The long-term treatment of social phobia with moclobemide

Practical guide for prescribing MAOIs: debunking myths and removing barriers

Despite the fact that monoamine oxidase inhibitors (MAOIs) can be highly effective therapeutic agents for depression and some anxiety disorders, they tend to be underutilized in clinical practice. This is due at least in part to the fact that there is a great deal of misinformation and mythology about their dietary and drug interactions. This article is intended to serve as a guide for clinicians who are not particularly familiar with MAO inhibitors; its aim is to help these clinicians competently integrate these agents into clinical practice when appropriate.

Comparison of treatment adherence between selective serotonin reuptake inhibitors and moclobemide in patients with social anxiety disorder

OBJECTIVE

With respect to the pharmacotherapy of social anxiety disorder (SAD), it has been suggested that treatment duration is an important factor that can significantly predict responses. The present study aimed to compare the treatment adherence of SAD patients who were taking either SSRIs or reversible inhibitors of MAO-A (moclobemide) by measuring treatment duration and all-cause discontinuation rates of pharmacotherapy in a natural clinical setting.

METHODS

We retrospectively analysed the data of 172 patients diagnosed with SAD. Depending on their medication, we divided the patients into two groups, SSRI (n=54) or moclobemide (n=118). The expected number of all-cause discontinuation every 2 weeks after starting treatment was calculated by life table survival methods. A multi-variable Cox proportional hazard regression was used to analyze the potential influence of explanatory variables.

RESULTS

Treatment duration was significantly longer in the SSRI group [46.41±56.96, median=12.0 (weeks)] than in the moclobemide group [25.53±34.74, median=12.0 (weeks), Z=2.352, p=0.019]. Overall, all-cause discontinuation rates were significantly lower with SSRIs (81%) than moclobemide (96%, χ²=4.532, p=0.033).

CONCLUSION

The SSRI group had a longer treatment duration and lower all-cause discontinuation rate than moclobemide. Further, only the type of medication had a significant effect on all-cause discontinuation rates and therefore, we could predict better treatment adherence with the SSRIs in the treatment of SAD.

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.

Monoamine oxidase inhibitors: a modern guide to an unrequited class of antidepressants

Monoamine oxidase inhibitors (MAOIs) currently have a "bad rap" and are thus infrequently used in psychopharmacology, even by experienced clinicians. Misinformation about the dietary and drug interactions of MAOIs is widespread, whereas pragmatic tips for utilizing MAOIs to minimize risks and to maximize therapeutic actions are largely lacking in the contemporary literature. While clearly not first-line treatments, MAOIs, in the hands of experienced and well-informed clinicians, can be a powerful therapeutic intervention for patients with depression, panic disorder, and other anxiety disorders who have failed first-line treatments. This article focuses on the pharmacologic mechanisms of MAOIs, since an understanding of these mechanisms may provide a rationale to empower experts to expand their use of these agents. Discussed here are not only the mechanisms of therapeutic action of MAOIs, but also the mechanisms explaining their side effects, including hypertensive interactions with dietary tyramine (so-called "cheese reactions") and drug interactions that can lead to hypertensive reactions with some drugs and serotonin toxicities with others. This article also provides practical tips on how to use MAOIs, including debunking certain myths and giving specific guidance about which foods and drugs to avoid. Those with no previous interest in MAOIs may discover in this article a new "secret weapon" to add to their therapeutic armamentarium for patients who fail to respond to the better-known agents.

Optimizing treatment in social phobia: a review of treatment resistance

Over the last 25 years, there has been a rapid expansion of our knowledge base of social phobia (SP). Although there are a number of well-validated treatment modalities, including pharmacotherapy and cognitive-behavioral therapy, significant gaps remain in our ability to achieve full remission in most patients. Despite advances in the neurobiology of SP, the etiology has yet to be determined. Investigations examining potential predictors of response have provided little guidance in selecting an appropriate treatment modality. These gaps in our knowledge have pushed us to examine issues related to treatment resistance. This paper presents a review of the current literature and issues related to treatment-resistant SP, including a discussion of the functional impairment associated with SP, definitions of treatment response and remission, as well as outcome measures that have been used in clinical investigations of SP. In addition, criteria for a standard treatment trial, predictors of treatment response, a review of treatment resistance studies, and potential directions for future research are examined. The most promising strategies to attain remission, will likely involve augmenting selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors with agents such as anticonvulsants, benzodiazepines, and antipsychotics as well as combining pharmacotherapy with cognitive-behavioral therapy. Our current treatment target of simply attaining a response needs to be refocused, so that an asymptomatic state and high end state functioning become the final goal of treatment.

