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Mitsui N, Fujii Y, Asakura S, Imai H, Yamada H, Yoshinaga N, Kanai Y, Inoue T, Shimizu E. Antidepressants for social anxiety disorder: A systematic review and meta-analysis. Neuropsychopharmacol Rep 2022; 42:398-409. [PMID: 35848723 PMCID: PMC9773641 DOI: 10.1002/npr2.12275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 05/09/2022] [Accepted: 05/24/2022] [Indexed: 01/03/2023] Open
Abstract
AIM This systematic review is aimed to update and reintegrate the pharmacotherapy of social anxiety disorder (SAD), including the Japanese medical database. METHODS We conducted a systematic review and meta-analysis of pharmacotherapy of SAD according to the Medical Information Distribution Service. We used data from a most recent systematic review, and updated search were conducted using MEDLINE, PubMed, CENTRAL, ICTRP, and ICHUSHI from August 1st, 2017 to January 31st, 2022. The outcome were response rates assessed by Clinical Global Impressions Improvement, efficacy assessed by the Liebowitz Social Anxiety Scale (LSAS), and dropout rates. We performed a random effect of meta-analysis to obtain the differences in each outcome between active medication and placebo. We used RevMan version 5.3 for analyses. RESULTS We identified 5 studies through update search and performed meta-analysis for 33 studies on selective serotonin reuptake inhibitor (SSRI) and 6 studies on serotonin noradrenalin reuptake inhibitor (SNRI). The response rate (RR = 1.62) and the LSAS score reduction (mean difference = -9.65) of SSRI, and the response rate (RR = 1.57) and the LSAS score reduction (mean difference = -11.72) of SNRI were significantly different from placebo. The dropout rates of SSRI or SNRI were not significant. The response rates of SSRIs in both Japanese studies (RR = 1.44) and countries other than Japan (RR = 1.67) were significant. Most findings were based on low quality of evidence. CONCLUSION SSRIs are valid option for pharmacotherapy of SAD including Japanese patients. SNRIs are another effective option. However, the results should be interpreted cautiously due to several risk of bias.
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Affiliation(s)
- Nobuyuki Mitsui
- Department of PsychiatryHokkaido University Graduate School of MedicineSapporoJapan,Health Care CenterHokkaido UniversitySapporoJapan
| | - Yutaka Fujii
- Department of PsychiatryHokkaido University Graduate School of MedicineSapporoJapan,Health Care CenterHokkaido UniversitySapporoJapan
| | - Satoshi Asakura
- Department of PsychiatryHokkaido University Graduate School of MedicineSapporoJapan,Health Care CenterHokkaido UniversitySapporoJapan
| | - Hissei Imai
- Department of Health Promotion and Human BehaviorKyoto University Graduate School of Medicine and School of Public HealthKyotoJapan
| | - Hisashi Yamada
- Department of NeuropsychiatryHyogo College of MedicineHyogoJapan
| | - Naoki Yoshinaga
- School of Nursing, Faculty of MedicineUniversity of MiyazakiMiyazakiJapan
| | - Yoshihiro Kanai
- Department of Human Science, Faculty of Liberal ArtsTohoku Gakuin UniversitySendaiJapan
| | - Takeshi Inoue
- Department of PsychiatryTokyo Medical UniversityTokyoJapan
| | - Eiji Shimizu
- Cognitive Behavioral Therapy CenterChiba University HospitalChibaJapan
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Felsch CL, Kuypers KPC. Don't be afraid, try to meditate- potential effects on neural activity and connectivity of psilocybin-assisted mindfulness-based intervention for social anxiety disorder: A systematic review. Neurosci Biobehav Rev 2022; 139:104724. [PMID: 35679988 DOI: 10.1016/j.neubiorev.2022.104724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/04/2022] [Accepted: 06/02/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Current first-line treatment for social anxiety disorder (SAD), one of the most prevalent anxiety disorders, is limited in its efficacy. Hence, novel treatment approaches are urgently needed. The current review suggests a combination of meditation-based interventions and the administration of a psychedelic as a future alternative treatment approach. While both separate treatments show promise in the treatment of (other) clinical conditions, their combination has not yet been investigated in the treatment of psychopathologies. AIM With a systematic literature review, we aim to identify the potential mechanisms by which combined psilocybin and mindfulness treatment could adjust anomalous neural activity underlying SAD and exert therapeutic effects. RESULTS Thirty experimental studies investigating the neural effects of meditation or psilocybin treatment in healthy and patient samples were included. Findings suggest that psilocybin-assisted meditation interventions might change cognitive processes like biased attention to threat linked to SAD by modulating connectivity of the salience network, balancing the activity and connectivity of cortical-midline structures, and increasing frontoparietal control over amygdala reactivity. CONCLUSIONS Future studies should investigate whether psilocybin-assisted mindfulness-based intervention can provide therapeutic benefits to SAD patients who are do not remit following conventional therapy.
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Affiliation(s)
- Corinna L Felsch
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, PO Box 616, 6200 MD Maastricht, the Netherlands
| | - Kim P C Kuypers
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, PO Box 616, 6200 MD Maastricht, the Netherlands.
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3
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Parker EL, Banfield M, Fassnacht DB, Hatfield T, Kyrios M. Contemporary treatment of anxiety in primary care: a systematic review and meta-analysis of outcomes in countries with universal healthcare. BMC FAMILY PRACTICE 2021; 22:92. [PMID: 33992082 PMCID: PMC8126070 DOI: 10.1186/s12875-021-01445-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 04/26/2021] [Indexed: 10/26/2022]
Abstract
BACKGROUND Anxiety disorders are highly prevalent mental health conditions and are managed predominantly in primary care. We conducted a systematic review and meta-analysis of psychological and pharmacological treatments in countries with universal healthcare, and investigated the influence of treatment provider on the efficacy of psychological treatment. METHOD PubMed, Cochrane, PsycINFO, CINAHL, and Scopus were searched in April 2017 for controlled studies of evidence-based anxiety treatment in adults in primary care, published in English since 1997. Searches were repeated in April 2020. We synthesised results using a combination of meta-analysis and narrative methods. Meta-analysis was conducted using a random-effects multi-level model to account for intercorrelation between effects contributed different treatment arms of the same study. Moderator variables were explored using meta-regression analyses. RESULTS In total, 19 articles (from an initial 2,247) reporting 18 studies were included. Meta-analysis including ten studies (n = 1,308) found a pooled effect size of g = 1.16 (95%CI = 0.63 - 1.69) for psychological treatment compared to waitlist control, and no significant effect compared to care as usual (p = .225). Substantial heterogeneity was present (I2 = 81.25). Specialist treatment produced large effects compared to both waitlist control (g = 1.46, 95%CI = 0.96 - 1.96) and care as usual (g = 0.76, 95%CI = 0.27 - 1.25). Treatment provided by non-specialists was only superior to waitlist control (g = 0.80, 95%CI = 0.31 - 1.28). We identified relatively few studies (n = 4) of medications, which reported small to moderate effects for SSRI/SNRI medications and hydroxyzine. The quality of included studies was variable and most studies had at least "unclear" risk of bias in one or more key domains. CONCLUSIONS Psychological treatments for anxiety are effective in primary care and are more effective when provided by a specialist (psychologist or clinical psychologist) than a non-specialist (GP, nurse, trainee). However, non-specialists provide effective treatment compared with no care at all. Limited research into the efficacy of pharmacological treatments in primary care needs to be considered carefully by prescribers TRIAL REGISTRATION: PROSPERO registration number CRD42018050659.
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Affiliation(s)
- Erin L Parker
- Research School of Psychology, Australian National University, Canberra, ACT, 2601, Australia.
| | - Michelle Banfield
- Centre for Mental Health Research, Australian National University, Canberra, Australia
| | - Daniel B Fassnacht
- Research School of Psychology, Australian National University, Canberra, ACT, 2601, Australia
- College of Education, Psychology and Social Work, Flinders University, Adelaide, Australia
| | - Timothy Hatfield
- Research School of Psychology, Australian National University, Canberra, ACT, 2601, Australia
| | - Michael Kyrios
- College of Education, Psychology and Social Work, Flinders University, Adelaide, Australia
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de Abreu MS, Giacomini ACVV, Genario R, Rech N, Carboni J, Lakstygal AM, Amstislavskaya TG, Demin KA, Leonard BE, Vlok M, Harvey BH, Piato A, Barcellos LJG, Kalueff AV. Non-pharmacological and pharmacological approaches for psychiatric disorders: Re-appraisal and insights from zebrafish models. Pharmacol Biochem Behav 2020; 193:172928. [PMID: 32289330 DOI: 10.1016/j.pbb.2020.172928] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/07/2020] [Indexed: 12/11/2022]
Abstract
Acute and chronic stressors are common triggers of human mental illnesses. Experimental animal models and their cross-species translation to humans are critical for understanding of the pathogenesis of stress-related psychiatric disorders. Mounting evidence suggests that both pharmacological and non-pharmacological approaches can be efficient in treating these disorders. Here, we analyze human, rodent and zebrafish (Danio rerio) data to compare the impact of non-pharmacological and pharmacological therapies of stress-related psychopathologies. Emphasizing the likely synergism and interplay between pharmacological and environmental factors in mitigating daily stress both clinically and in experimental models, we argue that environmental enrichment emerges as a promising complementary therapy for stress-induced disorders across taxa. We also call for a broader use of novel model organisms, such as zebrafish, to study such treatments and their potential interplay.
