defined by authors of the original study), withdrawal symptoms, and adverse events. Secondary outcomes were depressive symptoms, anxiety symptoms, quality of life, social and occupational functioning, and severity of illness.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane.

MAIN RESULTS

We included 33 studies involving 4995 participants. Nearly all studies were conducted in a specialist mental healthcare service and included participants with recurrent depression (i.e. two or more episodes of depression prior to discontinuation). All included trials were at high risk of bias. The main limitation of the review is bias due to confounding withdrawal symptoms with symptoms of relapse of depression. Withdrawal symptoms (such as low mood, dizziness) may have an effect on almost every outcome including adverse events, quality of life, social functioning, and severity of illness. Abrupt discontinuation Thirteen studies reported abrupt discontinuation of antidepressant. Very low-certainty evidence suggests that abrupt discontinuation without psychological support may increase risk of relapse (hazard ratio (HR) 2.09, 95% confidence interval (CI) 1.59 to 2.74; 1373 participants, 10 studies) and there is insufficient evidence of its effect on adverse events (odds ratio (OR) 1.11, 95% CI 0.62 to 1.99; 1012 participants, 7 studies; I² = 37%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of abrupt discontinuation on withdrawal symptoms (1 study) is very uncertain. None of these studies included successful discontinuation rate as a primary endpoint. Discontinuation by "taper" Eighteen studies examined discontinuation by "tapering" (one week or longer). Most tapering regimens lasted four weeks or less. Very low-certainty evidence suggests that "tapered" discontinuation may lead to higher risk of relapse (HR 2.97, 95% CI 2.24 to 3.93; 1546 participants, 13 studies) with no or little difference in adverse events (OR 1.06, 95% CI 0.82 to 1.38; 1479 participants, 7 studies; I² = 0%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of discontinuation on withdrawal symptoms (1 study) is very uncertain. Discontinuation with psychological support Four studies reported discontinuation with psychological support. Very low-certainty evidence suggests that initiation of preventive cognitive therapy (PCT), or MBCT, combined with "tapering" may result in successful discontinuation rates of 40% to 75% in the discontinuation group (690 participants, 3 studies). Data from control groups in these studies were requested but are not yet available. Low-certainty evidence suggests that discontinuation combined with psychological intervention may result in no or little effect on relapse (HR 0.89, 95% CI 0.66 to 1.19; 690 participants, 3 studies) compared to continuation of antidepressants. Withdrawal symptoms were not measured. Pooling data on adverse events was not possible due to insufficient information (3 studies). Discontinuation with minimal intervention Low-certainty evidence from one study suggests that a letter to the general practitioner (GP) to review antidepressant treatment may result in no or little effect on successful discontinuation rate compared to usual care (6% versus 8%; 146 participants, 1 study) or on relapse (relapse rate 26% vs 13%; 146 participants, 1 study). No data on withdrawal symptoms nor adverse events were provided. None of the studies used low-intensity psychological interventions such as online support or a changed pharmaceutical formulation that allows tapering with low doses over several months. Insufficient data were available for the majority of people taking antidepressants in the community (i.e. those with only one or no prior episode of depression), for people aged 65 years and older, and for people taking antidepressants for anxiety.

AUTHORS' CONCLUSIONS

Currently, relatively few studies have focused on approaches to discontinuation of long-term antidepressants. We cannot make any firm conclusions about effects and safety of the approaches studied to date. The true effect and safety are likely to be substantially different from the data presented due to assessment of relapse of depression that is confounded by withdrawal symptoms. All other outcomes are confounded with withdrawal symptoms. Most tapering regimens were limited to four weeks or less. In the studies with rapid tapering schemes the risk of withdrawal symptoms may be similar to studies using abrupt discontinuation which may influence the effectiveness of the interventions. Nearly all data come from people with recurrent depression.   There is an urgent need for trials that adequately address withdrawal confounding bias, and carefully distinguish relapse from withdrawal symptoms. Future studies should report key outcomes such as successful discontinuation rate and should include populations with one or no prior depression episodes in primary care, older people, and people taking antidepressants for anxiety and use tapering schemes longer than 4 weeks.

Residual anxiety may be associated with depressive relapse during continuation therapy of bipolar II depression

BACKGROUND

Anxiety symptoms are common in bipolar disorder. We explored the effect of anxiety on the outcome of acute and continuation pharmacotherapy of bipolar II depression.

METHODS

Data were derived from a randomized double-blind 12-week acute (N = 129) and 6-month continuation (N = 55) comparison of venlafaxine versus lithium monotherapy in bipolar II depression in adults. We distinguished between the items of the Hamilton Rating Scale for Depression (HRSD) that capture depression vs. anxiety (i.e., psychomotor agitation, psychic anxiety, somatic anxiety, hypochondriasis, and obsessive-compulsive concerns) and examined the effect of treatment on depression and anxiety. Additionally, we explored whether baseline anxiety or depression predicted changes over time in depression and anxiety ratings or moderated treatment outcomes. We also explored whether residual depressive and anxious symptoms predicted relapse during continuation therapy.

RESULTS

Venlafaxine was superior to lithium in reducing both depression and anxiety, though its effects on anxiety were more modest than those on depression. Baseline anxiety predicted change over time in anxiety, but not depression. By contrast, baseline depression did not predict change over time in depression or anxiety. Residual anxiety, specifically uncontrollable worry, was a stronger predictor of relapse than residual depression.

CONCLUSION

Successful treatment of symptoms of anxiety in bipolar depression may protect against depressive relapse.

Pharmacotherapy for social anxiety disorder (SAnD)

BACKGROUND

Recognition is growing that social anxiety disorder (SAnD) is a chronic and disabling disorder, and data from early trials demonstrate that medication may be effective in its treatment. This systematic review is an update of an earlier review of pharmacotherapy of SAnD.

OBJECTIVES

To assess the effects of pharmacotherapy for social anxiety disorder in adults and identify which factors (methodological or clinical) predict response to treatment.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR-Studies and CCMDCTR-References) to 17 August 2015. The CCMDCTR contains reports of relevant RCTs from MEDLINE (1950-), Embase (1974-), PsycINFO (1967-) and CENTRAL (all years). We scanned the reference lists of articles for additional studies. We updated the search in August 2017 and placed additional studies in Awaiting Classification, these will be incorporated in the next version of the review, as appropriate.

SELECTION CRITERIA

We restricted studies to randomised controlled trials (RCTs) of pharmacotherapy versus placebo in the treatment of SAnD in adults.

DATA COLLECTION AND ANALYSIS

Two authors (TW and JI) assessed trials for eligibility and inclusion for this review update. We extracted descriptive, methodological and outcome information from each trial, contacting investigators for missing information where necessary. We calculated summary statistics for continuous and dichotomous variables (if provided) and undertook subgroup and sensitivity analyses.