Pre-existing antidepressants and the outcome of group cognitive behaviour therapy for social phobia

OBJECTIVE

This is a naturalistic treatment outcome study investigating the impact of pre-existing antidepressant use on the effectiveness of group cognitive behaviour therapy (CBT) for social phobia.

METHOD

Of the 133 participants who completed the CBT program, 49 reported taking antidepressants (CBT + AD group), while 84 reported not taking antidepressants (CBT group). The treatment program involves 40 h of structured, group-based CBT over 7 weeks. The dependent measures included the Social Phobia Scale and Social Interaction Anxiety Scale, the Fear of Negative Evaluation Scale, the Depression, Anxiety and Stress Scale and the Short Form-12.

RESULTS

Both the CBT + AD group and the CBT group improved significantly across treatment on all dependent measures. There were no significant differences between the groups on any outcome measure and the rate of improvement from pre- to post-treatment for both groups did not differ.

CONCLUSIONS

Pre-existing antidepressants did not significantly enhance or detract from the positive treatment outcome of a structured, group-based CBT program for social phobia.

The lifelong course of social anxiety disorder: a clinical perspective

Social anxiety disorder (SAD) is among the most frequently observed psychiatric disorders, with estimates of approximately 10% of people likely to suffer from the disorder during their lifetime. However, despite causing significant impairment of normal functioning, this disorder is often mistaken as shyness and remains under-recognized and under-treated. Following onset in adolescence, patients with generalized SAD often experience a lifelong and unremitting mental disorder characterized by severe anxiety and disability. Typical duration of the illness is far in excess of that seen in panic disorder, and prospective, long-term, naturalistic studies have indicated that only one-third of individuals attain remission from SAD within 8 years, compared with over two-thirds of those with panic disorder. Comorbidity of other anxiety disorders, depression and personality disorders are common in SAD and associated with more pronounced impairment and a poorer long-term outcome. Effective treatment for SAD is available but use is low and may remain suboptimal, despite the development of pharmacotherapeutic agents with anxiolytic and antidepressant properties and the efficacy of psychotherapeutic approaches. Increased knowledge of the course of SAD highlights the need to examine the role of available treatments, administered individually or in combination, as acute, continuation or maintenance therapy to maximize the chances of remission and long-term benefit for patients.

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.

Efficacy of citalopram and moclobemide in patients with social phobia: some preliminary findings

The efficacy of irreversible and reversible monoamine oxidase inhibitors (MAOIs) in the treatment of social phobia (SP) is well established. Recently, selective serotonin reuptake inhibitors (SSRIs) have been used more frequently. In the present study, the efficacy and side-effect profile of citalopram, an SSRI, and moclobemide, the only MAOI used in Turkey, were compared. The 71 patients diagnosed with SP according to DSM-III-R were randomly assigned to two subgroups; citalopram (n = 36) or moclobemide (n = 35). The study was an 8-week, randomized, open-label, rater-blinded, parallel-group trial. All patients were assessed by Hamilton anxiety rating (HAM-A), Liebowitz social anxiety (LSAS), clinical global impression-severity of illness (CGI-SI) and clinical global impression-improvement (CGI-I) scales. There was a similar percentage of responders (citalopram 75%, n = 27 and moclobemide 74.3%, n = 26), with a >50% or greater reduction in LSAS total score and ratings of "very much" or "much improved" on the CGI-I. None of the patients withdrew from the study. The results of the present study suggest that citalopram has shown promising results in patients with SP.

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.

