Cognitive Behavioral Therapy Conquers Social Anxiety better than Antidepressants

A certain type of therapy beats antidepressants for treating social anxiety disorder.

Not only that, but unlike the medications, it can stay effective long after treatment has stopped, according to a new study from researchers at Johns Hopkins University.

In an analysis of 101 clinical trials comparing multiple types of medication and talk therapy, CBT came in at number one.

Cognitive behavioral therapy (CBT) helps patients focus on the interactions between thoughts, feelings, and behaviors.

“Social anxiety is more than just shyness,” says study leader Evan Mayo-Wilson. “People with this disorder can experience severe impairment, from shunning friendships to turning down promotions at work that would require increased social interaction. The good news from our study is that social anxiety is treatable. Now that we know what works best, we need to improve access to psychotherapy for those who are suffering.”

Social anxiety disorder is marked by intense fear and avoidance of social situations. Up to 13 percent of all North Americans and Europeans are affected by it.

And most never receive any treatment.

For those who do get treatment, medication is a more available option due to the shortage of trained psychotherapists.

Severe and Chronic Social Anxiety

In this study, data from 13,164 participants in 101 clinical trials was analyzed.

Researchers from Johns Hopkins, Oxford University, and University College London contributed to the study.

All participants studied suffered from severe and longstanding social anxiety.

Around 9,000 received medication or a placebo; more than 4,000 received a psychological intervention.

Not many of the trials looked at combining medication with talk therapy, and there was no evidence that combined therapy was better than talk therapy alone.

The data compared numerous different types of talk therapy and found individual cognitive behavioral therapy the most effective. CBT helps people challenge their irrational fears and surmount their avoidance of social situations, Mayo-Wilson says.

Selective Serotonin Reuptake Inhibitors

For those who don’t want talk therapy, or who have no access to CBT, the most commonly used antidepressants, known as selective serotonin reuptake inhibitors (SSRIs), are successful, researchers found.

These medications, however, can be associated with serious adverse effects, and they don’t work at all for many people, the researchers say. Improvements in symptoms do not last after people stop taking the pills.

Medication is still an important tool.

But it should be used as a second-line therapy for people who do not want or don’t respond to psychological therapy, the researchers say.

The study has already led to new treatment guidelines guidance in the United Kingdom and, Mayo-Wilson says, could have a significant impact on policymaking and the organization of care in the United States.

Quality of Life

Social anxiety disorder characteristically starts in adolescence or early adulthood. It may severely impair a person’s daily functioning by getting in the way of forming relationships, harmfully affecting work or school performance, and lowering overall quality of life.

Since it strikes at critical times in patients’ social and educational development, it can have important and lasting consequences.

“Greater investment in psychological therapies would improve quality of life, increase workplace productivity, and reduce health care costs,” Mayo-Wilson says. “The health care system does not treat mental health equitably, but meeting demand isn’t simply a matter of getting insurers to pay for psychological services.

We need to improve infrastructure to treat mental health problems as the evidence shows they should be treated.

We need more programs to train clinicians, more experienced supervisors who can work with new practitioners, more offices, and more support staff.”

Pharmacological treatments that had greater effects on outcomes compared with being on a waitlist (in other words no treatment) included monoamine oxidase inhibitors, benzodiazepines, selective serotonin-reuptake inhibitors and serotonin—norepinephrine reuptake inhibitors, and anticonvulsants.

Compared with being on a waitlist, effective kinds of psychological interventions included individual cognitive—behavioural therapy, group CBT, exposure and social skills therapy, self-help with support, self-help without support, and psychodynamic psychotherapy.

Individual CBT and SSRIs and SNRIs were the only treatments that had greater effects on outcomes than a placebo. Individual CBT also had a greater effect than psychodynamic psychotherapy, interpersonal psychotherapy, mindfulness, and supportive therapy.


Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis
Dr Evan Mayo-Wilson DPhil,Sofia Dias PhD,Ifigeneia Mavranezouli PhD,Kayleigh Kew MA,Prof David M Clark DPhil,Prof A E Ades PhD,Prof Stephen Pilling PhD
The Lancet Psychiatry – 26 September 2014 DOI: 10.1016/S2215-0366(14)70329-3