MAIN RESULTS

We included 66 RCTs in the review (> 24 weeks; 11,597 participants; age range 18 to 70 years) and 63 in the meta-analysis. For the primary outcome of treatment response, we found very low-quality evidence of treatment response for selective serotonin reuptake inhibitors (SSRIs) compared with placebo (number of studies (k) = 24, risk ratio (RR) 1.65; 95% confidence interval (CI) 1.48 to 1.85, N = 4984). On this outcome there was also evidence of benefit for monoamine oxidase inhibitors (MAOIs) (k = 4, RR 2.36; 95% CI 1.48 to 3.75, N = 235), reversible inhibitors of monoamine oxidase A (RIMAs) (k = 8, RR 1.83; 95% CI 1.32 to 2.55, N = 1270), and the benzodiazepines (k = 2, RR 4.03; 95% CI 2.45 to 6.65, N = 132), although the evidence was low quality. We also found clinical response for the anticonvulsants with gamma-amino butyric acid (GABA) analogues (k = 3, RR 1.60; 95% CI 1.16 to 2.20, N = 532; moderate-quality evidence). The SSRIs were the only medication proving effective in reducing relapse based on moderate-quality evidence. We assessed tolerability of SSRIs and the serotonin and norepinephrine reuptake inhibitor (SNRI) venlafaxine on the basis of treatment withdrawal; this was higher for medication than placebo (SSRIs: k = 24, RR 2.59; 95% CI 1.97 to 3.39, N = 5131, low-quality evidence; venlafaxine: k = 4, RR 3.23; 95% CI 2.15 to 4.86, N = 1213, moderate-quality evidence), but there were low absolute rates of withdrawal for both these medications classes compared to placebo. We did not find evidence of a benefit for the rest of the medications compared to placebo.For the secondary outcome of SAnD symptom severity, there was benefit for the SSRIs, the SNRI venlafaxine, MAOIs, RIMAs, benzodiazepines, the antipsychotic olanzapine, and the noradrenergic and specific serotonergic antidepressant (NaSSA) atomoxetine in the reduction of SAnD symptoms, but most of the evidence was of very low quality. Treatment with SSRIs and RIMAs was also associated with a reduction in depression symptoms. The SSRIs were the only medication class that demonstrated evidence of reduction in disability across a number of domains.We observed a response to long-term treatment with medication for the SSRIs (low-quality evidence), for the MAOIs (very low-quality evidence) and for the RIMAs (moderate-quality evidence).

AUTHORS' CONCLUSIONS

We found evidence of treatment efficacy for the SSRIs, but it is based on very low- to moderate-quality evidence. Tolerability of SSRIs was lower than placebo, but absolute withdrawal rates were low.While a small number of trials did report treatment efficacy for benzodiazepines, anticonvulsants, MAOIs, and RIMAs, readers should consider this finding in the context of potential for abuse or unfavourable side effects.

Risk of relapse after antidepressant discontinuation in anxiety disorders, obsessive-compulsive disorder, and post-traumatic stress disorder: systematic review and meta-analysis of relapse prevention trials

Objectives To examine the risk of relapse and time to relapse after discontinuation of antidepressants in patients with anxiety disorder who responded to antidepressants, and to explore whether relapse risk is related to type of anxiety disorder, type of antidepressant, mode of discontinuation, duration of treatment and follow-up, comorbidity, and allowance of psychotherapy.Design Systematic review and meta-analyses of relapse prevention trials.Data sources PubMed, Cochrane, Embase, and clinical trial registers (from inception to July 2016).Study selection Eligible studies included patients with anxiety disorder who responded to antidepressants, randomised patients double blind to either continuing antidepressants or switching to placebo, and compared relapse rates or time to relapse.Data extraction Two independent raters selected studies and extracted data. Random effect models were used to estimate odds ratios for relapse, hazard ratios for time to relapse, and relapse prevalence per group. The effect of various categorical and continuous variables was explored with subgroup analyses and meta-regression analyses respectively. Bias was assessed using the Cochrane tool.Results The meta-analysis included 28 studies (n=5233) examining relapse with a maximum follow-up of one year. Across studies, risk of bias was considered low. Discontinuation increased the odds of relapse compared with continuing antidepressants (summary odds ratio 3.11, 95% confidence interval 2.48 to 3.89). Subgroup analyses and meta-regression analyses showed no statistical significance. Time to relapse (n=3002) was shorter when antidepressants were discontinued (summary hazard ratio 3.63, 2.58 to 5.10; n=11 studies). Summary relapse prevalences were 36.4% (30.8% to 42.1%; n=28 studies) for the placebo group and 16.4% (12.6% to 20.1%; n=28 studies) for the antidepressant group, but prevalence varied considerably across studies, most likely owing to differences in the length of follow-up. Dropout was higher in the placebo group (summary odds ratio 1.31, 1.06 to 1.63; n=27 studies).Conclusions Up to one year of follow-up, discontinuation of antidepressant treatment results in higher relapse rates among responders compared with treatment continuation. The lack of evidence after a one year period should not be interpreted as explicit advice to discontinue antidepressants after one year. Given the chronicity of anxiety disorders, treatment should be directed by long term considerations, including relapse prevalence, side effects, and patients' preferences.

Long-term chamomile (Matricaria chamomilla L.) treatment for generalized anxiety disorder: A randomized clinical trial

BACKGROUND

Generalized Anxiety Disorder (GAD) is one of the most common anxiety disorders treated in primary care, yet current therapies have limited efficacy and substantial side effects.

PURPOSE

To evaluate long-term chamomile (Matricaria chamomilla L.) use for prevention of GAD symptom relapse.

METHODS

Outpatients from primary care practices and local communities with a primary diagnosis of moderate-to-severe GAD were enrolled for this two-phase study at a large US academic medical center. During Phase 1, eligible participants received 12 weeks of open-label therapy with chamomile pharmaceutical grade extract 1500mg (500mg capsule 3 times daily). During Phase 2, treatment responders were randomized to either 26 weeks of continuation chamomile therapy or placebo in a double-blinded, placebo-substitution design. The primary outcome was time to relapse during continuation therapy, analyzed using Cox proportional hazards. Secondary outcomes included the proportion who relapsed, treatment-emergent adverse events, and vital sign changes. This study is registered at ClinicalTrials.gov, identifier NCT01072344.

RESULTS

Between March 1, 2010, and June 30, 2015, we enrolled 179 participants. Of those, 93 (51.9%) were responders and agreed to continue in the double-blind randomized controlled trial. A numerically greater number of placebo-switched (n=12/47; 25.5%) versus chamomile-continuation (n = 7/46; 15.2%) participants relapsed during follow-up. Mean time to relapse was 11.4 ± 8.4 weeks for chamomile and 6.3 ± 3.9 weeks for placebo. Hazard of relapse was non-significantly lower for chamomile (hazard ratio, 0.52; 95% CI, 0.20-1.33; P = 0.16). During follow-up, chamomile participants maintained significantly lower GAD symptoms than placebo (P = 0.0032), with significant reductions in body weight (P = 0.046) and mean arterial blood pressure (P = 0.0063). Both treatments had similar low adverse event rates.

CONCLUSIONS

Long-term chamomile was safe and significantly reduced moderate-to-severe GAD symptoms, but did not significantly reduce rate of relapse. Our limited sample size and lower than expected rate of placebo group relapse likely contributed to the non-significant primary outcome finding. Possible chamomile superiority over placebo requires further examination in large-scale studies.

Pregabalin for the treatment of social anxiety disorder

INTRODUCTION

Social anxiety disorder (SAD) is one of the most common psychiatric disorders, causing a reduction of in the quality of life by impairing functioning in social situations. The lifetime prevalence of SAD is estimated to be 12%. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are considered first-line drugs for SAD. However, new effective therapeutic options are still needed. Pregabalin is a novel anxiolytic, which seems to be a promising therapy for SAD.

AREAS COVERED

This review presents the results of three randomized controlled trials (RCTs) comparing the efficacy and safety of pregabalin with placebo in patients with generalized SAD. The authors also discuss the long-term safety and tolerability data from an extension study.