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Affiliation(s)
- Murilo S de Abreu
- Bioscience Institute, University of Passo Fundo (UPF), Passo Fundo, RS, Brazil; The International Zebrafish Neuroscience Research Consortium (ZNRC), Slidell, LA, USA.
| | - Ana C V V Giacomini
- Bioscience Institute, University of Passo Fundo (UPF), Passo Fundo, RS, Brazil; Postgraduate Program in Environmental Sciences, University of Passo Fundo (UPF), Passo Fundo, Brazil
| | - Rafael Genario
- Bioscience Institute, University of Passo Fundo (UPF), Passo Fundo, RS, Brazil
| | - Nathália Rech
- Bioscience Institute, University of Passo Fundo (UPF), Passo Fundo, RS, Brazil
| | - Júlia Carboni
- Bioscience Institute, University of Passo Fundo (UPF), Passo Fundo, RS, Brazil
| | - Anton M Lakstygal
- Institute of Translational Biomedicine, St. Petersburg State University, St. Petersburg, Russia; Institute of Experimental Medicine, Almazov National Medical Research Center, St. Petersburg, Russia; Granov Russian Scientific Center of Radiology and Surgical Technologies, St. Petersburg, Russia
| | - Tamara G Amstislavskaya
- Scientific Research Institute of Physiology and Basic Medicine, Novosibirsk, Russia; Institute of Medicine and Psychology, Novosibirsk State University, Novosibirsk, Russia
| | - Konstantin A Demin
- Institute of Translational Biomedicine, St. Petersburg State University, St. Petersburg, Russia; Institute of Experimental Medicine, Almazov National Medical Research Center, St. Petersburg, Russia
| | - Brian E Leonard
- University College Galway, Pharmacology Department, Galway, Ireland
| | - Marli Vlok
- Center of Excellence for Pharmaceutical Sciences, School of Pharmacy, North-West University, Potchefstroom, South Africa
| | - Brian H Harvey
- Center of Excellence for Pharmaceutical Sciences, School of Pharmacy, North-West University, Potchefstroom, South Africa
| | - Angelo Piato
- The International Zebrafish Neuroscience Research Consortium (ZNRC), Slidell, LA, USA; Postgraduate Program in Neurosciences, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Leonardo J G Barcellos
- Postgraduate Program in Environmental Sciences, University of Passo Fundo (UPF), Passo Fundo, Brazil; Postgraduate Program in Bio-Experimentation, University of Passo Fundo (UPF), Passo Fundo, Brazil; Postgraduate Program in Pharmacology, Federal University of Santa Maria (UFSM), Santa Maria, Brazil
| | - Allan V Kalueff
- School of Pharmacy, Southwest University, Chongqing, China; Ural Federal University, Ekaterinburg, Russia.
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Behera N, Samantaray NN, Kar N, Nayak MR, Chaudhury S. Effectiveness of cognitive behavioral therapy on social anxiety disorder: A comparative study. Ind Psychiatry J 2020; 29:76-81. [PMID: 33776279 PMCID: PMC7989459 DOI: 10.4103/ipj.ipj_2_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 05/07/2020] [Accepted: 05/27/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Both cognitive behavior therapy (CBT) and paroxetine (PX) are the preferred treatments for social anxiety disorder (SAD). However, in literature, there have been divided opinions for the efficacy of the combination of these treatments. This study intended to evaluate whether the combination of CBT and PX would be superior to monotherapy of PX in the treatment of SAD. METHODS This was a single centre, rater-blind, non randomised study which included 40 consenting adult participants who received CBT+PX or PX only. The Liebowitz Social Anxiety Scale, Social Interaction Anxiety Scale, and Brief Fear of Negative Evaluation scale (BFNE) were assessed at baseline (0 weeks), immediate posttreatment (16-18 weeks for CBT + PX and 16-20 weeks for PX only), and at follow-ups 2 months after posttreatment. RESULTS Both the treatment groups have a statistically significant difference in mean scores in all outcome measures in posttreatment and follow-up stages compared with pretreatment scores. However, CBT + PX has a better treatment and maintenance gain as compared to PX alone in the posttreatment and follow-up stages. CONCLUSIONS In SAD management, combinations of CBT + PX are superior to PX alone, and the treatment gains are also better maintained in former than latter.
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Affiliation(s)
- Nirupama Behera
- Department of Clinical Psychology, Mental Health Institute (Centre of Excellence), SCB Medical College and Hospital, Cuttack, India
| | - Narendra Nath Samantaray
- Department of Clinical Psychology, Mental Health Institute (Centre of Excellence), SCB Medical College and Hospital, Cuttack, India
| | - Nilamadhab Kar
- Consultant Psychiatrist and College Tutor, Black Country Partnership NHS Foundation Trust, Wolverhampton, England
| | - Mihir Ranjan Nayak
- Department of Psychiatry, SCB Medical College and Hospital, Cuttack, India
| | - Supraksh Chaudhury
- Department of Psychiatry, Dr. D. Y. Patil Medical College, Hospital and Research Center, Dr. D. Y. Patil University, Pimpri, Pune, Maharashtra, India
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Pelissolo A, Abou Kassm S, Delhay L. Therapeutic strategies for social anxiety disorder: where are we now? Expert Rev Neurother 2019; 19:1179-1189. [PMID: 31502896 DOI: 10.1080/14737175.2019.1666713] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction: Classical well-established treatments of social anxiety disorder (SAD) are now complemented by more recent therapeutic strategies. This review aims to summarize available therapies for SAD and discuss recent evidence-based findings on the management of this disorder.Areas covered: Recent guidelines recommend psychotherapy, particularly cognitive-behavioral therapy (CBT), and pharmacotherapy, as first-line treatments of patients with SAD, without a clear superiority of one option over the other. CBT includes classical approaches such as in vivo exposure to social situations and cognitive therapy, but new modalities and techniques have been recently developed: third-wave approaches, internet-delivered therapy, virtual reality exposure, and cognitive bias modification. Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors have been also extensively studied and shown to be effective in SAD. Two alternative strategies have been developed to treat SAD with disappointing results: cognitive bias modification, and pharmacological augmentation of psychotherapy using D-cycloserine during exposure sessions.Expert opinion: Personalized treatments for SAD patients are now available. Innovative strategies such as online psychotherapy and virtual reality exposure are useful alternatives to CBT and SSRIs. Future developments and optimization of attention bias modification and of pharmacological augmentation of psychotherapy can be promising.
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Affiliation(s)
- Antoine Pelissolo
- AP-HP, Psychiatry Department, Hôpitaux Universitaires Henri-Mondor, Faculté de médecine, Créteil, France
| | - Sandra Abou Kassm
- Faculty of Medical Sciences, Psychiatry Department, Lebanese University, Beirut, Lebanon
| | - Lauriane Delhay
- AP-HP, Psychiatry Department, Hôpitaux Universitaires Henri-Mondor, Créteil, France
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Samantray N, Kar N, Singh P, Swain SP, Singh AR, Chaudhury S, Mahapatra J. Efficacy of cognitive behavioral therapy with paroxetine and paroxetine only for social anxiety disorder: A behavioral, placebo-controlled study. Ind Psychiatry J 2019; 28:211-217. [PMID: 33223713 PMCID: PMC7659996 DOI: 10.4103/ipj.ipj_13_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/26/2020] [Accepted: 05/07/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Individually, cognitive behavior therapy (CBT) and paroxetine (PX) are considered as frontline treatments for social anxiety disorder (SAD). However, the possibility of combined interventions of these might be more helpful than either intervention alone has met with mixed reviews. Hence, the goal of the current study was to examine whether combining CBT + PX would be superior to PX alone in the treatment of SAD in various stages of treatment. METHODOLOGY The present study is a single-center, rater-blind, behavioral placebo (Bh. PBO)-controlled study. Sixty-seven participants were prospectively observed in two groups, one receiving CBT + PX and PX + Bh. PBO for 24 weeks. The Social Interaction Anxiety Scale (SIAS) was measured at pre, post (12 weeks), end of booster (24 weeks), and 2-month follow-up (32 weeks) stage. The SIAS was measured at pre, post (12 weeks), end of booster (24 weeks), and 2-month follow-up (32 weeks) stage. RESULTS Both treatment groups have significant difference in the mean scores of SIAS in posttreatment, booster, and follow-up stages from their respective mean scores at prestage. Mann-Whitney U-test found no significant differences in the mean scores of SIAS between CBT + PX and PX + Bh. PBO at posttreatment and booster phase, whereas a statistically significance difference (P = 0.03) was found in 2-month follow-up stages. Both treatment groups have large effect size in posttreatment and end of booster phase. At 2-month follow-up stage, a large effect size of 1.11 was found in CBT + PX group as compared to medium size of 0.6 in PX + Bh. PBO group. CONCLUSIONS Combined treatment of CBT + PX provided no advantage over PX + Bh. PBO in acute stages of treatment, but the former have significantly better maintenance of treatment gains in 2-month follow-ups than the latter.
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Affiliation(s)
- Narendranath Samantray
- Department of Clinical Psychology, Mental Health Institute (Centre of Excellence), SCB Medical College and Hospital, Cuttack, Odisha, India
| | - Nilamadhab Kar
- Department of Psychiatry, Black Country Partnership NHS Foundation Trust, Wolverhampton, England, UK
| | - Preeti Singh
- Department of Clinical Psychology, Pt. Jawaharlal Nehru Memorial Medical College, Raipur, Chhattisgarh, India
| | - Sarada Prasanna Swain
- Department of Psychiatry, Mental Health Institute (Centre of Excellence), SCB Medical College and Hospital, Cuttack, Odisha, India
| | | | - Suprakash Chaudhury
- Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Jashobanta Mahapatra
- Department of Clinical Psychology, Mental Health Institute (Centre of Excellence), SCB Medical College and Hospital, Cuttack, Odisha, India
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Bernik M, Corregiari F, Savoia MG, de Barros Neto TP, Pinheiro C, Neto FL. Concomitant treatment with sertraline and social skills training improves social skills acquisition in social anxiety disorder: A double-blind, randomized controlled trial. PLoS One 2018; 13:e0205809. [PMID: 30372482 PMCID: PMC6205595 DOI: 10.1371/journal.pone.0205809] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 10/02/2018] [Indexed: 11/19/2022] Open
Abstract
Objectives To examine whether: (1) sertraline (SER) + psychotherapy is superior to psychotherapy alone; (2) group cognitive-behavioural therapy (GCBT) is superior to group psychodynamic therapy (GPT) and (3) SER+GCBT or SER+GPT is superior to Placebo (PLA)+GCBT or PLA+GPT in social anxiety disorder (SAD). Methods A double-blind randomized controlled trial. Participants were assigned either to: SER+GCBT (n = 34); SER+GPT (n = 36); PLA+GCBT (n = 36) or PLA+GPT (n = 41) for 20 weeks. SER (or PLA) was administered at doses from 50 to 200 mg/d. Primary measures were both categorial: remission (CGI score≤2), response of social symptoms (≥50% reduction in Scale of Avoidance and Social Discomfort (SASD)); and continuous: reduction of SASD and Multidimensional Scale of Social Expression(M-MSSE). Results SER exhibited better improvement of social anxiety symptoms rate than PLA (25.73% vs. 9.46%, P < .05). Neither GCBT differed from GPT (12.33% vs. 22.54%, P = .11) nor SER+GCBT from PLA+GCBT (17.65% vs. 7.69%, P = .20). However, SER+GPT was superior to PLA+GPT (33.33%, vs. 11.43%, P < .05). M-MSSE had superior improvement for SER+GCBT vs PLA+GCBT (P < .01) but not for SER+GPT vs. PLA+GPT (P = .80). SASD scores improvement were greater for SER than PLA (P < .01) and for SER+GCBT vs. PLA+GCBT (P < .05), but neither GCBT differed from GPT(P = .60) nor SER+GPT differed from PLA+GPT (P = .09). Conclusions In overall, SER+psychotherapy was superior to psychotherapy alone. SER potentiated GCBT by enhancing social skills acquisition. Trial registration ISRCTN 57551461.