[Evaluated treatment approaches in child and adolescent psychiatry II]

OBJECTIVES

The principle of evidence-based medicine is to integrate data concerning the efficacy of interventions into clinical practice. This article assesses the level of evaluation of psychosocial, psychopharmacological and combined interventions for mental disorders in childhood and adolescence (schizophrenic disorders, affective disorders, phobias and anxiety disorders, obsessive-compulsive disorder, posttraumatic stress disorder, anorexia nervosa, and bulimia nervosa).

METHODS

Three different levels of evaluation were defined for both psychosocial and psychopharmacological interventions: A (> or = 2 randomized controlled studies), B (1 randomized controlled study), and C (open studies and case studies). The level of evaluation was judged on the basis of original papers found in a comprehensive literature search.

RESULTS

The number of controlled studies examining these disorders in children and adolescents is small, especially with regard to pharmacotherapy. However, the efficacy of (cognitive) behavior therapy for depressive disorders, phobias and anxiety disorders, as well as posttraumatic stress disorder has been demonstrated.

CONCLUSIONS

There is still a considerable need to evaluate pharmacological treatment approaches for schizophrenic and affective disorders. Looking at psychosocial interventions in schizophrenic disorders, obsessive-compulsive disorder and eating disorders, specific aspects of treatment for young patients should be examined. Overall, the psychotherapy approach evaluated best is (cognitive) behavioral therapy.

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.

Management of anxiety disorders: the added challenge of comorbidity

Patients with anxiety present with a wide variety of disorders that cause significant impairment to their everyday lives. To complicate matters, patients seldom present with just one anxiety disorder. Such comorbidity, particularly where depression is also present, has important implications for both the patient and the physician. The patient typically suffers from a greater degree of everyday impairment, is more reliant on healthcare services, in particular mental health services, and may be at a greater risk of attempting suicide. For the physician, comorbidity in anxiety disorders presents a challenge as the patient's symptoms are often more severe, present earlier in life, and are frequently prolonged which makes their management more complex. This review will focus on the anxiety disorders: panic disorder, obsessive-compulsive disorder, social anxiety disorder, and post-traumatic stress disorder. The impact of co-existing multiple anxiety disorders, depression, or a history of substance abuse will be discussed with a view to choosing the appropriate management strategy. Treatment options will be reviewed.

Antidepressants in social anxiety disorder

Social anxiety disorder (SAD) is a marked and persistent fear of doing almost everything in front of people due to concerns about being judge by others. An up-to-date review is needed in order to reach a practical judgement of all psychopharmacological data. Case reports, open and double-blind trials with SAD were described and commented upon from a clinical point of view. The MEDLINE system was searched from 1975 to 2001. The references from the selected papers were also used as a source. MAOIs (fenelzine, tranylcypromine), reversible monoamino oxidase-A inhibitors (moclobemide, brofaromine), SSRIs (paroxetine, sertraline, fluoxetine, fluvoxamine) and some other antidepressants (venlafaxine, nefazodone) have proven effective in several studies with various methodologies. The MAOIs have more serious adverse effects and the SSRIs have the best tolerance. SSRIs are efficacious and the first choice of treatment.

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.

Social phobia: diagnosis and epidemiology, neurobiology and pharmacology, comorbidity and treatment

Social phobia is a common disorder associated with significant psychosocial impairment, representing a substantial public health problem largely determined by the high prevalence, and the lifelong chronicity. Social phobia starts in early childhood or adolescence and is often comorbid with depression, other anxiety disorders, alcohol and substance abuse or eating disorders. This cascade of comorbidity, usually secondary to social phobia, increases the disability associated with the condition. The possibility that social phobia may be a trigger for later developing comorbid disorders directs attention to the need for early effective treatment as a preventive measure. The most recent drug class to be investigated for the psychopharmacological treatment of social phobia is the SSRI group for which there is growing support. The other drug classes that have been evaluated are monoamine oxidase inhibitors (MAOIs), benzodiazepines, and beta-blockers. The SSRIs represent a new and attractive therapeutic choice for patients with generalized social phobia. Recently the first, large scale, placebo-controlled study to assess the efficacy of drug treatment in generalized social phobia has been completed with paroxetine. Paroxetine was more effective in reducing the symptoms than placebo and was well tolerated. Many now regard SSRIs as the drugs of choice in social phobia because of their effectiveness and because they avoid the problems of treatment with benzodiazepines or classical MAOIs.