EXPERT OPINION

The results of the RCTs have demonstrated efficacy and safety with pregabalin at doses of 600 mg or 450 mg/d for treating generalized SAD. Thus, pregabalin may be an effective therapeutic option, especially for patients who cannot tolerate the adverse effects or who demonstrate a lack of efficacy with SSRIs or SNRIs. In addition to being an alternative therapy to SSRIs or SNRIs, it may also have value as an add-on therapy, either to augment pharmacotherapy or in addition to cognitive-behavioral therapy.

Long-Term Chamomile Therapy of Generalized Anxiety Disorder: A Study Protocol for a Randomized, Double-Blind, Placebo- Controlled Trial

BACKGROUND

Anxiety symptoms are among the most common reasons for consumers to use Complementary and Alternative Medicine (CAM) therapy. Although many botanicals have been proposed as putative remedies for anxiety symptoms, there has been a paucity of controlled trials of these remedies. A preliminary study of the anxiolytic effect of Chamomile (Matricaria recutita) in humans suggests that chamomile may have anxiolytic and antidepressant activity. We now seek to conduct a 5-year randomized, double-blind, placebo-substitution study to examine the short and long-term safety and efficacy of chamomile extract in Generalized Anxiety Disorder (GAD).

METHODS/DESIGN

180 subjects with moderate to severe GAD will receive initial open-label pharmaceutical-grade chamomile extract 500-1,500 mg daily for 8 weeks. Responders to treatment who remain well for an additional 4 weeks of consolidation therapy, will be randomized to double-blind continuation therapy with either chamomile extract 500-1,500 mg daily or placebo for an additional 26 weeks. The primary outcome will be the time to relapse during study continuation therapy in each treatment condition. Secondary outcomes will include the proportion of subjects in each treatment condition who relapse, as well as the proportion of subjects with treatment-emergent adverse events. Quality of life ratings will also be compared between treatment conditions during short and long-term therapy.

DISCUSSION

Many individuals with mental disorders decline conventional therapy and seek CAM therapies for their symptoms. Thus, the identification of effective CAM therapy is of relevance to reducing the burden of mental illness. This study builds upon our prior findings of significant superiority of chamomile versus placebo in reducing GAD symptoms. We now extend these preliminary findings by conducting a randomized long-term safety and efficacy study of chamomile in GAD.

Long-term treatment of anxiety disorders with pregabalin: a 1 year open-label study of safety and tolerability

OBJECTIVE

Short-term clinical trials have demonstrated the efficacy and safety of pregabalin in the treatment of generalized anxiety disorder (GAD). This study examined long-term safety and tolerability of pregabalin in patients with GAD, social anxiety disorder (SAD), or panic disorder (PD).

RESEARCH DESIGN AND METHODS

Patients (n = 528) completing one of four randomized, double-blind, placebo-controlled trials of pregabalin for GAD, SAD, or PD were treated, open label, with flexible-dose pregabalin (150-600 mg/day) for 1 year.

CLINICAL TRIAL REGISTRATION

NCT00150449.

MAIN OUTCOME MEASURES

The primary outcomes were safety and tolerability. Illness severity was assessed at baseline and Weeks 27/52 using the Clinical Global Impression of Severity (CGI-S) scale. Patients were characterized as 'responders' or 'non-responders' based on CGI-S scores ≤2 and >2, respectively. Analyses were performed on the total anxiety (GAD, SAD and PD) and GAD groups.

RESULTS

During 1 year of treatment with pregabalin, dizziness (12.5%) was the only treatment-related adverse event (AE) occurring ≥10%. Somnolence, weight gain, headache and insomnia occurred at 7.6%, 5.5%, 5.3% and 4.7%, respectively. Few treatment-related AEs were rated as severe in the total anxiety (5.1%) or GAD (3.6%) groups. Discontinuation rates due to AEs were similar (9.7% and 10.6%, respectively). No clinically significant laboratory, electrocardiogram, or other treatment-related safety findings were noted, except for treatment-related weight gain, which occurred in both the total (24.4%) and GAD (19.4%) groups. Mean CGI-S scores were similar at baseline in the total (n = 528; score, 3.4) and GAD groups (n = 330; score, 3.6), and CGI-S responder rates were similar at last-observation-carried-forward endpoint (51.3% and 48.1%, respectively).

CONCLUSIONS

Pregabalin was generally well tolerated in the long-term treatment of anxiety disorders. Improvement in illness severity was maintained over time. The key limitations of this study were that it was not randomized and neither placebo- nor active-comparator-controlled.

Evaluation of the pharmacokinetics, safety and clinical efficacy of sertraline used to treat social anxiety

INTRODUCTION

Social anxiety disorder (SAD) is an emerging, often invalidating, syndrome with deep personal, social and psychological implications. While multiple treatment strategies exist, presently none of them can be considered superior to all others.

AREAS COVERED

The aim of this review is to provide the latest information on sertraline (SRT), one of the most important selective serotonin reuptake inhibitors (SSRIs) currently used for the pharmacological therapy of SAD. A literature search was carried out with the keywords 'sertraline', 'social anxiety', 'social phobia' and 'clinical trials'. In this process, particular attention is paid to the pharmacokinetic characteristics of the drug and its safety in clinical use.

EXPERT OPINION

SRT is an effective drug in the treatment of SAD, especially when used in combination with some form of psychological support. While it does not seem to be significantly more effective than other SSRIs, SRT could offer some peculiar advantages: for example, it has a long half-life, allowing a single daily administration, and seems to be particularly indicated for the control of specific symptoms of SAD.

Issues and controversies surrounding the diagnosis and treatment of social anxiety disorder

Although much has been learned about social anxiety disorder (SAD) in recent decades, many questions and controversies surrounding its diagnosis and treatment have remained. Similar to the state of affairs with other psychiatric disorders, no clear pathophysiology has been identified for SAD, and the question of where to draw the line between shyness, SAD and even avoidant personality disorder continues to be debated. Much of the evidence to date suggests that among persons with SAD, it is under-recognized and undertreated; however, other researchers contend that it may be overdiagnosed in some individuals. Questions also remain as to how best treat these individuals, such as with pharmacotherapy, psychotherapy or a combination of the two. The aim of this review is to provide an overview of the controversies related to the diagnosis and treatment of SAD. In addition, suggestions for future research are provided that could perhaps clarify these remaining questions, such as maximizing treatment efficacy by targeting broader outcomes such as quality of life and addressing common comorbidities that occur with SAD.

The evidence-based pharmacotherapy of social anxiety disorder

Social anxiety disorder (SAD) is a highly prevalent and often disabling disorder. This paper reviews the pharmacological treatment of SAD based on published placebo-controlled studies and published meta-analyses. It addresses three specific questions: What is the first-line pharmacological treatment of SAD? How long should treatment last? What should be the management of treatment-resistant cases? Based on their efficacy for SAD and common co-morbid disorders, tolerability and safety, selective serotonin reuptake inhibitors (SSRIs) and venlafaxine should be considered the first-line treatment for most patients. Less information is available regarding the optimal length of treatment, although individuals who discontinue treatment after 12-20 wk appear more likely to relapse than those who continue on medication. Even less empirical evidence is available to support strategies for treatment-resistant cases. Clinical experience suggests that SSRI non-responders may benefit from augmentation with benzodiazepines or gabapentin or from switching to monoamine oxidase inhibitors, reversible inhibitors of monoamine oxidase A, benzodiazepines or gabapentin. Cognitive-behavioural is a well-established alternative first line therapy that may also be a helpful adjunct in non-responders to pharmacological treatment of SAD.