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Affiliation(s)
- Marcio Bernik
- Anxiety Disorders Program, Department and Institute of Psychiatry, University of Sao Paulo, Sao Paulo, Brazil
- * E-mail:
| | - Fabio Corregiari
- Anxiety Disorders Program, Department and Institute of Psychiatry, University of Sao Paulo, Sao Paulo, Brazil
| | - Mariangela Gentil Savoia
- Anxiety Disorders Program, Department and Institute of Psychiatry, University of Sao Paulo, Sao Paulo, Brazil
| | - Tito Paes de Barros Neto
- Anxiety Disorders Program, Department and Institute of Psychiatry, University of Sao Paulo, Sao Paulo, Brazil
| | - Cristiane Pinheiro
- Anxiety Disorders Program, Department and Institute of Psychiatry, University of Sao Paulo, Sao Paulo, Brazil
| | - Francisco Lotufo Neto
- Anxiety Disorders Program, Department and Institute of Psychiatry, University of Sao Paulo, Sao Paulo, Brazil
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Klumpp H, Fitzgerald JM. Neuroimaging Predictors and Mechanisms of Treatment Response in Social Anxiety Disorder: an Overview of the Amygdala. Curr Psychiatry Rep 2018; 20:89. [PMID: 30155657 PMCID: PMC9278878 DOI: 10.1007/s11920-018-0948-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW Aberrant amygdala activity is implicated in the neurobiology of social anxiety disorder (SAD) and is, therefore, a treatment target. However, the extent to which amygdala predicts clinical improvement or is impacted by treatment has not been critically examined. This review highlights recent neuroimaging findings from clinical trials and research that test links between amygdala and mechanisms of action. RECENT FINDINGS Neuropredictor studies largely comprised psychotherapy where improvement was foretold by amygdala activity and regions beyond amygdala such as frontal structures (e.g., anterior cingulate cortex, medial prefrontal cortex) and areas involved in visual processes (e.g., occipital regions, superior temporal gyrus). Pre-treatment functional connectivity between amygdala and frontal areas was also shown to predict improvement signifying circuits that support emotion processing and regulation interact with treatment. Pre-to-post studies revealed decreases in amygdala response and altered functional connectivity in amygdala pathways regardless of treatment modality. In analogue studies of fear exposure, greater reduction in anxiety was predicted by less amygdala response to a speech challenge and amygdala activity decreased following exposures. Yet, studies have also failed to detect amygdala effects reporting instead treatment-related changes in regions and functional systems that support sensory, emotion, and regulation processes. An array of regions in the corticolimbic subcircuits and extrastriate cortex appear to be viable sites of action. The amygdala and amygdala pathways predict treatment outcome and are altered following treatment. However, further study is needed to establish the role of the amygdala and other candidate regions and brain circuits as sites of action.
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Affiliation(s)
- Heide Klumpp
- Departments of Psychiatry and Psychology, University of Illinois at Chicago, 1747 W. Roosevelt Rd, Chicago, IL, 60608, USA.
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Shepardson RL, Buchholz LJ, Weisberg RB, Funderburk JS. Psychological interventions for anxiety in adult primary care patients: A review and recommendations for future research. J Anxiety Disord 2018; 54:71-86. [PMID: 29427898 PMCID: PMC7909724 DOI: 10.1016/j.janxdis.2017.12.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 11/07/2017] [Accepted: 12/23/2017] [Indexed: 10/18/2022]
Abstract
Anxiety symptoms are prevalent in primary care, yet treatment rates are low. The integration of behavioral health providers into primary care via the Primary Care Behavioral Health (PCBH) model offers a promising way to improve treatment options by adding a team member with the necessary skillset to deliver evidence-based psychological interventions for anxiety. We conducted a narrative review of psychological interventions for anxiety applied within adult primary care settings (k = 44) to update the literature and evaluate the fit of existing interventions with the PCBH model. The majority of studies were randomized controlled trials (RCTs; 70.5%). Most interventions utilized cognitive-behavioral therapy (68.2%) and were delivered individually, face-to-face (52.3%). Overall, 65.9% of interventions (58.6% of RCTs, 91.7% of pre-post) were effective in reducing anxiety symptoms, and 83.3% maintained the gains at follow-up. Although it is encouraging that most interventions significantly reduced anxiety, their longer formats (i.e., number and duration of sessions) and narrow symptom targets make translation into practice difficult. Methodological limitations of the research included homogenous samples, failure to report key procedural details, pre-post designs, and restrictive eligibility criteria. We offer recommendations to guide future research to improve the likelihood of successful translation of anxiety interventions into clinical practice.
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Affiliation(s)
- Robyn L Shepardson
- Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY, United States; Department of Psychology, Syracuse University, Syracuse, NY, United States.
| | - Laura J Buchholz
- Center for Integrated Healthcare, VA Western New York Healthcare System at Buffalo, Buffalo, NY, United States; Department of Psychology, University at Buffalo/State University of New York, Buffalo, NY, United States; Department of Psychology, University of Tampa, Tampa, FL, United States.
| | - Risa B Weisberg
- VA Boston Healthcare System, Boston, MA, United States; Boston University School of Medicine, Boston, MA, United States; Alpert Medical School of Brown University, Providence, RI, United States.
| | - Jennifer S Funderburk
- Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY, United States; Department of Psychology, Syracuse University, Syracuse, NY, United States; Department of Psychiatry, University of Rochester School of Medicine, Rochester, NY, United States.
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Tolin DF. Can Cognitive Behavioral Therapy for Anxiety and Depression Be Improved with Pharmacotherapy? A Meta-analysis. Psychiatr Clin North Am 2017; 40:715-738. [PMID: 29080596 DOI: 10.1016/j.psc.2017.08.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The present meta-analysis examined controlled trials of pharmacologic augmentation of cognitive-behavioral therapy (CBT) for patients with anxiety or depressive disorders. The additive effect of medications was small for both anxiety and depressive disorders at posttreatment, and there was no additive benefit after medications were discontinued. A small body of evidence suggested that antidepressant medications are an efficacious second-line treatment for patients failing to respond to CBT alone. In anxiety disorders, novel agents thought to potentiate the biological mechanisms of CBT showed small effects at posttreatment; after discontinuation, some of these agents were associated with an increasing effect.
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Affiliation(s)
- David F Tolin
- The Institute of Living, Anxiety Disorders Center, 200 Retreat Avenue, Hartford, CT 06106, USA.
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12
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Williams T, Hattingh CJ, Kariuki CM, Tromp SA, van Balkom AJ, Ipser JC, Stein DJ. Pharmacotherapy for social anxiety disorder (SAnD). Cochrane Database Syst Rev 2017; 10:CD001206. [PMID: 29048739 PMCID: PMC6360927 DOI: 10.1002/14651858.cd001206.pub3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recognition is growing that social anxiety disorder (SAnD) is a chronic and disabling disorder, and data from early trials demonstrate that medication may be effective in its treatment. This systematic review is an update of an earlier review of pharmacotherapy of SAnD. OBJECTIVES To assess the effects of pharmacotherapy for social anxiety disorder in adults and identify which factors (methodological or clinical) predict response to treatment. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR-Studies and CCMDCTR-References) to 17 August 2015. The CCMDCTR contains reports of relevant RCTs from MEDLINE (1950-), Embase (1974-), PsycINFO (1967-) and CENTRAL (all years). We scanned the reference lists of articles for additional studies. We updated the search in August 2017 and placed additional studies in Awaiting Classification, these will be incorporated in the next version of the review, as appropriate. SELECTION CRITERIA We restricted studies to randomised controlled trials (RCTs) of pharmacotherapy versus placebo in the treatment of SAnD in adults. DATA COLLECTION AND ANALYSIS Two authors (TW and JI) assessed trials for eligibility and inclusion for this review update. We extracted descriptive, methodological and outcome information from each trial, contacting investigators for missing information where necessary. We calculated summary statistics for continuous and dichotomous variables (if provided) and undertook subgroup and sensitivity analyses. MAIN RESULTS We included 66 RCTs in the review (> 24 weeks; 11,597 participants; age range 18 to 70 years) and 63 in the meta-analysis. For the primary outcome of treatment response, we found very low-quality evidence of treatment response for selective serotonin reuptake inhibitors (SSRIs) compared with placebo (number of studies (k) = 24, risk ratio (RR) 1.65; 95% confidence interval (CI) 1.48 to 1.85, N = 4984). On this outcome there was also evidence of benefit for monoamine oxidase inhibitors (MAOIs) (k = 4, RR 2.36; 95% CI 1.48 to 3.75, N = 235), reversible inhibitors of monoamine oxidase A (RIMAs) (k = 8, RR 1.83; 95% CI 1.32 to 2.55, N = 1270), and the benzodiazepines (k = 2, RR 4.03; 95% CI 2.45 to 6.65, N = 132), although the evidence was low quality. We also found clinical response for the anticonvulsants with gamma-amino butyric acid (GABA) analogues (k = 3, RR 1.60; 95% CI 1.16 to 2.20, N = 532; moderate-quality evidence). The SSRIs were the only medication proving effective in reducing relapse based on moderate-quality evidence. We assessed tolerability of SSRIs and the serotonin and norepinephrine reuptake inhibitor (SNRI) venlafaxine on the basis of treatment withdrawal; this was higher for medication than placebo (SSRIs: k = 24, RR 2.59; 95% CI 1.97 to 3.39, N = 5131, low-quality evidence; venlafaxine: k = 4, RR 3.23; 95% CI 2.15 to 4.86, N = 1213, moderate-quality evidence), but there were low absolute rates of withdrawal for both these medications classes compared to placebo. We did not find evidence of a benefit for the rest of the medications compared to placebo.For the secondary outcome of SAnD symptom severity, there was benefit for the SSRIs, the SNRI venlafaxine, MAOIs, RIMAs, benzodiazepines, the antipsychotic olanzapine, and the noradrenergic and specific serotonergic antidepressant (NaSSA) atomoxetine in the reduction of SAnD symptoms, but most of the evidence was of very low quality. Treatment with SSRIs and RIMAs was also associated with a reduction in depression symptoms. The SSRIs were the only medication class that demonstrated evidence of reduction in disability across a number of domains.We observed a response to long-term treatment with medication for the SSRIs (low-quality evidence), for the MAOIs (very low-quality evidence) and for the RIMAs (moderate-quality evidence). AUTHORS' CONCLUSIONS We found evidence of treatment efficacy for the SSRIs, but it is based on very low- to moderate-quality evidence. Tolerability of SSRIs was lower than placebo, but absolute withdrawal rates were low.While a small number of trials did report treatment efficacy for benzodiazepines, anticonvulsants, MAOIs, and RIMAs, readers should consider this finding in the context of potential for abuse or unfavourable side effects.