O tratamento farmacológico da fobia social

A fobia social é o medo acentuado e persistente de comer, beber, tremer, enrubescer, falar, escrever, enfim, de agir de forma ridícula ou inadequada na presença de outras pessoas. A fobia social apresenta-se em dois tipos básicos: a circunscrita, restrita a apenas um tipo de situação social, e a generalizada, caracterizada pelo temor a todas ou quase todas situações sociais. As características clínicas da fobia social são a ansiedade antecipatória, os sintomas físicos, a esquiva e a baixa auto-estima. Conforme o rigor diagnóstico, estima-se que 5% a 13% da população geral apresentem sintomas fóbicos sociais que resultem em diferentes graus de incapacitação e limitações sociais e ocupacionais. O tratamento médico de escolha é o uso de medicamentos associados à psicoterapia cognitivo-comportamental. Beta-bloqueadores (atenolol, propranolol), antidepressivos inibidores da monoamino oxidase (IMAO) (fenelzine, tanilcipromina), inibidores reversíveis da monoamino oxidase tipo-A (RIMA) (moclobemida, brofaromina), benzodiazepínicos (clonazepam, bromazepam, alprazolam) e antidepressivos inibidores seletivos de serotonina (ISRS) (paroxetina, sertralina, fluoxetina e fluvoxamina) e alguns outros (venlafaxina, nefazodone, gabapentina, clonidina) têm demonstrado eficácia em inúmeros estudos com diferentes metodologias. Os antidepressivos tricíclicos (imipramina, clomipramina), o ácido valproico e a buspirona têm apresentado resultados negativos. A paroxetina é o medicamento mais estudado com metodologia duplo-cega, com melhores resultados e com boa tolerância. Atualmente, os indivíduos que têm sua vida prejudicada pela fobia social podem, com o tratamento eficaz, adquirir uma postura mais segura em situações sociais.

The noradrenergic system in pathological anxiety: a focus on panic with relevance to generalized anxiety and phobias

Over the past three decades of psychiatric research, abnormalities in the noradrenergic system have been identified in particular anxiety disorders such as panic disorder. Simultaneously, neuroscience research on fear pathways and the stress response have delineated central functions for the noradrenergic system. This review focuses on the noradrenergic system in anxiety spectrum disorders such as panic disorder, generalized anxiety disorder, and phobias for the purpose of elucidating current conceptualizations of the pathophysiologies. Neuroanatomic pathways that are theoretically relevant in anxiogenesis are discussed and the implications for treatment reviewed.

Social phobia: issues in assessment and management

Social phobia was initially classified with phobic anxiety states and was believed to be quite rare, but it is now gaining due recognition as a widespread and often crippling disorder. The boundaries of social phobia merge into traits of shyness and universal performance anxiety, with symptoms commonly appearing in the teenage years. If left untreated, social phobia is a remarkably persistent condition, leading to potentially lifelong impairment in social development and occupational functioning. It may also give rise to other co-morbid disorders, particularly dysthymia, depression, obsessive-compulsive disorder, other phobic disorders, and substance abuse. Over the years, social phobia has been all too frequently viewed as a somewhat trivial, minor form of psychiatric illness and has received little clinical attention. This erroneous perception is now giving way under the mounting evidence in support of the extensive morbidity and disability associated with social phobia and the probable role of genetic and environmental influences. Furthermore, data from multiple controlled clinical trials reveal that this is a treatable condition, responding to both psychosocial and pharmacologic interventions. Here we examine issues to consider in the differential diagnosis of social phobia, review the goals of treatment, and summarize evidence in support of the effectiveness of individual pharmacologic treatments.

Assessment of sexual dysfunction in depressed patients and reporting attitudes in routine daily practice: Results of the postmarketing observational studies with moclobemide, a reversible MAO-A inhibitor

OBJECT

The aim of this study was to assess the effect of moclobemide on sexual dysfunction in depressed patients treated under routine conditions in private practice and hospital settings.

METHOD

sexual function was systematically assessed by a specific questionnaire and by recording spontaneously reported adverse events during large prospective postmarketing surveillance studies with moclobemide, carried out in Germany between 1992 and 1995. The data of 4333 patients were collected in two different settings: (a) specialized psychiatric and neurological private practices and (b) psychiatric hospitals.