Optimal treatment of social phobia: systematic review and meta-analysis

This article proposes a number of recommendations for the treatment of generalized social phobia, based on a systematic literature review and meta-analysis. An optimal treatment regimen would include a combination of medication and psychotherapy, along with an assertive clinical management program. For medications, selective serotonin reuptake inhibitors and dual serotonin-norepinephrine reuptake inhibitors are first-line choices based on their efficacy and tolerability profiles. The nonselective monoamine oxidase inhibitor, phenelzine, may be more potent than these two drug classes, but because of its food and drug interaction liabilities, its use should be restricted to patients not responding to selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors. There are other medication classes with demonstrated efficacy in social phobia (benzodiazepines, antipsychotics, alpha-2-delta ligands), but due to limited published clinical trial data and the potential for dependence and withdrawal issues with benzodiazepines, it is unclear how best to incorporate these drugs into treatment regimens. There are very few clinical trials on the use of combined medications. Cognitive behavior therapy appears to be more effective than other evidence-based psychological techniques, and its effects appear to be more enduring than those of pharmacotherapy. There is some evidence, albeit limited to certain drug classes, that the combination of medication and cognitive behavior therapy may be more effective than either strategy used alone. Generalized social phobia is a chronic disorder, and many patients will require long-term support and treatment.

Anxiety disorders through a transcultural perspective: implications for migrants

BACKGROUND/METHODS

This paper analyses the psychopathology and differential diagnosis of anxiety disorders and their worldwide prevalence. It focuses particularly on migrant-specific aetiopathogenetic factors and approaches prevalence and important cultural aspects of anxiety disorders in migrants as a narrative empirical review.

RESULTS

Transcultural research demonstrates the universal existence of anxiety disorders. However, the cross-cultural comparison of the epidemiological data is complicated and often leads to systematic bias. The described psychopathology varies significantly across cultures, indicating different ways of expressing and experiencing the basic emotion of anxiety. As a result, anxiety disorders manifest themselves differently across cultures, which may affect the diagnostic and therapeutic procedure. Migration is an additional extraordinary stressor playing a substantial role in the development of anxiety disorders. However, despite the high prevalence of anxiety disorders among migrants, a high threshold due to several barriers leads to an underrepresentation of migrants in the utilization of the mental health system.

CONCLUSIONS

In the transcultural differential diagnosis of anxiety disorders, as among migrants, understanding and openness to other cultures and their standards is essential. Thereby, a migrant-specific treatment approach with a long-term binding of patients in a multimodal and culture-sensitive and -permissive treatment option is of vital importance.

Pharmacotherapy of social anxiety disorder

INTRODUCTION

Social anxiety disorder (SAD) is one of the most common psychiatric disorders, with a lifetime prevalence of 5-12%. Fears of scrutiny and embarrassment in social and public situations are accompanied by anxiety symptoms, avoidance behavior, and impairment in social and work functioning. Several classes of medication, as well as cognitive-behavioral therapies, have evidence for efficacy in the treatment of SAD, but only a minority of individuals with the disorder receives treatment.

AREAS COVERED

This review focuses on the evidence-based treatment of SAD with medications including serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, monoamine oxidase inhibitors, other antidepressants, benzodiazepines, alpha-delta calcium-channel agents, and beta-adrenergic blockers. It discusses clinical considerations in the selection and monitoring of treatments, including issues of safety, duration of treatment, comorbidity, and integration of medication with psychotherapeutic treatment. For this review, a PubMed literature search was conducted during July, 2010.

EXPERT OPINION

Medications in several classes have been demonstrated efficacious in the treatment of SAD. Treatment selection and implementation require attention to clinical diagnosis, patient education, and appropriate monitoring.

Current management of obsessive and phobic states

Obsessional states show an average point prevalence of 1%-3% and a lifetime prevalence of 2%-2.5%. Most treatment-seeking patients with obsessions continue to experience significant symptoms after 2 years of prospective follow-up. A significant burden of impairment, distress, and comorbidity characterize the course of the illness, leading to an increased need for a better understanding of the nature and management of this condition. This review aims to give a representation of the current pharmacological and psychotherapeutic strategies used in the treatment of obsessive-compulsive disorder. Antidepressants (clomipramine and selective serotonin reuptake inhibitors) are generally the first-line choice used to handle obsessional states, showing good response rates and long-term positive outcomes. About 40% of patients fail to respond to selective serotonin reuptake inhibitors. So far, additional pharmacological treatment strategies have been shown to be effective, ie, administration of high doses of selective serotonin reuptake inhibitors, as well as combinations of different drugs, such as dopamine antagonists, are considered efficacious and well tolerated strategies in terms of symptom remission and side effects. Psychotherapy also plays an important role in the management of obsessive-compulsive disorder, being effective for a wide range of symptoms, and many studies have assessed its long-term efficacy, especially when added to appropriate pharmacotherapy. In this paper, we also give a description of the clinical and psychological features likely to characterize patients refractory to treatment for this illness, with the aim of highlighting the need for greater attention to more patient-oriented management of the disease.

Comparative efficacy of antidepressants in preventing relapse in anxiety disorders - a meta-analysis

BACKGROUND

We assessed the efficacy of continuation treatment with antidepressants in a meta-analysis of relapse prevention studies in the five principal anxiety disorders, to explore the benefit of continuation treatment in each disorder, and their relative efficacy across these disorders.

METHOD

Double-blind placebo-controlled studies with relapse prevention designs in Panic Disorder, Generalized Anxiety Disorder, Social Phobia, Post-Traumatic Stress Disorder and Obsessive-Compulsive Disorder were identified in a systematic literature search. The primary efficacy comparison was relapse rates between active and placebo arms calculated as odds ratios (ORs) using Review Manager version 5.0. Relapse data were also used to calculate relative risk (RR), risk difference (RD) and number needed to treat (NNT).

RESULTS

Twenty-two relapse prevention trials were identified for these 5 disorders. Continuation antidepressant treatment produced robust treatment effects for each disorder, however the magnitude varied by indication. The greatest treatment effect was noted for GAD (pooled OR 0.20), whereas the pooled ORs for PD and OCD were for almost 2-fold higher (0.35 and 0.38 respectively). RR, RD and NNT showed similar statistically significant trends.

LIMITATIONS

This study cannot identify an optimal duration of therapy. This analysis only examined studies testing monoamine reuptake inhibiting antidepressants, and therefore these results might not be generalizable to other classes of antianxiety agents.

CONCLUSIONS

This meta-analysis underscores the importance of continuation treatment following acute response in all 5 anxiety disorders, however the relative efficacy of continuation antidepressant treatment appears to vary by disorder.

Social phobia: an update on treatment

Social phobia is a prevalent anxiety disorder that may be treated with pharmacotherapy, psychotherapy, or both. This article reviews the empirical evidence for these interventions and discusses new treatment developments. Active ingredients and mechanisms involved in the effectiveness of treatment are discussed. In addition, the elements of social phobia and its treatment that are similar to other anxiety and non-anxiety disorders are considered. Finally, it discusses future efforts to improve diagnosis and treatment for social phobia, including possible revisions to the diagnostic criteria that might be considered in the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, as well as routine care and obstacles for dissemination.