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Affiliation(s)
- Taryn Williams
- University of Cape TownDepartment of Psychiatry and Mental HealthEducation Centre, Valkenberg HospitalPrivate Bage X1, ObservatoryCape TownSouth Africa7925
| | - Coenie J Hattingh
- University of Cape TownDepartment of Psychiatry and Mental HealthEducation Centre, Valkenberg HospitalPrivate Bage X1, ObservatoryCape TownSouth Africa7925
| | - Catherine M Kariuki
- University of Cape TownDepartment of Psychiatry and Mental HealthEducation Centre, Valkenberg HospitalPrivate Bage X1, ObservatoryCape TownSouth Africa7925
| | - Sean A Tromp
- University of Cape TownFaculty of Health Sciences4 Roughmoor Rd, MowbrayCape TownWestern CapeSouth Africa7700
| | - Anton J van Balkom
- VU‐University Medical Centre and GGZ inGeestDepartment of Psychiatry and EMGO+ InstituteA.J. Ernststraat 887AmsterdamNetherlands1081 HL
| | - Jonathan C Ipser
- University of Cape TownDepartment of Psychiatry and Mental HealthEducation Centre, Valkenberg HospitalPrivate Bage X1, ObservatoryCape TownSouth Africa7925
| | - Dan J Stein
- University of Cape TownDepartment of Psychiatry and Mental HealthEducation Centre, Valkenberg HospitalPrivate Bage X1, ObservatoryCape TownSouth Africa7925
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13
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Nordahl HM, Vogel PA, Morken G, Stiles TC, Sandvik P, Wells A. Paroxetine, Cognitive Therapy or Their Combination in the Treatment of Social Anxiety Disorder with and without Avoidant Personality Disorder: A Randomized Clinical Trial. PSYCHOTHERAPY AND PSYCHOSOMATICS 2017; 85:346-356. [PMID: 27744447 DOI: 10.1159/000447013] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 05/23/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND The most efficacious treatments for social anxiety disorder (SAD) are the SSRIs and cognitive therapy (CT). Combined treatment is advocated for SAD but has not been evaluated in randomized trials using CT and SSRI. Our aim was to evaluate whether one treatment is more effective than the other and whether combined treatment is more effective than the single treatments. METHODS A total of 102 patients were randomly assigned to paroxetine, CT, the combination of CT and paroxetine, or pill placebo. The medication treatment lasted 26 weeks. Of the 102 patients, 54% fulfilled the criteria for an additional diagnosis of avoidant personality disorder. Outcomes were measured at posttreatment and 12-month follow-up assessments. RESULTS CT was superior to paroxetine alone and to pill placebo at the end of treatment, but it was not superior to the combination treatment. At the 12-month follow-up, the CT group maintained benefits and was significantly better than placebo and paroxetine alone, whereas there were no significant differences among combination treatment, paroxetine alone, and placebo. Recovery rates at 12 months were much higher in the CT group (68%) compared to 40% in the combination group, 24% in the paroxetine group, and 4% in the pill placebo group. CONCLUSIONS CT was the most effective treatment for SAD at both posttreatment and follow-up compared to paroxetine and better than combined treatment at the 12-month follow-up on the Liebowitz Social Anxiety Scale. Combined treatment provided no advantage over single treatments; rather there was less effect of the combined treatment compared to CT alone.
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Affiliation(s)
- Hans M Nordahl
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
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14
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Curtiss J, Andrews L, Davis M, Smits J, Hofmann SG. A meta-analysis of pharmacotherapy for social anxiety disorder: an examination of efficacy, moderators, and mediators. Expert Opin Pharmacother 2017; 18:243-251. [DOI: 10.1080/14656566.2017.1285907] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Joshua Curtiss
- Department of Psychological and Brain Sciences, Boston University, Boston, USA
| | - Leigh Andrews
- Department of Psychological and Brain Sciences, Boston University, Boston, USA
| | - Michelle Davis
- The University of Texas at Austin, Department of Psychology and Institute for Mental Health Research, Austin, USA
| | - Jasper Smits
- The University of Texas at Austin, Department of Psychology and Institute for Mental Health Research, Austin, USA
| | - Stefan G. Hofmann
- Department of Psychological and Brain Sciences, Boston University, Boston, USA
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15
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Capron DW, Norr AM, Allan NP, Schmidt NB. Combined "top-down" and "bottom-up" intervention for anxiety sensitivity: Pilot randomized trial testing the additive effect of interpretation bias modification. J Psychiatr Res 2017; 85:75-82. [PMID: 27837660 DOI: 10.1016/j.jpsychires.2016.11.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 09/24/2016] [Accepted: 11/03/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Anxiety disorders contribute substantially to the overall public health burden. Anxiety sensitivity (AS), a fear of anxiety-related sensations, is one of the few known malleable risk factors for anxiety pathology. Previous AS reduction treatments have primarily utilized "top-down" (e.g., psychoeducation) interventions. The goal of the current study was to evaluate the effect of adding a "bottom-up" (interpretation bias modification; CBM-I) intervention to an AS psychoeducation intervention. DESIGN Single-site randomized controlled trial. Participants completed either a 1) Psychoeducation + active CBM-I or 2) Psychoeducation + control CBM-I intervention. Change in AS was assessed post-intervention and at a one-month follow-up. PARTICIPANTS Individuals with elevated levels of AS. INTERVENTION Single-session computer-delivered intervention for AS. RESULTS Accounting for baseline ASI-3 scores, post-intervention ASI-3 scores were significantly lower in the combined condition than in the psychoeducation + control CBM-I condition (β = 0.24, p < 0.05; d = 0.99). The active CBM-I plus psychoeducation AS intervention was successful in reducing overall AS (59% post-intervention; p < 0.05, Cohen's d = 0.99) and these reductions were maintained through one-month post-intervention (52%; p < 0.05, Cohen's d = 1.18). Participants in the active condition reported significantly lower rates of panic responding to a vital-capacity CO2 challenge (OR = 6.34, 95% CI = 1.07-37.66). Lastly, change in interpretation bias significantly mediated the relationship between treatment condition and post-treatment AS reductions. CONCLUSIONS The current intervention was efficacious in terms of immediate and one-month AS reductions. Given its brevity, low-cost, low-stigma and portability, this intervention could lead to reducing the burden of anxiety disorders.
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Affiliation(s)
- Daniel W Capron
- Department of Psychology, University of Southern Mississippi, Hattiesburg, MS, USA; Department of Psychology, Florida State University, Tallahassee, FL, USA.
| | - Aaron M Norr
- Department of Psychology, Florida State University, Tallahassee, FL, USA
| | - Nicholas P Allan
- Department of Psychology, Florida State University, Tallahassee, FL, USA
| | - Norman B Schmidt
- Department of Psychology, Florida State University, Tallahassee, FL, USA
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16
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Gingnell M, Frick A, Engman J, Alaie I, Björkstrand J, Faria V, Carlbring P, Andersson G, Reis M, Larsson EM, Wahlstedt K, Fredrikson M, Furmark T. Combining escitalopram and cognitive-behavioural therapy for social anxiety disorder: randomised controlled fMRI trial. Br J Psychiatry 2016; 209:229-35. [PMID: 27340112 DOI: 10.1192/bjp.bp.115.175794] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 02/15/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND Selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioural therapy (CBT) are often used concomitantly to treat social anxiety disorder (SAD), but few studies have examined the effect of this combination. AIMS To evaluate whether adding escitalopram to internet-delivered CBT (ICBT) improves clinical outcome and alters brain reactivity and connectivity in SAD. METHOD Double-blind, randomised, placebo-controlled neuroimaging trial of ICBT combined either with escitalopram (n = 24) or placebo (n = 24), including a 15-month clinical follow-up (trial registration: ISRCTN24929928). RESULTS Escitalopram+ICBT, relative to placebo+ICBT, resulted in significantly more clinical responders, larger reductions in anticipatory speech state anxiety at post-treatment and larger reductions in social anxiety symptom severity at 15-month follow-up and at a trend-level (P = 0.09) at post-treatment. Right amygdala reactivity to emotional faces also decreased more in the escitalopram+ICBT combination relative to placebo+ICBT, and in treatment responders relative to non-responders. CONCLUSIONS Adding escitalopram improves the outcome of ICBT for SAD and decreased amygdala reactivity is important for anxiolytic treatment response.