RESULTS

Up to 70% of depressed patients suffered from Some type of sexual dysfunction at baseline and in about two thirds the dysfunction was rated as moderate to severe. The severity and frequency of sexual dysfunction corresponded well to the severity of depressive syndrome. Sexual functions improved during treatment with moclobemide and the extent of improvement corresponded to the favourable outcome of antidepressant treatment. Deterioration of sexual functions under moclobemide treatment was infrequent and experienced by less than 3% of patients. The frequency of spontaneously reported sexual dysfunction, reported as adverse event, was lower than 0.1%. For a considerable proportion of patients included in the studies sexual function was not systematically recorded: up to 10-20% of data for variables related to sexual function were missing. Unreported sexual functioning varied in dependence of the type of function, age and gender of the patient and treatment settings.

CONCLUSION

The results of the observational studies with moclobemide do not provide evidence that moclobemide induces or intensifies sexual dysfunction in depressed patients under routine daily treatment. The results also demonstrate that the assessment of sexual function in the practice is clearly influenced by the reporting attitudes of patients and physicians.

Therapeutic strategies for patients with social phobia

Social phobia is a serious condition in the range of anxiety disorders which, until quite recently, has not been given due attention in research. In this paper we compare existing studies and follow-up results of behaviour therapy and pharmacotherapy. We have endeavoured to work out an effective therapy for this serious condition. Apart from psychological education as a basic therapeutic element, the use of effective drugs promises to yield good results, especially in conjunction with behaviour therapy, including training in social skills, cognitive therapy and exposure therapy. Whichever form of treatment is chosen depends on the patient's preference and the availability of services. If the patient does not respond, the possible causes should be examined thoroughly and new types of treatment considered. A combination of behaviour and drug treatments might be provided for special groups.

Placebo-controlled trial of moclobemide in social phobia

BACKGROUND

Moclobemide, a reversible inhibitor of monoamine oxidase A, previously has been reported to have efficacy in the treatment of social phobia.

METHOD

Seventy-seven non-responders to one week of single-blind placebo were randomly assigned to moclobemide or placebo for eight weeks of double-blind treatment. Outcome was assessed by independent evaluator, treating psychiatrist and self-ratings. After eight weeks, patients who were at least minimally improved continued treatment for a further eight weeks.

RESULTS

Intention-to-treat sample response rates at week 8 were 7/40 (17.5%) for the moclobemide group and 5/37 (13.5%) for placebo (NS). Moclobemide was significantly superior to placebo on 2 of 10 primary outcome measures. Moclobemide was well tolerated.

CONCLUSIONS

Moclobemide may have efficacy in the treatment of social phobia, but absence of significant differences on most primary outcome measures and small effect sizes for all outcome measures suggest that the magnitude of its clinical effect is small.

Assessment and treatment of social phobia

Social phobia is an anxiety disorder characterized by heightened fear and avoidance of one or more social or performance situations, including public speaking, meeting new people, eating or writing in front of others, and attending social gatherings. People with social phobia are typically anxious about the possibility that others will evaluate them negatively and/or notice symptoms of their anxiety. Social phobia affects up to 13% of individuals at some time in their lives and is usually associated with at least moderate functional impairment. Research on the nature and treatment of social phobia has increased dramatically over the past decade. As with many of the anxiety disorders, sensitive assessment instruments and effective treatments now exist for people suffering from heightened social anxiety. Typical assessment strategies include clinical interviews, behavioural assessments, monitoring diaries, and self-report questionnaires. Treatments with demonstrated efficacy for social phobia include pharmacotherapy (for example, phenelzine, moclobemide, selective serotonin reuptake inhibitor [SSRI] medications) and cognitive behaviour therapy (CBT) (for example, cognitive restructuring, in vivo exposure, social skills training). Although preliminary comparative studies suggest that both approaches are about equally effective in the short term, each approach has advantages and disadvantages over the other. Trials examining combined psychological and pharmacological treatments are now under way, although no published data on the relative efficacy of combined treatments are currently available.