An evidence-based review of the clinical use of sertraline in mood and anxiety disorders

Sertraline is a selective serotonin reuptake inhibitor that has been used and studied extensively throughout the world and found to be safe and well tolerated in numerous patient populations, including those with either psychiatric and/or medical comorbidities. Randomized clinical trials have shown that it is an effective treatment for depressive and anxiety disorders and its efficacy is unaffected by psychiatric comorbidity. In non-comorbid patients, sertraline is effective for the acute treatment of major depressive disorders and prevention of relapse or recurrence. It is effective for acute treatment and longer-term management of social anxiety disorder, posttraumatic stress disorder,panic disorder, and generalized anxiety disorder. In adults and in pediatric patients, it is an effective short-term and long-term treatment for obsessive compulsive disorder.Sertraline has a good tolerability profile and has low fatal toxicity. In summary, sertraline is as effective as other antidepressants over a wide range of indications but may offer tolerability benefits as well as efficacy in patients with psychiatric and/or medical comorbidities and certain subtypes of depression.

Recent advances in understanding and treating social anxiety disorder

The common occurrence and high level of morbidity and burden associated with social anxiety disorder (SAD) are gaining widespread recognition. Interest in understanding and treating the disorder has also grown in response to large-scale investigations that have demonstrated high levels of efficacy with both pharmacologic and nonpharmacologic treatments. Such trials indicate that many patients with generalized SAD (roughly 40% to 60%) respond (eg, Clinical Global Impressions-Improvement rating 1 or 2) after an adequate treatment trial, despite having suffered with disabling symptoms for most of their adult lives. First-line therapy options include the selective serotonin reuptake inhibitors and the dual-acting serotonin-norepinephrine reuptake inhibitor venlafaxine. Second-line options consist of anticonvulsants (gabapentin, pregabalin, valproic acid) and benzodiazepines (clonazepam). Reversible and irreversible monoamine oxidase inhibitors (moclobemide and phenelzine, respectively), while effective, are not widely used. Nonpharmacologic approaches, such as cognitive-behavioral therapy (CBT), are also effective for SAD. Newer treatment strategies such as levetiracetam, atypical antipsychotics, or D-cycloserine in combination with CBT appear promising but require further investigation. Finding a well-tolerated, safe, and effective treatment for each individual patient is crucial as most will require ongoing treatment in order to maintain benefits, prevent SAD relapse, and to experience optimal outcomes in the long term.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders - first revision

In this report, which is an update of a guideline published in 2002 (Bandelow et al. 2002, World J Biol Psychiatry 3:171), recommendations for the pharmacological treatment of anxiety disorder, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) are presented. Since the publication of the first version of this guideline, a substantial number of new randomized controlled studies of anxiolytics have been published. In particular, more relapse prevention studies are now available that show sustained efficacy of anxiolytic drugs. The recommendations, developed by the World Federation of Societies of Biological Psychiatry (WFSBP) Task Force for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-traumatic Stress Disorders, a consensus panel of 30 international experts, are now based on 510 published randomized, placebo- or comparator-controlled clinical studies (RCTs) and 130 open studies and case reports. First-line treatments for these disorders are selective serotonin reuptake inhibitors (SSRIs), serotonin-noradrenaline reuptake inhibitors (SNRIs) and the calcium channel modulator pregabalin. Tricyclic antidepressants (TCAs) are equally effective for some disorders, but many are less well tolerated than the SSRIs/SNRIs. In treatment-resistant cases, benzodiazepines may be used when the patient does not have a history of substance abuse disorders. Potential treatment options for patients unresponsive to standard treatments are described in this overview. Although these guidelines focus on medications, non-pharmacological were also considered. Cognitive behavioural therapy (CBT) and other variants of behaviour therapy have been sufficiently investigated in controlled studies in patients with anxiety disorders, OCD, and PTSD to support them being recommended either alone or in combination with the above medicines.

Pharmacotherapy of social anxiety disorder

A range of medications have been shown effective for the treatment of social anxiety disorder. The largest trials to date have been with various selective serotonin reuptake inhibitors (SSRIs). Several of these agents have been registered for the treatment of social anxiety disorder with agencies such as the FDA or EMEA, meta-analyses confirm their efficacy and safety, and expert consensus guidelines have often recommended them as a first-line pharmacotherapy of choice. Despite such advances, there are many unanswered questions in the pharmacotherapy of social anxiety disorder, including the optimal pharmacotherapy of patients refractory to first-line intervention, and the optimal sequencing of pharmacotherapy and psychotherapy. Translational research has already had an impact on concepts of treatment, and may ultimately lead to novel interventions.

Long-term outcome of anxiety disorders: a review of double-blind studies

PURPOSE OF REVIEW

Although anxiety disorders are acknowledged as chronic, the issue of the pharmacological treatment duration remains unsettled. This review focuses on the long-term outcome of patients with anxiety disorders as demonstrated by randomized controlled trials.

RECENT FINDINGS

Results from long-term randomized controlled trials of antidepressants in anxiety disorders indicate that maintenance treatment significantly reduces the odds of relapse, whatever the anxiety disorder is. This result appears to be similar to what is reported in long-term studies in depressive disorders. In addition, regarding the natural course of depressive disorders, acknowledged as mostly recurrent, some patients may require very long-term treatment, that is, more than 2 years. Moreover, naturalistic studies in anxiety disorders indicate that the relapse risk after discontinuation is not associated with the treatment duration. Finally, there is no predictor to identify those patients who require long-term pharmacotherapy for anxiety disorders.

SUMMARY

In light of this review, other long-term studies in anxiety disorders have to be undertaken to identify predictors of relapse after treatment discontinuation. As it is now acknowledged for depressive disorders, some patients may require very long-term pharmacological treatment for anxiety disorders.

Anxiety disorders: a comprehensive review of pharmacotherapies

This article reviews the evidence from randomized, placebo-controlled trials and meta-analyses of pharmacological treatments of the following anxiety disorders: generalized anxiety disorder, panic disorder, social anxiety disorder, and post-traumatic stress disorder. There is evidence from multiple randomized, placebo-controlled trials to support the use of selective serotonin reuptake inhibitors as first-line pharmacotherapy in these disorders, and a number of the selective serotonin reuptake inhibitors have received US Food and Drug Administration approval for these indications. Serotonin-norepinephrine reuptake inhibitors are now emerging as first-line treatments for these anxiety disorders alongside the selective serotonin reuptake inhibitors and have been US Food and Drug Administration-approved for some of these indications as well. Benzodiazepines are also effective treatments for anxiety disorders, and although this medication class has the advantage of a rapid onset of action, their use is limited by their potential for abuse and lack of antidepressant properties. In addition to reviewing the clinical trials that have investigated the anxiolytic effects of these commonly used medications, we review the evidence for novel uses of other agents, including anticonvulsants and atypical antipsychotics, in anxiety disorders.

Analysis of health-related quality of life and costs based on a randomised clinical trial of escitalopram for relapse prevention in patients with generalised social anxiety disorder

BACKGROUND

Social anxiety disorder (SAD) is associated with substantial reduction in health-related quality of life (HRQoL). Escitalopram has proven efficacy in the short-term treatment of SAD and prevention of relapse.

OBJECTIVES

To determine whether the clinical effects of treatment translated into HRQoL benefits and to investigate costs of SAD treatment.

METHODS

Data on HRQoL and resource utilisation were collected in a previously published clinical trial of escitalopram in relapse prevention. Among 517 patients, 371 responded to 12 weeks of open-label treatment with escitalopram and were randomised to escitalopram or placebo for 24 weeks. HRQoL was assessed using the short form (SF)-36 instrument and SF-6D utilities (preference-based index scores for overall HRQoL) were calculated. Costs were calculated for responders over the acute phase and for non-relapsed patients over the continuation phase, applying UK unit costs.