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Affiliation(s)
- Malin Gingnell
- Malin Gingnell, MD, PhD, Andreas Frick, PhD, Jonas Engman, MSc, Iman Alaie, MSc, Johannes Björkstrand, MSc, Department of Psychology, Uppsala University, Uppsala, Sweden; Vanda Faria, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden, and Center for Pain and the Brain, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Per Carlbring, PhD, Department of Psychology, Stockholm University, Stockholm, Sweden; Gerhard Andersson, PhD, Department of Behavioural Sciences and Learning, Psychology, Linköping University, Linköping, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Margareta Reis, PhD, Division of Drug Research/Clinical Pharmacology, Department of Health Sciences, Linköping University, Linköping, Sweden; Elna-Marie Larsson, MD, PhD, Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden; Kurt Wahlstedt, MD, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden; Mats Fredrikson, DMSc, PhD, Department of Psychology, Uppsala University, Uppsala, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Tomas Furmark, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Andreas Frick
- Malin Gingnell, MD, PhD, Andreas Frick, PhD, Jonas Engman, MSc, Iman Alaie, MSc, Johannes Björkstrand, MSc, Department of Psychology, Uppsala University, Uppsala, Sweden; Vanda Faria, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden, and Center for Pain and the Brain, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Per Carlbring, PhD, Department of Psychology, Stockholm University, Stockholm, Sweden; Gerhard Andersson, PhD, Department of Behavioural Sciences and Learning, Psychology, Linköping University, Linköping, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Margareta Reis, PhD, Division of Drug Research/Clinical Pharmacology, Department of Health Sciences, Linköping University, Linköping, Sweden; Elna-Marie Larsson, MD, PhD, Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden; Kurt Wahlstedt, MD, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden; Mats Fredrikson, DMSc, PhD, Department of Psychology, Uppsala University, Uppsala, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Tomas Furmark, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Jonas Engman
- Malin Gingnell, MD, PhD, Andreas Frick, PhD, Jonas Engman, MSc, Iman Alaie, MSc, Johannes Björkstrand, MSc, Department of Psychology, Uppsala University, Uppsala, Sweden; Vanda Faria, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden, and Center for Pain and the Brain, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Per Carlbring, PhD, Department of Psychology, Stockholm University, Stockholm, Sweden; Gerhard Andersson, PhD, Department of Behavioural Sciences and Learning, Psychology, Linköping University, Linköping, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Margareta Reis, PhD, Division of Drug Research/Clinical Pharmacology, Department of Health Sciences, Linköping University, Linköping, Sweden; Elna-Marie Larsson, MD, PhD, Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden; Kurt Wahlstedt, MD, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden; Mats Fredrikson, DMSc, PhD, Department of Psychology, Uppsala University, Uppsala, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Tomas Furmark, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Iman Alaie
- Malin Gingnell, MD, PhD, Andreas Frick, PhD, Jonas Engman, MSc, Iman Alaie, MSc, Johannes Björkstrand, MSc, Department of Psychology, Uppsala University, Uppsala, Sweden; Vanda Faria, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden, and Center for Pain and the Brain, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Per Carlbring, PhD, Department of Psychology, Stockholm University, Stockholm, Sweden; Gerhard Andersson, PhD, Department of Behavioural Sciences and Learning, Psychology, Linköping University, Linköping, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Margareta Reis, PhD, Division of Drug Research/Clinical Pharmacology, Department of Health Sciences, Linköping University, Linköping, Sweden; Elna-Marie Larsson, MD, PhD, Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden; Kurt Wahlstedt, MD, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden; Mats Fredrikson, DMSc, PhD, Department of Psychology, Uppsala University, Uppsala, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Tomas Furmark, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Johannes Björkstrand
- Malin Gingnell, MD, PhD, Andreas Frick, PhD, Jonas Engman, MSc, Iman Alaie, MSc, Johannes Björkstrand, MSc, Department of Psychology, Uppsala University, Uppsala, Sweden; Vanda Faria, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden, and Center for Pain and the Brain, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Per Carlbring, PhD, Department of Psychology, Stockholm University, Stockholm, Sweden; Gerhard Andersson, PhD, Department of Behavioural Sciences and Learning, Psychology, Linköping University, Linköping, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Margareta Reis, PhD, Division of Drug Research/Clinical Pharmacology, Department of Health Sciences, Linköping University, Linköping, Sweden; Elna-Marie Larsson, MD, PhD, Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden; Kurt Wahlstedt, MD, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden; Mats Fredrikson, DMSc, PhD, Department of Psychology, Uppsala University, Uppsala, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Tomas Furmark, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Vanda Faria
- Malin Gingnell, MD, PhD, Andreas Frick, PhD, Jonas Engman, MSc, Iman Alaie, MSc, Johannes Björkstrand, MSc, Department of Psychology, Uppsala University, Uppsala, Sweden; Vanda Faria, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden, and Center for Pain and the Brain, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Per Carlbring, PhD, Department of Psychology, Stockholm University, Stockholm, Sweden; Gerhard Andersson, PhD, Department of Behavioural Sciences and Learning, Psychology, Linköping University, Linköping, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Margareta Reis, PhD, Division of Drug Research/Clinical Pharmacology, Department of Health Sciences, Linköping University, Linköping, Sweden; Elna-Marie Larsson, MD, PhD, Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden; Kurt Wahlstedt, MD, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden; Mats Fredrikson, DMSc, PhD, Department of Psychology, Uppsala University, Uppsala, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Tomas Furmark, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Per Carlbring
- Malin Gingnell, MD, PhD, Andreas Frick, PhD, Jonas Engman, MSc, Iman Alaie, MSc, Johannes Björkstrand, MSc, Department of Psychology, Uppsala University, Uppsala, Sweden; Vanda Faria, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden, and Center for Pain and the Brain, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Per Carlbring, PhD, Department of Psychology, Stockholm University, Stockholm, Sweden; Gerhard Andersson, PhD, Department of Behavioural Sciences and Learning, Psychology, Linköping University, Linköping, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Margareta Reis, PhD, Division of Drug Research/Clinical Pharmacology, Department of Health Sciences, Linköping University, Linköping, Sweden; Elna-Marie Larsson, MD, PhD, Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden; Kurt Wahlstedt, MD, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden; Mats Fredrikson, DMSc, PhD, Department of Psychology, Uppsala University, Uppsala, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Tomas Furmark, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Gerhard Andersson
- Malin Gingnell, MD, PhD, Andreas Frick, PhD, Jonas Engman, MSc, Iman Alaie, MSc, Johannes Björkstrand, MSc, Department of Psychology, Uppsala University, Uppsala, Sweden; Vanda Faria, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden, and Center for Pain and the Brain, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Per Carlbring, PhD, Department of Psychology, Stockholm University, Stockholm, Sweden; Gerhard Andersson, PhD, Department of Behavioural Sciences and Learning, Psychology, Linköping University, Linköping, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Margareta Reis, PhD, Division of Drug Research/Clinical Pharmacology, Department of Health Sciences, Linköping University, Linköping, Sweden; Elna-Marie Larsson, MD, PhD, Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden; Kurt Wahlstedt, MD, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden; Mats Fredrikson, DMSc, PhD, Department of Psychology, Uppsala University, Uppsala, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Tomas Furmark, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Margareta Reis
- Malin Gingnell, MD, PhD, Andreas Frick, PhD, Jonas Engman, MSc, Iman Alaie, MSc, Johannes Björkstrand, MSc, Department of Psychology, Uppsala University, Uppsala, Sweden; Vanda Faria, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden, and Center for Pain and the Brain, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Per Carlbring, PhD, Department of Psychology, Stockholm University, Stockholm, Sweden; Gerhard Andersson, PhD, Department of Behavioural Sciences and Learning, Psychology, Linköping University, Linköping, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Margareta Reis, PhD, Division of Drug Research/Clinical Pharmacology, Department of Health Sciences, Linköping University, Linköping, Sweden; Elna-Marie Larsson, MD, PhD, Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden; Kurt Wahlstedt, MD, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden; Mats Fredrikson, DMSc, PhD, Department of Psychology, Uppsala University, Uppsala, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Tomas Furmark, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Elna-Marie Larsson
- Malin Gingnell, MD, PhD, Andreas Frick, PhD, Jonas Engman, MSc, Iman Alaie, MSc, Johannes Björkstrand, MSc, Department of Psychology, Uppsala University, Uppsala, Sweden; Vanda Faria, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden, and Center for Pain and the Brain, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Per Carlbring, PhD, Department of Psychology, Stockholm University, Stockholm, Sweden; Gerhard Andersson, PhD, Department of Behavioural Sciences and Learning, Psychology, Linköping University, Linköping, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Margareta Reis, PhD, Division of Drug Research/Clinical Pharmacology, Department of Health Sciences, Linköping University, Linköping, Sweden; Elna-Marie Larsson, MD, PhD, Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden; Kurt Wahlstedt, MD, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden; Mats Fredrikson, DMSc, PhD, Department of Psychology, Uppsala University, Uppsala, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Tomas Furmark, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Kurt Wahlstedt
- Malin Gingnell, MD, PhD, Andreas Frick, PhD, Jonas Engman, MSc, Iman Alaie, MSc, Johannes Björkstrand, MSc, Department of Psychology, Uppsala University, Uppsala, Sweden; Vanda Faria, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden, and Center for Pain and the Brain, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Per Carlbring, PhD, Department of Psychology, Stockholm University, Stockholm, Sweden; Gerhard Andersson, PhD, Department of Behavioural Sciences and Learning, Psychology, Linköping University, Linköping, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Margareta Reis, PhD, Division of Drug Research/Clinical Pharmacology, Department of Health Sciences, Linköping University, Linköping, Sweden; Elna-Marie Larsson, MD, PhD, Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden; Kurt Wahlstedt, MD, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden; Mats Fredrikson, DMSc, PhD, Department of Psychology, Uppsala University, Uppsala, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Tomas Furmark, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Mats Fredrikson
- Malin Gingnell, MD, PhD, Andreas Frick, PhD, Jonas Engman, MSc, Iman Alaie, MSc, Johannes Björkstrand, MSc, Department of Psychology, Uppsala University, Uppsala, Sweden; Vanda Faria, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden, and Center for Pain and the Brain, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Per Carlbring, PhD, Department of Psychology, Stockholm University, Stockholm, Sweden; Gerhard Andersson, PhD, Department of Behavioural Sciences and Learning, Psychology, Linköping University, Linköping, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Margareta Reis, PhD, Division of Drug Research/Clinical Pharmacology, Department of Health Sciences, Linköping University, Linköping, Sweden; Elna-Marie Larsson, MD, PhD, Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden; Kurt Wahlstedt, MD, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden; Mats Fredrikson, DMSc, PhD, Department of Psychology, Uppsala University, Uppsala, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Tomas Furmark, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Tomas Furmark
- Malin Gingnell, MD, PhD, Andreas Frick, PhD, Jonas Engman, MSc, Iman Alaie, MSc, Johannes Björkstrand, MSc, Department of Psychology, Uppsala University, Uppsala, Sweden; Vanda Faria, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden, and Center for Pain and the Brain, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Per Carlbring, PhD, Department of Psychology, Stockholm University, Stockholm, Sweden; Gerhard Andersson, PhD, Department of Behavioural Sciences and Learning, Psychology, Linköping University, Linköping, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Margareta Reis, PhD, Division of Drug Research/Clinical Pharmacology, Department of Health Sciences, Linköping University, Linköping, Sweden; Elna-Marie Larsson, MD, PhD, Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden; Kurt Wahlstedt, MD, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden; Mats Fredrikson, DMSc, PhD, Department of Psychology, Uppsala University, Uppsala, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Tomas Furmark, PhD, Department of Psychology, Uppsala University, Uppsala, Sweden
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Abstract
Practical clinical trials (PCTs) are randomized experiments under typical practice conditions with the aim of testing the "real-life" benefits and risks of therapeutic interventions. Influential PCTs have been conducted in cardiology, oncology, and internal medicine. Psychotropic medications are widely and increasingly used in medical practice. This review examines recent progress in conducting PCTs in psychopharmacology. The January 2000 to October 2014 MEDLINE, Scopus, and ClinicalTrials.gov databases were searched for peer-reviewed publications of PCTs with at least 100 subjects per treatment arm. Most PCTs in psychiatry evaluated mental health services or psychosocial interventions rather than specific pharmacotherapies. Of 157 PCTs in psychiatry, 30 (19%) were in psychopharmacology, with a median of 2 publications per year and no increase during the period of observation. Sample size ranged from 200 to 18,154; only 11 studies randomized 500 patients or more. Psychopharmacology PCTs were equally likely to be funded by industry as by public agencies. There were 10 PCTs of antidepressants, for a total of 4206 patients (in comparison with at least 46 PCTs of antihypertensive medications, for a total of 208,014 patients). Some psychopharmacology PCTs used suicidal behavior, treatment discontinuation, or mortality as primary outcome and produced effectiveness and safety data that have influenced both practice guidelines and regulatory decisions. Practical clinical trials can constitute an important source of information for clinicians, patients, regulators, and policy makers but have been relatively underused in psychopharmacology. Electronic medical records and integrated practice research networks offer promising platforms for a more efficient conduct of PCTs.
