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Treatment of Social Phobia with Antidepressants

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Treatment of Social Phobia with Antidepressants Antidepressants for Social Phobia Treatment of Social Phobia With Antidepressants Franklin R. Schneier, M.D. This article reviews evidence for the utility of antidepressant medications in the treatment of social phobia. Monoamine oxidase inhibitors (MAOIs) were the first antidepressants shown to be effective © Copyrightfor social phobia, but 2001dietary restrictions Physicians and a relatively Postgraduate high rate of adverse effects Press, often relegate Inc. MAOIs to use after other treatments have been found ineffective. Reversible inhibitors of monoamine oxidase (RIMAs) hold promise as safer alternatives to MAOIs, but RIMAs may be less effective and are currently unavailable in the United States. Selective serotonin reuptake inhibitors (SSRIs), of which paroxetine has been the best studied in social phobia to date, have recently emerged as a first- line treatment for the generalized subtype of social phobia. The SSRIs are well tolerated and consis- tently have been shown to be efficacious in controlled trials. (J Clin Psychiatry 2001;62[suppl 1]:43–48) arly evidence that antidepressantsOne might personal have utility copy maypressant be printed treatment of other anxiety disorders, such as panic E in the treatment of social phobia emerged in the disorder and obsessive-compulsive disorder. In particular, 1970s when studies found efficacy for monoamine oxidase the high rate of comorbidity of anxiety disorders with de- inhibitors (MAOIs) in patient samples that included both pression3 makes treatment with antidepressants an efficient patients with agoraphobia and those with social phobia.1 In choice in patients with marked comorbid depression. It the early 1980s, the MAOI phenelzine was also reported to should be noted, however, that most controlled trials of be particularly effective in patients with atypical depres- antidepressants for social phobia have excluded patients sion for reducing interpersonal sensitivity, a feature com- with comorbid major depression or scores above a speci- mon to social phobia.2 During the 15 years that followed, a fied cutoff on depression rating scales. These studies have variety of small clinical trials of antidepressants further demonstrated the efficacy of antidepressants for social pho- established the efficacy of MAOIs for social phobia, sug- bia independent of comorbid depressive symptoms. gested the lack of efficacy for tricyclic antidepressants, and Additionally, for SSRIs in particular, high levels of pa- found selective serotonin reuptake inhibitors (SSRIs) effi- tient acceptance and low liability of abuse in comparison cacious. The turn of the millennium has seen the publica- with the benzodiazepines are significant advantages, the tion of several large multicenter studies confirming the latter especially for patients with substance abuse, which utility of SSRIs and investigating reversible inhibitors of is also frequently comorbid with social phobia.3 Finally, monoamine oxidase (RIMAs), as well as the first accep- some patients unwilling or unable to tolerate the anxiety- tance of social phobia as a drug indication by the U.S. Food provoking aspects of cognitive-behavioral therapy (CBT) and Drug Administration (FDA). may become able to do so after an antidepressant medica- For the treatment of social phobia, antidepressants have tion has partially controlled their symptoms. advantages similar to those previously reported for antide- This review will focus on placebo-controlled trials of antidepressant medications. In considering this literature, it is important to take into account the generalizability of the findings. Most treatment trials in patients with social From the Anxiety Disorders Clinic, New York State phobia that have reported diagnosis by subtype have pre- Psychiatric Institute and the College of Physicians and dominantly recruited individuals with a generalized sub- Surgeons of Columbia University, New York. This article is based on “Antidepressants for the Treatment type—those who fear most social situations—and some tri- of Social Anxiety,” a presentation made by Dr. Schneier at a als have specifically limited enrollment to this subtype. It symposium entitled Advances and Emerging Treatments in Social Phobia. The symposium took place on January 10, 2000, seems likely, therefore, that most of the findings from the in Atlanta, Ga. Advances and Emerging Treatments in Social literature are relevant to individuals with the generalized Phobia was sponsored by Duke University School of Medicine subtype of social phobia, but not necessarily relevant to and supported through an unrestricted educational grant from Pfizer Inc. those with nongeneralized forms, such as public-speaking