RESULTS

Health-related quality of life was significantly improved after the acute phase when compared with baseline. The SF-6D utility increased by 0.047 in responders (p < 0.0001) and 0.021 in non-responders (p = 0.0005). Healthcare costs were non-significantly lower in acute phase than during prestudy phase (p = 0.0587 from NHS perspective), as were productivity costs (p = 0.1440). HRQoL at last visit was lower in relapsed than non-relapsed patients. The difference in utility was -0.026 (p = 0.0007). Healthcare and productivity costs were non-significantly lower in the escitalopram group than in the placebo group.

CONCLUSIONS

Both effective acute treatment of SAD and prevention of relapse with escitalopram are associated with significant HRQoL benefits. Despite some limitations, the cost analysis suggests that savings in physician-visits and inpatient care may offset drug acquisition costs.

Social anxiety disorder

Our understanding of social anxiety disorder (also known as social phobia) has moved from rudimentary awareness that it is not merely shyness to a much more sophisticated appreciation of its prevalence, its chronic and pernicious nature, and its neurobiological underpinnings. Social anxiety disorder is the most common anxiety disorder; it has an early age of onset--by age 11 years in about 50% and by age 20 years in about 80% of individuals--and it is a risk factor for subsequent depressive illness and substance abuse. Functional neuroimaging studies point to increased activity in amygdala and insula in patients with social anxiety disorder, and genetic studies are increasingly focusing on this and other (eg, personality trait neuroticism) core phenotypes to identify risk loci. A range of effective cognitive behavioural and pharmacological treatments for children and adults now exists; the challenges lie in optimum integration and dissemination of these treatments, and learning how to help the 30-40% of patients for whom treatment does not work.

Evidence-based treatment of anxiety disorders

Evidence-based medicine combines the best currently available evidence from systematic medical research, together with clinical expertise, in order to provide the best available care for patients. In conjunction with systematic reviews (meta-analyses), a critical review of evidence-based literature forms the basis for the development of clinical treatment guidelines. Current treatment guidelines for generalized anxiety disorder (GAD) advocate the use of selective serotonin reuptake inhibitors (SSRIs) or serotonin-noradrenaline reuptake inhibitors (SNRIs) as the first line of pharmacotherapy. The safety and tolerability profiles of other medications, such as the benzodiazepines, limit their use, especially for long-term treatment. Since data comparing the efficacy in GAD of different SSRIs are limited, selection of one SSRI over another is generally based on consideration of tolerability profiles. Treatment guidelines for patients with social anxiety disorder (SAD) often recommend SSRIs as the first line of medication treatment, as this class has the largest evidence-base in support of efficacy. Less consistent evidence of efficacy exists for other agents, such as reversible inhibitors of monoamine oxidase inhibitor A (RIMAs), and issues of safety are a concern when considering the use of benzodiazepines. Again, there are few head-to-head studies of the SSRIs, and treatment selection is usually made on the basis of tolerability issues. The efficacy and tolerability of the SSRI, escitalopram, has been evaluated in patients with GAD and with SAD. In long-term studies of SAD, escitalopram demonstrated superior efficacy to placebo and paroxetine. It also exhibited a better tolerability profile, as assessed by discontinuation emergent signs and symptoms (DESS), in both patient groups. Furthermore, in relapse prevention trials of SAD, escitalopram conferred a significant benefit relative to placebo.

Efficacy of low and higher dose extended-release venlafaxine in generalized social anxiety disorder: a 6-month randomized controlled trial

RATIONALE

There is a need for new pharmacological treatments for generalized social anxiety disorder (GSAD), which is a common, often disabling condition.

OBJECTIVE

To compare the efficacy and safety over 6 months duration of two dose ranges of venlafaxine extended-release (ER) with placebo in patients with GSAD.

METHOD

Twenty-eight-week, double-blind, multi-center study in 386 adult outpatients with DSM-IV GSAD. Patients were randomized to placebo, venlafaxine ER fixed low dose (75 mg/day), or venlafaxine ER flexible higher dose (150-225 mg/day). Primary efficacy variable was change on the Liebowitz Social Anxiety Scale (LSAS). Secondary efficacy variables included, among others, the proportion of responders on the CGI Global Improvement Item (score 1 or 2), and the proportion of remitters (defined as an LSAS score of <or=30).

RESULTS

Improvement on the LSAS was greater with venlafaxine ER (at 75 mg/day or 150-225 mg/day) than placebo, and was sustained throughout the 6-month trial. Of patients receiving venlafaxine ER (at any dose), 58% responded to treatment compared to 33% of those receiving placebo (P<0.001); corresponding remission rates were 31% and 16% (P<0.01). There were no differences in outcome according to venlafaxine ER dosage.

CONCLUSIONS

Venlafaxine ER was effective in the treatment of GSAD. The comparable efficacy at low and higher doses may indicate that norepinephrine reuptake blockade does not contribute to therapeutic effect in GSAD. This hypothesis should be tested using agents with specific actions on norepinephrine reuptake blockade.

The treatment of social anxiety disorder

We review the available treatments for social anxiety disorder, focusing primarily on psychotherapeutic interventions for adults, but also giving briefer summaries of pharmacological treatments and treatments for children and adolescents. The most well-researched psychosocial treatments for social anxiety disorder are cognitive-behavioral therapies (CBTs), and meta-analyses indicate that all forms of CBT appear likely to provide some benefit for adults. In addition, there are several pharmacological treatments with demonstrated efficacy, and cognitive-behavioral interventions have some demonstrated efficacy for children and adolescents. We outline a number of concerns regarding this literature, including the questions of what influences treatment response and what role combinations of CBT and medication might have. Clearly, although a number of treatments appear well-established in regard to their effects on social anxiety disorder, a number of opportunities for future research remain, including the search for predictors of who will benefit from which treatment.

Pharmacotherapy for social phobia

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.

Tryptophan depletion reverses the therapeutic effect of selective serotonin reuptake inhibitors in social anxiety disorder

BACKGROUND

Tryptophan depletion studies have suggested that central serotonin (5-hydroxytryptamine, 5-HT) function mediates the therapeutic effect of selective serotonin reuptake inhibitors (SSRIs) in depression and panic disorder. The present study tested the hypothesis that temporary reduction in central 5-HT transmission, through acute tryptophan depletion, could reverse the therapeutic effect of the SSRIs in social anxiety disorder (SAD) patients.

METHODS

Fourteen patients with SAD who showed sustained clinical improvement with SSRI treatment underwent tryptophan depletion in a double-blind, placebo-controlled, crossover design, over 2 days 1 week apart. At the peak time of depletion, the participants also underwent three behavioral challenges: autobiographical script, verbal task, and neutral script. Psychological outcome was assessed with the Spielberger State Anxiety Inventory (STAI) Form Y-1 and visual analog scales (VAS) measuring anxiety, depression, and somatic symptoms.

RESULTS

Anxiety was significantly increased on the depletion day compared with the control day, both on the STAI Form Y-1 and composite VAS score. Furthermore, there was a significant depletion x time interaction, explained mainly by the anxiogenic effect of the autobiographical script. In contrast, the verbal and the neutral tasks failed to differentiate between depletion and placebo.

CONCLUSIONS

Tryptophan depletion induced significant increase of anxiety in treated SAD patients, which was more prominent during the recital of an autobiographical script. This finding supports the notion that SSRIs improve social anxiety by increasing 5-HT availability. The autobiographical script seems to be a more robust challenge test for SAD than the stressful verbal task.