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Singewald N, Schmuckermair C, Whittle N, Holmes A, Ressler KJ. Pharmacology of cognitive enhancers for exposure-based therapy of fear, anxiety and trauma-related disorders. Pharmacol Ther 2014; 149:150-90. [PMID: 25550231 PMCID: PMC4380664 DOI: 10.1016/j.pharmthera.2014.12.004] [Citation(s) in RCA: 275] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 12/24/2014] [Indexed: 12/20/2022]
Abstract
Pathological fear and anxiety are highly debilitating and, despite considerable advances in psychotherapy and pharmacotherapy they remain insufficiently treated in many patients with PTSD, phobias, panic and other anxiety disorders. Increasing preclinical and clinical evidence indicates that pharmacological treatments including cognitive enhancers, when given as adjuncts to psychotherapeutic approaches [cognitive behavioral therapy including extinction-based exposure therapy] enhance treatment efficacy, while using anxiolytics such as benzodiazepines as adjuncts can undermine long-term treatment success. The purpose of this review is to outline the literature showing how pharmacological interventions targeting neurotransmitter systems including serotonin, dopamine, noradrenaline, histamine, glutamate, GABA, cannabinoids, neuropeptides (oxytocin, neuropeptides Y and S, opioids) and other targets (neurotrophins BDNF and FGF2, glucocorticoids, L-type-calcium channels, epigenetic modifications) as well as their downstream signaling pathways, can augment fear extinction and strengthen extinction memory persistently in preclinical models. Particularly promising approaches are discussed in regard to their effects on specific aspects of fear extinction namely, acquisition, consolidation and retrieval, including long-term protection from return of fear (relapse) phenomena like spontaneous recovery, reinstatement and renewal of fear. We also highlight the promising translational value of the preclinial research and the clinical potential of targeting certain neurochemical systems with, for example d-cycloserine, yohimbine, cortisol, and L-DOPA. The current body of research reveals important new insights into the neurobiology and neurochemistry of fear extinction and holds significant promise for pharmacologically-augmented psychotherapy as an improved approach to treat trauma and anxiety-related disorders in a more efficient and persistent way promoting enhanced symptom remission and recovery.
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Affiliation(s)
- N Singewald
- Department of Pharmacology and Toxicology, Institute of Pharmacy and CMBI, Leopold-Franzens University of Innsbruck, Innrain 80-82, A-6020 Innsbruck, Austria.
| | - C Schmuckermair
- Department of Pharmacology and Toxicology, Institute of Pharmacy and CMBI, Leopold-Franzens University of Innsbruck, Innrain 80-82, A-6020 Innsbruck, Austria
| | - N Whittle
- Department of Pharmacology and Toxicology, Institute of Pharmacy and CMBI, Leopold-Franzens University of Innsbruck, Innrain 80-82, A-6020 Innsbruck, Austria
| | - A Holmes
- Laboratory of Behavioral and Genomic Neuroscience, National Institute on Alcohol Abuse and Alcoholism, NIH, Bethesda, MD, USA
| | - K J Ressler
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
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Are participants in pharmacological and psychotherapy treatment trials for social anxiety disorder representative of patients in real-life settings? J Clin Psychopharmacol 2014; 34:697-703. [PMID: 25154011 DOI: 10.1097/jcp.0000000000000204] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The present study sought to quantify the generalizability of clinical trial results in individuals with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of social anxiety disorder (SAD) to a large representative community sample. METHODS Data were derived from the 2004-2005 National Epidemiologic Survey on Alcohol and Related Conditions, a large nationally representative sample of 34,653 adults from the US population. We applied a standard set of exclusion criteria representative of pharmacological and psychotherapy clinical trials to all adults with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of SAD (n = 965) in the past 12 months and then to a subsample of participants seeking treatment (n = 363). Our aim was to assess how many participants with SAD would fulfill typical eligibility criteria. RESULTS We found that more than 7 of 10 respondents from the overall SAD sample in a typical pharmacological efficacy trial and more than 6 of 10 participants in a typical psychotherapy efficacy trial would have been excluded by at least 1 criterion. In addition, more than 8 of 10 respondents seeking treatment for SAD would have been excluded from participation in a typical pharmacological or psychotherapy efficacy trial. Having a current major depression explained a large proportion of ineligibility. CONCLUSIONS Clinical trials should carefully consider the impact of exclusion criteria on the generalizability of their results and explain the rationale for their use. For SAD treatment trials to adequately inform clinical practice, the eligibility rate must be increased through a general relaxation of overly stringent eligibility criteria.
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Davis ML, Smits JAJ, Hofmann SG. Update on the efficacy of pharmacotherapy for social anxiety disorder: a meta-analysis. Expert Opin Pharmacother 2014; 15:2281-91. [PMID: 25284086 DOI: 10.1517/14656566.2014.955472] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Social anxiety disorder (SAD) is a common mental health problem that tends to be chronic in nature; fortunately, effective pharmacotherapy options exist. The current study provides an updated meta-analytic review of their efficacy and potential guidelines for their application in SAD. METHODS A comprehensive search of the current literature yielded 39 randomized, pill placebo-controlled trials of pharmacotherapy for adults diagnosed with SAD. Data on potential moderators of treatment outcome were collected, as well as data necessary to calculate effect sizes using Hedges's g. RESULTS The overall effect size of pharmacotherapy for SAD is small to medium (Hedges's g = 0.39). The most effective pharmacotherapy type was phenelzine (Hedges's g = 1.14), followed by paroxetine (Hedges's g = 0.49), venlafaxine ER (Hedges's g = 0.45) and moclobemide (Hedges's g = 0.23). CONCLUSION Effect sizes were not moderated by age, sex, length of treatment, diagnostic subtype initial severity, maximum potential dose, or publication year. It is concluded that pharmacotherapy is effective for treating SAD, but there is considerable variation and room for further improvement. Future directions may include pharmacological enhancement of psychological processes, such as d-cycloserine augmentation of exposure procedures.
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Affiliation(s)
- Michelle L Davis
- The University of Texas, Department of Psychology and Institute for Mental Health Research , 305 E 23rd St, Stop E9000, Austin, TX 78712 , USA
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Cuijpers P, Sijbrandij M, Koole SL, Andersson G, Beekman AT, Reynolds CF. Adding psychotherapy to antidepressant medication in depression and anxiety disorders: a meta-analysis. World Psychiatry 2014; 13:56-67. [PMID: 24497254 PMCID: PMC3918025 DOI: 10.1002/wps.20089] [Citation(s) in RCA: 202] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
We conducted a meta-analysis of randomized trials in which the effects of treatment with antidepressant medication were compared to the effects of combined pharmacotherapy and psychotherapy in adults with a diagnosed depressive or anxiety disorder. A total of 52 studies (with 3,623 patients) met inclusion criteria, 32 on depressive disorders and 21 on anxiety disorders (one on both depressive and anxiety disorders). The overall difference between pharmacotherapy and combined treatment was Hedges' g = 0.43 (95% CI: 0.31-0.56), indicating a moderately large effect and clinically meaningful difference in favor of combined treatment, which corresponds to a number needed to treat (NNT) of 4.20. There was sufficient evidence that combined treatment is superior for major depression, panic disorder, and obsessive-compulsive disorder (OCD). The effects of combined treatment compared with placebo only were about twice as large as those of pharmacotherapy compared with placebo only, underscoring the clinical advantage of combined treatment. The results also suggest that the effects of pharmacotherapy and those of psychotherapy are largely independent from each other, with both contributing about equally to the effects of combined treatment. We conclude that combined treatment appears to be more effective than treatment with antidepressant medication alone in major depression, panic disorder, and OCD. These effects remain strong and significant up to two years after treatment. Monotherapy with psychotropic medication may not constitute optimal care for common mental disorders.
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Affiliation(s)
- Pim Cuijpers
- Department of Clinical Psychology, VU University AmsterdamThe Netherlands,Leuphana UniversityLünebrug, Germany
| | - Marit Sijbrandij
- Department of Clinical Psychology, VU University AmsterdamThe Netherlands,EMGO Institute for Health and Care Research, VU University and VU University Medical Center AmsterdamThe Netherlands
| | - Sander L Koole
- Department of Clinical Psychology, VU University AmsterdamThe Netherlands,EMGO Institute for Health and Care Research, VU University and VU University Medical Center AmsterdamThe Netherlands
| | - Gerhard Andersson
- Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, University of LinköpingSweden,Department of Clinical Neuroscience, Psychiatry Section, Karolinska InstitutetStockholm, Sweden
| | - Aartjan T Beekman
- EMGO Institute for Health and Care Research, VU University and VU University Medical Center AmsterdamThe Netherlands,Department of Psychiatry, VU University Medical Center AmsterdamThe Netherlands
| | - Charles F Reynolds
- Department of Psychiatry, University of Pittsburgh School of MedicinePittsburgh, PA, USA
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23
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Ipser JC, Kariuki CM, Stein DJ. Pharmacotherapy for social anxiety disorder: a systematic review. Expert Rev Neurother 2014; 8:235-57. [DOI: 10.1586/14737175.8.2.235] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Mandrioli R, Mercolini L, Raggi MA. Evaluation of the pharmacokinetics, safety and clinical efficacy of sertraline used to treat social anxiety. Expert Opin Drug Metab Toxicol 2013; 9:1495-505. [PMID: 23834458 DOI: 10.1517/17425255.2013.816675] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Social anxiety disorder (SAD) is an emerging, often invalidating, syndrome with deep personal, social and psychological implications. While multiple treatment strategies exist, presently none of them can be considered superior to all others. AREAS COVERED The aim of this review is to provide the latest information on sertraline (SRT), one of the most important selective serotonin reuptake inhibitors (SSRIs) currently used for the pharmacological therapy of SAD. A literature search was carried out with the keywords 'sertraline', 'social anxiety', 'social phobia' and 'clinical trials'. In this process, particular attention is paid to the pharmacokinetic characteristics of the drug and its safety in clinical use. EXPERT OPINION SRT is an effective drug in the treatment of SAD, especially when used in combination with some form of psychological support. While it does not seem to be significantly more effective than other SSRIs, SRT could offer some peculiar advantages: for example, it has a long half-life, allowing a single daily administration, and seems to be particularly indicated for the control of specific symptoms of SAD.
