Drug Update: SSRIs in Social Phobia - Brief Article

0 Comments | Family Practice News, Feb 1, 2001 | by Mitchel L. Zoler

Social phobia, also known as social anxiety disorder, is the third most common psychiatric condition after depression and alcoholism. Roughly 7% of patients in primary care settings are significantly impaired due to social phobia, but only a minority are on adequate therapy.

Few patients seek help specifically for social phobia. Instead, they present with depression, panic disorder, substance abuse, or other comorbidities. Trembling, flushing, and sweating are common presenting physical complaints. Teens may have academic problems. Experts advise routinely asking all depressed or distressed patients about a history of social avoidance due to social fears, since this is rarely volunteered.

Selective serotonin reuptake inhibitors (SSRIs) are the workhorse drugs for this condition, even though social phobia is less responsive to these agents than is depression. Partial responses are the rule. For optimal responses, patients should also enroll in cognitive-behavioral therapy featuring cognitive restructuring and exposure therapy Informal exposure advice is also helpful: Patients with social phobia can sometimes improve when they confront distressing situations.

A major challenge is to distinguish "normal" shyness from mild social phobia. Experts say there is no clear threshold for drug intervention. Other SSRI-responsive disorders, such as depression and panic disorder, often occur in patients along with social phobia. When this happens, it can tip the balance in favor of drug therapy in patients with subthreshold or mild social phobia. If a patient's social anxiety is limited to a specific type of situation, a course of cognitive-behavioral therapy may be simpler and more effective.

As with drug treatment of depression, SSRI side effects occur somewhat idiosyncratically in patients with social phobia. The most common include insomnia, agitation, sexual dysfunction, and GI distress. Adding trazodone at bedtime often helps insomnia. Switching SSRIs works best when the problem is the side effects rather than a lack of efficacy.

When a pregnant or breast-feeding patient and her physician deem the disorder sufficiently disruptive, SSRIs are often used during pregnancy and breast-feeding, despite a lack of well-controlled studies in such women. Side effects in the elderly are similar to those in younger patients. However, because the elderly have less efficient drug clearance, starting dosages are often reduced.

The relapse rate while off medication is high; leave patients on an SSRI for 18 months before considering a trial without medication. Many social phobia patients also have recurrent depression, an indication for lifelong treatment.

Other effective drugs are the monoamine oxidase inhibitors and the benzodiazepines (clonazepam is the best studied), but these are best used by specialists. Gabapentin has recently been reported to be effective, as well.

Drug        Dosage         Cost/Day
paroxetine  40-60 mg/day   $2.53
 (Paxil)                   (40 mg/day) [*]
citalopram  40-60 mg/day   $2.15
 (Celexa)                  (40 mg/day) [**]
fluoxetine  20-40 mg/day   $2.69
 (Prozac)                  (20 mg/day) [**]
fluvoxamine 100-300 mg/day $2.82
 (Luvox)                   (100 mg/day) [**]
sertraline  100-200 mg/day $2.41
 (Zoloft)                  (100 mg/day) [**]
Drug        Comment [ ]
paroxetine  Start patients on 20 mg/day, the same recommended initial
 (Paxil)    dosage as for depression, unless they have comorbid
            panic disorder or prominent somatic fixations and
            concerns about side effects. In that case, a dosage of
            10 mg/day is less likely to cause an agitation
            response that might turn the patient against SSRIs
            forever. Most patients respond best to 40-60 mg/day, but
            there are no good data to guide SSRI dosage titration
            for social phobia. Since clinical improvement may
            take longer than in depressed patients, a full medication
            trial should be more drawn out as well.
                 Paroxetine in the only drug labeled for
            social phobia, but controlled studies show
            that the other SSRIs are also effective, and most experts
            believe the benefit is a class effect. In general, start with
            paroxetine because of the specific safety and efficacy
            data available, but don't hesitate to use any other
            SSRI based on a patient's adverse event reaction or prior
            experiences, formulary restrictions, cost, or other
            considerations. The only way to find the best SSRI for a
            patient is by empiric trial.
citalopram  Starting dosage for most patients is the standard
 (Celexa)   initial antidepressant dosage of 20 mg/day, with
            the same caveats and titration principles
            as for paroxetine. Most patients respond best to 40-60 mg/day.
fluoxetine  Start most patients on 20 mg/day, with the same caveats and
 (Prozac)   titration principles as for paroxetine. Most patients respond
            best to 20-40 mg/day.
fluvoxamine Start most patients on 50 mg/day, with the same
 (Luvox)    caveats and titration principles as for
            paroxetine. Most patients respond best to 100-300 mg/day.
sertraline  Start most patients on 50 mg/day, with the same caveats and
 (Zoloft)   titration principles as for paroxetine. Most patients respond
            best to 100-200 mg/day.