Reprint requests to: Franklin R. Schneier, M.D., Anxiety anxiety only. Studies of the generalized subtype reflect the Disorders Clinic, New York State Psychiatric Institute, 1051 Riverside Dr., Unit 69, New York, NY 10032 (e-mail: population that is most likely to experience impairment and [email protected]). seek treatment for social phobia.4 However, even patients J Clin Psychiatry 2001;62 (suppl 1) 43 Franklin R. Schneier Figure 1. Response Rates in Placebo-Controlled Studies of some other active treatments, including the benzodiaze- Phenelzine for Social Phobia pine alprazolam, the β-blocker atenolol, the RIMA moclo- bemide, and CBT. 80 The most recent published study of phenelzine for so- 70 Liebowitz et al, 19929 (N = 74) cial phobia compared it with cognitive-behavioral group 60 Gelernter et al, 199111 (N = 65) therapy (CBGT), placebo, and an educational-supportive Versiani et al, 199210 (N = 78) 8 50 Heimberg et al, 19988 (N = 133) therapy control group (N = 133). Both phenelzine and 40 CBGT were superior to control conditions, and phenelzine 30 was superior to CBGT on some measures after both 6 and 12 weeks of treatment. Most phenelzine-treated patients 20 © Copyright 2001 Physiciansmaintained Postgraduate their gains during Press, a 6-month Inc. continuation of 10 Response Rate (% of patients) treatment, and about half remained well during the 6 0 months after treatment was discontinued.12 In a prior Phenelzine Placebo study, Liebowitz et al.9 compared phenelzine and atenolol in outpatients (N = 74), most of whom had the generalized subtype of social phobia. After 8 weeks of treatment, 64% presenting with fears of public speaking as a chief com- of patients were much improved on phenelzine treatment, plaint often turn out to have more generalized fears on significantly more than the 23% treated with placebo further investigation. (p = .003) and 30% treated with atenolol (p = .02). Most of the existing trials are studies of only 8 to 12 Phenelzine was compared with moclobemide (a RIMA weeks’ duration, with just a few studies looking at longer- not currently marketed in the United States) and placebo term treatment. This is an importantOne limitation personal of the copy lit- mayin abe double-blind printed trial in Brazil (N = 78).10 After 8 weeks erature because social phobia is often a chronic, lifelong of treatment, both phenelzine and moclobemide were sig- condition.5 Data about persistence of effects after discon- nificantly superior to placebo. After 16 weeks of treat- tinuation of antidepressants are also rather limited, and ment, 73% of patients receiving phenelzine and 54% of evidence establishing guidelines for optimal duration of patients receiving moclobemide were much improved, treatment is virtually nonexistent. significantly more than the 12% of patients receiving pla- The clinical trials in individuals with social phobia cebo (p < .001 and p < .001, respectively). have used a variety of different outcome measures, which Phenelzine, alprazolam, pill placebo, and CBGT were must be considered when comparing findings across stud- compared over 12 weeks of treatment (N = 65) in a study ies. Many have used a categorical measure of response, conducted at the National Institute of Mental Health.11 such as the Clinical Global Impressions scale (CGI), This study differed from those above in that few patients which categorizes patients on a 7-point scale beginning had the generalized subtype, and treating clinicians ac- with 1 = very much improved, 2 = much improved, tively encouraged all patients to enter phobic situations 3=minimally improved, and 4 through 7 for patients un- each week. By categorical outcome (response vs. nonre- changed or worse. Most studies have classified respond- sponse), the authors found a trend toward superiority for ers as patients rated much or very much improved at last phenelzine (p = .09). They identified unequivocal im- observation. The most commonly used continuous mea- provement in 69% of the phenelzine arm, compared with sure of social phobia severity has been the Liebowitz So- 38% of the alprazolam arm, 24% of the CBGT arm, and cial Anxiety Scale (LSAS).6 The LSAS rates severity of 20% of the placebo arm. There were few other group dif- anxiety and avoidance on 4-point scales for 24 different ferences, however. At follow-up 2 months after discon- social or performance situations, and it is well validated.7 tinuation of treatment, phenelzine patients retained most Unless otherwise stated, results reviewed here for each of their improvement and were significantly less impaired trial will pertain to the intent-to-treat sample of all patients than were alprazolam- or placebo-treated patients. randomized. Selegiline, another irreversible MAOI, at daily doses ≤ 10 mg is specific for monoamine oxidase B (MAO-B). IRREVERSIBLE MONOAMINE The MAO-B
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