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Affiliation(s)
- Roberto Mandrioli
- Alma Mater Studiorum - University of Bologna, Department for Life Quality Studies (QuVi) , Corso D'Augusto 237, 47921 Rimini , Italy +39 054 143 4624 ; +39 051 209 9740 ;
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Hofmann SG, Smits JAJ, Rosenfield D, Simon N, Otto MW, Meuret AE, Marques L, Fang A, Tart C, Pollack MH. D-Cycloserine as an augmentation strategy with cognitive-behavioral therapy for social anxiety disorder. Am J Psychiatry 2013; 170:751-8. [PMID: 23599046 PMCID: PMC4058999 DOI: 10.1176/appi.ajp.2013.12070974] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors examined whether D-cycloserine, a partial agonist at the glutamatergic N-methyl-d-aspartate receptor, augments and accelerates a full course of comprehensive cognitive-behavioral therapy (CBT) in adults with generalized social anxiety disorder. METHOD This was a multisite randomized placebo-controlled efficacy study with 169 medication-free adults with generalized social anxiety disorder, of whom 144 completed the 12-week treatment and 131 completed the three follow-up assessments. Patients were randomly assigned to receive 50 mg of D-cycloserine or placebo 1 hour before each of five exposure sessions that were part of a 12-session cognitive-behavioral group treatment. Response and remission status was determined at baseline, throughout treatment, at end of treatment, and at 1-, 3-, and 6-month follow-up assessments by assessors who were blind to treatment condition. RESULTS D-Cycloserine-augmented and placebo-augmented CBT were associated with similar completion rates (87% and 82%), response rates (79.3% and 73.3%), and remission rates (34.5% and 24.4%) at the posttreatment assessment; response and remission rates were largely maintained at the follow-up assessments. Although D-cycloserine was associated with a 24%-33% faster rate of improvement in symptom severity and remission rates relative to placebo during the treatment phase, the groups did not differ in response and remission rates. CONCLUSIONS D-Cycloserine did not augment a full course of comprehensive CBT for social anxiety disorder.
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Affiliation(s)
| | | | | | - Naomi Simon
- Massachusetts General Hospital, Harvard Medical School, and Rush Medical School
| | | | | | - Luana Marques
- Massachusetts General Hospital, Harvard Medical School, and Rush Medical School
| | | | - Candyce Tart
- Department of Psychology, Southern Methodist University
| | - Mark H. Pollack
- Massachusetts General Hospital, Harvard Medical School, and Rush Medical School
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Cuijpers P, Sijbrandij M, Koole SL, Andersson G, Beekman AT, Reynolds CF. The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: a meta-analysis of direct comparisons. World Psychiatry 2013; 12:137-48. [PMID: 23737423 PMCID: PMC3683266 DOI: 10.1002/wps.20038] [Citation(s) in RCA: 294] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Although psychotherapy and antidepressant medication are efficacious in the treatment of depressive and anxiety disorders, it is not known whether they are equally efficacious for all types of disorders, and whether all types of psychotherapy and antidepressants are equally efficacious for each disorder. We conducted a meta-analysis of studies in which psychotherapy and antidepressant medication were directly compared in the treatment of depressive and anxiety disorders. Systematic searches in bibliographical databases resulted in 67 randomized trials, including 5,993 patients that met inclusion criteria, 40 studies focusing on depressive disorders and 27 focusing on anxiety disorders. The overall effect size indicating the difference between psychotherapy and pharmacotherapy after treatment in all disorders was g=0.02 (95% CI: -0.07 to 0.10), which was not statistically significant. Pharmacotherapy was significantly more efficacious than psychotherapy in dysthymia (g=0.30), and psychotherapy was significantly more efficacious than pharmacotherapy in obsessive-compulsive disorder (g=0.64). Furthermore, pharmacotherapy was significantly more efficacious than non-directive counseling (g=0.33), and psychotherapy was significantly more efficacious than pharmacotherapy with tricyclic antidepressants (g=0.21). These results remained significant when we controlled for other characteristics of the studies in multivariate meta-regression analysis, except for the differential effects in dysthymia, which were no longer statistically significant.
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Affiliation(s)
- Pim Cuijpers
- Department of Clinical Psychology, VU University Amsterdam, Van der Boechorststraat 1, 1081, BT Amsterdam, The Netherlands; EMGO Institute for Health and Care Research, VU University and VU University Medical Center, Amsterdam, The Netherlands; Leuphana University, Lünebrug, Germany
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28
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Mula M. Treatment of anxiety disorders in epilepsy: An evidence-based approach. Epilepsia 2013; 54 Suppl 1:13-8. [DOI: 10.1111/epi.12101] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Marco Mula
- Division of Neurology, Trinity Hospital; Borgomanero; Italy
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Yoshinaga N, Ohshima F, Matsuki S, Tanaka M, Kobayashi T, Ibuki H, Asano K, Kobori O, Shiraishi T, Ito E, Nakazato M, Nakagawa A, Iyo M, Shimizu E. A preliminary study of individual cognitive behavior therapy for social anxiety disorder in Japanese clinical settings: a single-arm, uncontrolled trial. BMC Res Notes 2013; 6:74. [PMID: 23448435 PMCID: PMC3602169 DOI: 10.1186/1756-0500-6-74] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Accepted: 02/26/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cognitive behavior therapy (CBT) is regarded as an effective treatment for social anxiety disorder (SAD) in Europe and North America. Individual CBT might be acceptable and effective for patients with SAD even in non-Western cultures; therefore, we conducted a feasibility study of individual CBT for SAD in Japanese clinical settings. We also examined the baseline predictors of outcomes associated with receiving CBT. METHODS This single-arm trial employed a 14-week individual CBT intervention. The primary outcome was the self-rated Liebowitz Social Anxiety Scale, with secondary measurements of other social anxiety and depressive severity. Assessments were conducted at baseline, after a waiting period before CBT, during CBT, and after CBT. RESULTS Of the 19 subjects screened, 15 were eligible for the study and completed the outcome measures at all assessment points. Receiving CBT led to significant improvements in primary and secondary SAD severity (ps < .001). The mean total score on the Liebowitz Social Anxiety Scale improved from 91.8 to 51.7 (before CBT to after CBT), and the within-group effect size at the end-point assessment was large (Cohen's d = 1.71). After CBT, 73% of participants were judged to be treatment responders, and 40% met the criteria for remission. We found no significant baseline predictors of those outcomes. CONCLUSION Despite several limitations, our treatment-which comprises a 14-week, individual CBT program-seems feasible and may achieve favorable treatment outcomes for SAD in Japanese clinical settings. Further controlled trials are required in order to address the limitations of this study. TRIAL REGISTRATION UMIN-CTR UMIN000005897.
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Affiliation(s)
- Naoki Yoshinaga
- Department of Cognitive Behavioral Physiology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan.
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Dalrymple KL. Issues and controversies surrounding the diagnosis and treatment of social anxiety disorder. Expert Rev Neurother 2013; 12:993-1008; quiz 1009. [PMID: 23002942 DOI: 10.1586/ern.12.81] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Although much has been learned about social anxiety disorder (SAD) in recent decades, many questions and controversies surrounding its diagnosis and treatment have remained. Similar to the state of affairs with other psychiatric disorders, no clear pathophysiology has been identified for SAD, and the question of where to draw the line between shyness, SAD and even avoidant personality disorder continues to be debated. Much of the evidence to date suggests that among persons with SAD, it is under-recognized and undertreated; however, other researchers contend that it may be overdiagnosed in some individuals. Questions also remain as to how best treat these individuals, such as with pharmacotherapy, psychotherapy or a combination of the two. The aim of this review is to provide an overview of the controversies related to the diagnosis and treatment of SAD. In addition, suggestions for future research are provided that could perhaps clarify these remaining questions, such as maximizing treatment efficacy by targeting broader outcomes such as quality of life and addressing common comorbidities that occur with SAD.
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Affiliation(s)
- Kristy L Dalrymple
- Rhode Island Hospital and the Alpert Medical School of Brown University, 235 Plain Street Suite 501, Providence, RI 02905, USA.
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Yoshinaga N, Niitsu T, Hanaoka H, Sato Y, Ohshima F, Matsuki S, Kobori O, Nakazato M, Nakagawa A, Iyo M, Shimizu E. Strategy for treating selective serotonin reuptake inhibitor-resistant social anxiety disorder in the clinical setting: a randomised controlled trial protocol of cognitive behavioural therapy in combination with conventional treatment. BMJ Open 2013; 3:e002242. [PMID: 23408078 PMCID: PMC3586054 DOI: 10.1136/bmjopen-2012-002242] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2012] [Revised: 01/23/2013] [Accepted: 01/24/2013] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Pharmacotherapy and cognitive behavioural therapy (CBT) are consistently effective as first-line treatments for social anxiety disorders (SADs). Nevertheless, pharmacotherapy is often the first choice in clinical practice. In many countries, the first line of pharmacotherapy involves the administration of a selective serotonin reuptake inhibitor (SSRI). Although a significant proportion of patients with SAD fail to respond to the initial SSRI administration, there is no standard approach to the management of SSRI-resistant SAD. This paper describes the study protocol for a randomised controlled trial to evaluate the clinical effectiveness of CBT as a next-step strategy, concomitant with conventional treatment, for patients with SSRI-resistant SAD. METHODS AND ANALYSIS This Prospective Randomized Open Blinded End-point study is designed with two parallel groups, with dynamic allocation at the individual level. The interventions for the two groups are conventional treatment, alone, and CBT combined with conventional treatment, for 16 weeks. The primary end-point of SAD severity will be assessed by an independent assessor using the Liebowitz Social Anxiety Scale, and secondary end-points include severity of other social anxieties, depressive severity and functional impairment. All measures will be assessed at weeks 0 (baseline), 8 (halfway point) and 16 (postintervention) and the outcomes will be analysed based on the intent-to-treat. Statistical analyses are planned for the study design stage so that field materials can be appropriately designed. ETHICS AND DISSEMINATION This study will be conducted at the academic outpatient clinic of Chiba University Hospital. Ethics approval was granted by the Institutional Review Board of Chiba University Hospital. All participants will be required to provide written informed consent. The trial will be implemented and reported in accordance with the recommendations of CONSORT. CLINICAL TRIAL REGISTRATION NUMBER UMIN000007552.
