Antidepressants boost CBT for social anxiety

Treatments for social anxiety disorder often include either selective serotonin reuptake inhibitors (SSRIs) or cognitive behavioural therapy (CBT), but new research from Uppsala University indicates that social anxiety disorder is best treated with the combination of SSRI and CBT, which also improves emotion processing in the brain.

Many people feel anxious if they have to speak in front of an audience or socialise with others. If the anxiety becomes frequent and forceful it may mean that the person suffers from social anxiety disorder.

Combining SSRI drugs and CBT is rather common in clinical practice but clinical trials evaluating the efficacy of combined treatments are scarce. Researchers at Uppsala University have now examined the effects of the SSRI escitalopram given simultaneously with an internet-delivered CBT program for sufferers of social anxiety disorder. This was compared to a group of patients that received placebo combined with CBT and neither the patients nor the clinicians knew beforehand if they were given the SSRI or placebo, i.e. the trial was double-blind. In addition, all patients underwent brain scanning with functional magnetic resonance imaging (fMRI) to assess changes in neural activity with treatment.

The study, which is published in the British Journal of Psychiatry, shows that, after nine weeks of combined treatment, patients receiving SSRI and CBT were more improved than those who were treated with placebo and CBT. This effect was evident both in the patients' everyday social anxiety and on a laboratory speech anxiety test. The clinical difference between the compared treatment groups was even further pronounced at a long term follow-up assessment 15 months later.

Furthermore, fMRI scans revealed that larger symptom improvement in the group receiving combined SSRI and CBT, was accompanied by a reduced neural response to emotional stimuli in the amygdala, a brain structure highly involved in generating anxiety and fear.

These results are of great importance for clinical practitioners when deciding proper treatment for individuals with social anxiety disorder and the study also sheds light on the neurobiology underlying effective treatment of anxiety.

"We have now preliminary support to say that the SSRI escitalopram adds to the effect of CBT for social anxiety disorder and that clinical response is linked to reduced activation of the amygdala." says Malin Gingnell, researcher at the Department of Psychology, Uppsala University.