A double-blind, placebo-controlled study of a flexible dose of venlafaxine ER in adult outpatients with generalized social anxiety disorder

Venlafaxine extended release (ER) is a dual serotonin-norepinephrine reuptake inhibitor previously shown to be effective in the treatment of major depressive disorder and generalized anxiety disorder. This placebo-controlled, multicenter, randomized, double-blind trial examined the efficacy and safety of venlafaxine ER in outpatients with generalized social anxiety disorder. Two hundred seventy-two outpatients were randomly assigned to receive either a flexible dose of venlafaxine ER (75 to 225 mg/d) or placebo for 12 weeks. Venlafaxine ER was statistically significantly more effective than placebo as demonstrated by the Liebowitz Social Anxiety Scale total scores at weeks 4 to 12. Scores of both the Clinical Global Impression-Severity and Clinical Global Impression-Improvement scales showed that venlafaxine ER was significantly more effective than placebo at weeks 4 to 12. In addition, more venlafaxine ER-treated patients achieved CGI-Improvement scores of 1 or 2 than placebo-treated patients at weeks 4 to 12, demonstrating a greater percentage of responders to venlafaxine ER treatment. Assessment using the fear/anxiety and avoidance subscales of the Liebowitz Social Anxiety Scale and the Social Phobia Inventory Scale also showed venlafaxine ER to be more effective than placebo at weeks 4 to 12 and 6 to 12, respectively. The Sheehan Disability Inventory showed that patients in the venlafaxine ER-treated group had significantly better outcomes in social life at weeks 4 and 12, and in work at week 12. Adverse events were similar to those reported in studies of venlafaxine ER in depression and generalized anxiety disorder. Venlafaxine ER was safe, well tolerated, and efficacious in the short-term treatment of generalized social anxiety disorder.

Neurobiologie et pharmacothérapie de la phobie sociale

Social phobia (also known as social anxiety disorder) is still not clearly understood. It was not established as an authentic psychiatric entity until the diagnostic nomenclature of the American Psychiatric Association DSM III in 1980. In recent years, increasing attention among researchers has contributed to provide important information about the genetic, familial and temperamental bases of social phobia and its neurochemical, neuroendocrinological and neuroanatomical substrates, which remain to be further investigated. Up to date, there have been several findings about the possible influence of variables, including particularly genetic, socio-familial and early temperamental (eg behavioral inhibition) factors that represent risk for the later development of social phobia. Clinical neurobiological studies, based on the use of exogenous compounds such as lactate, CO2, caffeine, epinephrine, flumazenil or cholecystokinin/pentagastrin to reproduce naturally occurring phobic anxiety, have shown that patients with social phobia appear to exhibit an intermediate sensitivity between patients with panic disorder and control subjects. No difference in the rate of panic attacks in response to lactate, low concentrations of CO2 (5%), epinephrine or flumazenil was observed between patients with social phobia and normal healthy subjects, both being less reactive compared to patients with panic disorder. However, patients with social phobia had similar anxiety reactions to high concentrations of CO2 (35%), caffeine or cholecystokinin/pentagastrin than those seen in patients with panic disorder, both being more intensive than in controls. Several lines of evidence suggest specific neurotransmitter system alterations in social phobia, especially with regard to the serotoninergic, noradrenergic and dopaminergic systems. Although no abnormality in platelet serotonin transporter density has been found, patients with social phobia appear to show an enhanced sensitivity of both post-synaptic 5HT1A and 5HT2 serotonin receptor subtypes, as reflected by increased anxiety and hormonal responses to serotoninergic probes. Platelet 5HT2 receptor density has also been reported to be positively correlated to symptom severity in patients with social phobia. During anticipation of public speaking, heart rate was elevated in patients with social phobia compared to controls. Norepinephrine response to the orthostatic challenge test or to the Valsalva maneuver was also greater in patients with social phobia. While normal beta-adrenergic receptor number was observed in lymphocytes, a blunted response of growth hormone to clonidine, an a2-adrenergic agonist, was reported. This suggests reduced post-synaptic a2-adrenergic receptor functioning related to norepinephrine overactivity in social phobia. Decreased cerebrospinal fluid levels of the dopamine metabolite homovanillic acid have also been observed. There are relatively few reports of involvement of the adrenal and thyroid functions in social phobia, and all that has been noted is that patients with social phobia show an exaggerated adrenocortical response to a psychological stressor. Recent advances in neuro-imaging have contributed to find low striatal dopamine D2 receptor binding or low dopamine transporter site density in patients with social phobia. They have also demonstrated the involvement of the cortico-limbic pathways, including the prefrontal cortex, hippocampus and amygdala, which show an increased activity in different experimental conditions. These brain regions have extensively been reported to play an important role in the cognitive appraisal in determining the significance of environmental stimuli, in the emotional and mnemonic integration of information, and in the expression of contextual fear-conditioned behaviors, which might be disrupted in the light of the phenomelogical aspects of social phobia. A substantial body of literature based on case reports, open and placebo-controlled trials, has now clearly examined the efficacy of major classes of psychotropic agents including monoamine oxidase inhibitors, beta-blockers, selective serotonin reuptake inhibitors and benzodiazepines in social phobia. Until recently, irreversible non-selective monoamine oxidase inhibitors, of which phenelzine was the most extensively evaluated, were considered as the most efficacious treatment in reducing the symptomatology associated with social phobia in 50-70% of cases after 4 to 6 weeks. However, side effects and dietary restrictions limit their use. This led to the development of reversible inhibitors of monoamine oxidase A, for which careful dietary monitoring is not required. Moclobemide has been the most widely studied but produced unconvincingly therapeutic effects on social phobic symptoms. To date, selective serotonin reuptake inhibitors may be considered as a reasonable first-line pharmacotherapy for social phobia. There is growing evidence for the efficacy of the selective serotonin reuptake inhibitors fluvoxamine, fluoxetine, citalopram, paroxetine and sertraline. They have beneficial effects with response rates ranging from 50 to 80% in social phobia. It has been recommended that the treatment period should be extended at least 6 months beyond the early improvement achieved within the first 4 to 6 weeks. The overall advantages include tolerability with a low risk of adverse events. The benzodiazepines clonazepam and alprazolam have also been proposed for the treatment of social phobia. Symptomatic relief occurred in 40 to 80% of the cases with a relatively rapid onset of action within the first two weeks. Untoward effects, discontinuation-related withdrawal symptoms and abuse or dependence liability constitute major concerns about the use of benzodiazepines, so they should be reserved for cases unresponsive to the safer medications cited above. Beta-blockers such as atenolol and propanolol have commonly been employed in performance anxiety, decreasing autonomic symptoms (eg, tachycardia, sweating and dry mouth). However, they are not effective in the generalized form of social phobia. Other pharmacologic alternatives seem helpful for the management of social phobia, including venlafaxine, gabapentin, bupropion, nefazodone or augmentation with buspirone. Preliminary studies point to promising effects of these agents. Larger controlled clinical trials are now needed to confirm their potential role in the treatment of social phobia.

Cognitive causes of social phobia: A critical appraisal

This review examined critically studies issuing from the cognitive therapy (CT) model claiming to have unveiled cognitive causal factors of social phobia. Additionally, it examined outcome studies of CT-inspired interventions and other treatments having included measurements of cognitive constructs. Overall, we found no evidence consistently supporting the claim that social phobics are characterized by typical cognitive processes. Moreover, we found neither corroborating evidence for a controlling effect of such cognitive processes on social phobic conduct, nor consistent indications that cognitive therapies or techniques effect cognitive changes differently than other approaches. The evidence suggests rather, that cognitive factors change concurrently with other features of psychopathology as part of an overall improvement during or after effective therapy, regardless of therapeutic approach.

