Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis

Background Social anxiety disorder-a chronic and naturally unremitting disease that causes substantial impairment-can be treated with pharmacological, psychological, and self-help interventions. We aimed to compare these interventions and to identify which are most effective for the acute treatment of social anxiety disorder in adults. Methods We did a systematic review and network meta-analysis of interventions for adults with social anxiety disorder, identified from published and unpublished sources between 1988 and Sept 13, 2013. We analysed interventions by class and individually. Outcomes were validated measures of social anxiety, reported as standardised mean differences (SMDs) compared with a waitlist reference. This study is registered with PROSPERO, number CRD42012003146. Findings We included 101 trials (13 164 participants) of 41 interventions or control conditions (17 classes) in the analyses. Classes of pharmacological interventions that had greater effects on outcomes compared with waitlist were monoamine oxidase inhibitors (SMD -1.01, 95% credible interval [CrI] -1.56 to -0.45), benzodiazepines (-0.96, -1.56 to -0.36), selective serotonin-reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors (SSRIs and SNRIs; -0.91, -1.23 to -0.60), and anticonvulsants (-0.81, -1.36 to -0.28). Compared with waitlist, efficacious classes of psychological interventions were individual cognitive-behavioural therapy (CBT; SMD -1.19, 95% CrI -1.56 to -0.81), group CBT (-0.92, -1.33 to -0.51), exposure and social skills (-0.86, -1.42 to -0.29), self-help with support (-0.86, -1.36 to -0.36), self-help without support (-0.75, -1.25 to -0.26), and psychodynamic psychotherapy (-0.62, -0.93 to -0.31). Individual CBT compared with psychological placebo (SMD -0.56, 95% CrI -1.00 to -0.11), and SSRIs and SNRIs compared with pill placebo (-0.44, -0.67 to -0.22) were the only classes of interventions that had greater effects on outcomes than appropriate placebo. Individual CBT also had a greater effect than psychodynamic psychotherapy (SMD -0.56, 95% CrI -1.03 to -0.11) and interpersonal psychotherapy, mindfulness, and supportive therapy (-0.82, -1.41 to -0.24). Interpretation Individual CBT (which other studies have shown to have a lower risk of side-effects than pharmacotherapy) is associated with large effect sizes. Thus, it should be regarded as the best intervention for the initial treatment of social anxiety disorder. For individuals who decline psychological intervention, SSRIs show the most consistent evidence of benefit.