WCA recommendations for the long-term treatment of social phobia

What is the best approach for treating patients with social phobia (social anxiety disorder) over the long term? Social phobia is the most common anxiety disorder, with reported prevalence rates of up to 18.7%. Social phobia is characterized by a marked and persistent fear of being observed or evaluated by others in social performance or interaction situations and is associated with physical, cognitive, and behavioral (ie, avoidance) symptoms. The onset of social phobia typically occurs in childhood or adolescence and the clinical course, if left untreated, is usually chronic, unremitting, and associated with significant functional impairment. Social phobia exhibits a high degree of comorbidity with other psychiatric disorders, including mood disorders, anxiety disorders, and substance abuse/dependence. Few people with social phobia seek professional help despite the existence of beneficial treatment approaches. The efficacy, tolerability, and safety of the selective serotonin reuptake inhibitors (SSRIs), evidenced in randomized clinical trials, support these agents as first-line treatment. The benzodiazepine clonazepam and certain monoamine oxidase inhibitors (representing both reversible and nonreversible inhibitors) may also be of benefit. Treatment of social phobia may need to be continued for several months to consolidate response and achieve full remission. The SSRIs have shown benefit in long-term treatment trials, while long-term treatment data from clinical studies of clonazepam are limited but support the drug's efficacy. There is also evidence for the effectiveness of exposure-based strategies of cognitive-behavioral therapy, and controlled studies suggest that the effects of treatment are generally maintained at long-term follow-up. In light of the chronicity and disability associated with social phobia, as well as the high relapse rate after short-term therapy, it is recommended that effective treatment be continued for at least 12 months.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders

In this report, recommendations for the pharmacological treatment of anxiety and obsessive-compulsive disorders are presented, based on available randomized, placebo- or comparator-controlled clinical studies. Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for panic disorder. Tri2-cyclic antidepressants (TCAs) are equally effective, but they are less well tolerated than the SSRIs. In treatment-resistant cases, benzodiazepines like alprazolam may be used when the patient does not have a history of dependency and tolerance. Due to possible serious side effects and interactions with other drugs and food components, the irreversible monamine oxidase inhibitor (MAOI) phenelzine should be used only when first-line drugs have failed. In generalised anxiety disorder, venlafaxine and SSRIs can be recommended, while buspirone and imipramine may be alternatives. For social phobia, SSRIs are recommended for the first line, and MAOIs, moclobemide and benzodiazepines as second line. Obsessive-compulsive disorder is best treated with SSRIs or clomipramine.

Moclobemide is effective and well tolerated in the long-term pharmacotherapy of social anxiety disorder with or without comorbid anxiety disorder

Social phobia (social anxiety disorder) is a highly prevalent and chronic disorder that is associated with significant comorbidity and disability. Despite recent advances in the pharmacotherapy of the disorder, there is a paucity of randomized controlled trials on patients with comorbid disorders and on maintenance treatment. A randomized placebo-controlled, double-blind multi-site trial of moclobemide, a reversible inhibitor of monoamine oxidase A, was undertaken with 390 subjects. After an initial 12 weeks, there was the option of continuing for an additional 6 months of treatment. The primary efficacy parameter chosen was responder status as defined by the Clinical Global Impression scale change item. From week 4 onwards, there was a significantly higher response rate on moclobemide than on placebo. Superiority of medication over placebo was similar in patients with comorbid anxiety disorders (33% of subjects) and without, as well as in patients with different subtypes of social anxiety disorder; indeed, treatment with moclobemide rather than placebo was the strongest predictor of response. Adverse events were similar across treatment groups, and were typically mild and transient. In the extension phase, response rates remained higher in the moclobemide group, and ratings of tolerability were equally high in both groups. Thus, in a large sample of social anxiety disorder patients with and without comorbid anxiety disorders, moclobemide was both effective and well-tolerated in the short as well as long-term. These data confirm and extend previous findings on the value of moclobemide in the treatment of social anxiety disorder, and strengthen the range of therapeutic options for managing this important disorder.

Pharmacotherapy of social anxiety disorder

Over the last few years, a number of medications have demonstrated their efficacy in the acute treatment of social anxiety disorder. At present, selective serotonin reuptake inhibitors probably constitute the first line treatment, based on their safety, tolerability, and efficacy in the treatment of social anxiety disorder and common comorbid conditions. Data from single trials suggest that clonazepam, bromazepam, and gabapentin may have efficacy similar to the serotonin reuptake inhibitors, but further studies are needed to confirm these findings. The monoamine oxidase inhibitor phenelzine appears to be at least as efficacious as these other agents, but should be reserved for cases that fail to respond to these safer medications. Among the reversible inhibitors of monoamine oxidase A, brofaromine may also be an effective drug, while moclobemide appears to be less potent. Future research directions should include delineating ways to achieve remission (as opposed to response); developing strategies for augmenting partial responders and treating nonresponders to first line approaches; studying the long-term response to medication and prevention of relapse when medication is discontinued; clarifying ways to integrate psychosocial and pharmacological treatment approaches; developing predictors of which patients do best with which treatments; and the treatment of social anxiety disorder in children and adolescents.

Pharmacotherapy of social anxiety disorder at the turn of the millennium

Over the past 21 years since the birth of SP into the diagnostic nomenclature, there have been significant gains in knowledge about effective pharmacologic and psychotherapeutic treatments. The SSRIs have emerged as the first-line pharmacologic treatment, although good evidence shows efficacy of benzodiazepines; MAOIs; and anticonvulsant agents, such as gabapentin and pregabalin. There is also emerging evidence about the efficacy of the novel antidepressant venlafaxine and also optimism for the potential utility of nefazodone and possibly bupropion. However, there are many areas requiring further investigation. There has been a great deal of excitement about the publication of the RUPP Anxiety Study, demonstrating efficacy for fluvoxamine in socially phobic youth. Given that SP starts in childhood and adolescence, more data are needed to support the use of pharmacotherapy in this age group because early intervention may prevent the sequelae of chronic SP. There needs to be more investigation into what is required for social phobic individuals who obtain a good response to pharmacotherapy to move into full-remission status. Additional research is needed regarding the evaluation of the comparative efficacy of different drug classes and to develop an improved capability of predicting treatment response to a particular type of treatment. In addition, more research is needed regarding treatment resistance. In most of the anxiety disorders that have been studied, combining CBT with psychopharmacologic treatment has shown little advantage over either treatment alone. These findings may be due to methodologic problems. Research is needed on how to sequence treatments to maximize the benefits of combining the two types of effective treatments together. Finally, many clinicians are seeing an emerging trend of individuals who have had untreated SP all of their lives and are now presenting for treatment in their "golden years." The current established treatments need to be evaluated further in this geriatric population.

Social anxiety disorder: recent findings in the areas of epidemiology, etiology, and treatment

Social anxiety disorder is a common and chronic disorder that leads to substantial psychosocial impairment. The disorder occurs early in childhood, and is frequently comorbid with a variety of other psychiatric diagnoses like depression, other anxiety disorders, substance abuse, and eating disorders. Given these serious implications of social anxiety disorder, early effective treatment is extremely important. Pharmacotherapy, with a selective serotonin reuptake inhibitor, and cognitive behavioral therapy are the first choice of treatments for social anxiety disorder. This paper reviews recent findings on the epidemiology, etiology, and treatment for social anxiety disorder, and highlights areas where future research should be directed.