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Affiliation(s)
- Naoki Yoshinaga
- Department of Cognitive Behavioral Physiology, Chiba University Graduate School of Medicine, Chiba, Japan
- Research Center for Child Mental Development, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Tomihisa Niitsu
- Research Center for Child Mental Development, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hideki Hanaoka
- Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yasunori Sato
- Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Fumiyo Ohshima
- Department of Cognitive Behavioral Physiology, Chiba University Graduate School of Medicine, Chiba, Japan
- Research Center for Child Mental Development, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Satoshi Matsuki
- Department of Cognitive Behavioral Physiology, Chiba University Graduate School of Medicine, Chiba, Japan
- Research Center for Child Mental Development, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Osamu Kobori
- Research Center for Child Mental Development, Chiba University Graduate School of Medicine, Chiba, Japan
- Center for Forensic Mental Health, Chiba University, Chiba, Japan
| | - Michiko Nakazato
- Research Center for Child Mental Development, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Akiko Nakagawa
- Research Center for Child Mental Development, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masaomi Iyo
- Center for Forensic Mental Health, Chiba University, Chiba, Japan
- Department of Psychiatry, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Eiji Shimizu
- Department of Cognitive Behavioral Physiology, Chiba University Graduate School of Medicine, Chiba, Japan
- Research Center for Child Mental Development, Chiba University Graduate School of Medicine, Chiba, Japan
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Seekles W, Cuijpers P, Kok R, Beekman A, van Marwijk H, van Straten A. Psychological treatment of anxiety in primary care: a meta-analysis. Psychol Med 2013; 43:351-361. [PMID: 22717105 DOI: 10.1017/s0033291712000670] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Guidelines and mental healthcare models suggest the use of psychological treatment for anxiety disorders in primary care but systematic estimates of the effect sizes in primary care settings are lacking. The aim of this study was to examine the effectiveness of psychological therapies in primary care for anxiety disorders. METHOD The Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Medline, PsycINFO and Pubmed databases were searched in July 2010. Manuscripts describing psychological treatment for anxiety disorders/increased level of anxiety symptoms in primary care were included if the research design was a randomized controlled trial (RCT) and if the psychological treatment was compared with a control group. RESULTS In total, 1343 abstracts were identified. Of these, 12 manuscripts described an RCT comparing psychological treatment for anxiety with a control group in primary care. The pooled standardized effect size (12 comparisons) for reduced symptoms of anxiety at post-intervention was d = 0.57 [95% confidence interval (CI) 0.29-0.84, p = 0.00, the number needed to treat (NNT) = 3.18]. Heterogeneity was significant among the studies (I 2 = 58.55, Q = 26.54, p < 0.01). The quality of studies was not optimal and missing aspects are summarized. CONCLUSIONS We found a moderate effect size for the psychological treatment of anxiety disorders in primary care. Several aspects of the treatment are related to effect size. More studies are needed to evaluate the long-term effects given the chronicity and recurrent nature of anxiety.
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Affiliation(s)
- W Seekles
- Department of Clinical Psychology, VU University, Amsterdam, The Netherlands.
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Abstract
Social anxiety disorder (SAD) is a highly prevalent and often disabling disorder. This paper reviews the pharmacological treatment of SAD based on published placebo-controlled studies and published meta-analyses. It addresses three specific questions: What is the first-line pharmacological treatment of SAD? How long should treatment last? What should be the management of treatment-resistant cases? Based on their efficacy for SAD and common co-morbid disorders, tolerability and safety, selective serotonin reuptake inhibitors (SSRIs) and venlafaxine should be considered the first-line treatment for most patients. Less information is available regarding the optimal length of treatment, although individuals who discontinue treatment after 12-20 wk appear more likely to relapse than those who continue on medication. Even less empirical evidence is available to support strategies for treatment-resistant cases. Clinical experience suggests that SSRI non-responders may benefit from augmentation with benzodiazepines or gabapentin or from switching to monoamine oxidase inhibitors, reversible inhibitors of monoamine oxidase A, benzodiazepines or gabapentin. Cognitive-behavioural is a well-established alternative first line therapy that may also be a helpful adjunct in non-responders to pharmacological treatment of SAD.
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Kawaguchi A, Watanabe N, Nakano Y, Ogawa S, Suzuki M, Kondo M, Furukawa TA, Akechi T. Group cognitive behavioral therapy for patients with generalized social anxiety disorder in Japan: outcomes at 1-year follow up and outcome predictors. Neuropsychiatr Dis Treat 2013; 9:267-75. [PMID: 23450841 PMCID: PMC3581286 DOI: 10.2147/ndt.s41365] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Social anxiety disorder (SAD) is one of the most common psychiatric disorders worldwide. Cognitive behavioral therapy (CBT) is an effective treatment option for patients with SAD. In the present study, we examined the efficacy of group CBT for patients with generalized SAD in Japan at 1-year follow-up and investigated predictors with regard to outcomes. METHODS This study was conducted as a single-arm, naturalistic, follow-up study in a routine Japanese clinical setting. A total of 113 outpatients with generalized SAD participated in group CBT from July 2003 to August 2010 and were assessed at follow-ups for up to 1 year. Primary outcome was the total score on the Social Phobia Scale/Social Interaction Anxiety Scale (SPS/SIAS) at 1 year. Possible baseline predictors were investigated using mixed-model analyses. RESULTS Among the 113 patients, 70 completed the assessment at the 1-year follow-up. The SPS/SIAS scores showed significant improvement throughout the follow-ups for up to 1 year. The effect sizes of SPS/SIAS at the 1-year follow-up were 0.68 (95% confidence interval 0.41-0.95)/0.76 (0.49-1.03) in the intention-to-treat group and 0.77 (0.42-1.10)/0.84 (0.49-1.18) in completers. Older age at baseline, late onset, and lower severity of SAD were significantly associated with good outcomes as a result of mixed-model analyses. CONCLUSIONS CBT for patients with generalized SAD in Japan is effective for up to 1 year after treatment. The effect sizes were as large as those in previous studies conducted in Western countries. Older age at baseline, late onset, and lower severity of SAD were predictors for a good outcome from group CBT.
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Affiliation(s)
- Akiko Kawaguchi
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Ricci LA, Morrison TR, Melloni RH. Serotonin modulates anxiety-like behaviors during withdrawal from adolescent anabolic-androgenic steroid exposure in Syrian hamsters. Horm Behav 2012; 62:569-78. [PMID: 23026540 PMCID: PMC3612524 DOI: 10.1016/j.yhbeh.2012.09.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 09/20/2012] [Accepted: 09/21/2012] [Indexed: 12/27/2022]
Abstract
From the U.S. to Europe and Australia anabolic steroid abuse remains high in the adolescent population. This is concerning given that anabolic steroid use is associated with a higher incidence of pathological anxiety that often appears during withdrawal from use. This study uses pubertal Syrian hamsters (Mesocricetus auratus) to investigate the hypothesis that adolescent anabolic/androgenic steroid (AAS) exposure predisposes hamsters to heightened levels of anxiety during AAS withdrawal that is modulated by serotonin (5HT) neural signaling. In the first two sets of experiments, adolescent AAS-treated hamsters were tested for anxiety 21 days after the cessation of AAS administration (i.e., during AAS withdrawal) using the elevated plus maze (EPM), dark/light (DL), and seed finding (SF) tests and then examined for differences in 5HT afferent innervation to select areas of the brain important for anxiety. In the EPM and DL tests, adolescent AAS exposure leads to significant increases in anxiety-like response during AAS withdrawal. AAS-treated hamsters showed long-term reductions in 5HT innervation within several areas of the hamster brain implicated in anxiety, most notably the anterior hypothalamus and the central and medial amygdala. However, no differences in 5HT were found in other anxiety areas, e.g., frontal cortex and lateral septum. In the last experiment, adolescent AAS-treated hamsters were scored for anxiety on the 21st day of AAS withdrawal following the systemic administration of saline or one of three doses of fluoxetine, a selective serotonin reuptake inhibitor. Saline-treated hamsters showed high levels of AAS withdrawal-induced anxiety, while treatment with fluoxetine reduced AAS withdrawal-induced anxiety. These findings indicate that early AAS exposure has potent anxiogenic effects during AAS withdrawal that are modulated, in part, by 5HT signaling.
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Abstract
An evidence-based review of nonpharmacological treatments for anxiety disorders is presented. The vast majority of the controlled research is devoted to cognitive behavior therapy (CBT) and shows its efficiency and effectiveness in all the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) anxiety disorders in meta-analyses. Relaxation, psychoanalytic therapies, Rogerian nondirective therapy, hypnotherapy and supportive therapy were examined in a few controlled studies, which preclude any definite conclusion about their effectiveness in specific phobias, agoraphobia, panic disorder, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD), CBT was clearly better than psychoanalytic therapy in generalized anxiety disorder (GAD) and performance anxiety Psychological debriefing for PTSD appeared detrimental to the patients in one high-quality meta-analysis. Uncontrolled studies of psychosurgery techniques for intractable OCD demonstrated a limited success and detrimental side effects. The same was true for sympathectomy in ereutophobia. Transcranial neurostimulation for OCD is under preliminary study. The theoretical and practical problems of CBT dissemination are discussed.
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Affiliation(s)
- Jean Cottraux
- Anxiety Disorder Unit, Hôpital Neurologique, Lyon, France
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Abstract
This article proposes a number of recommendations for the treatment of generalized social phobia, based on a systematic literature review and meta-analysis. An optimal treatment regimen would include a combination of medication and psychotherapy, along with an assertive clinical management program. For medications, selective serotonin reuptake inhibitors and dual serotonin-norepinephrine reuptake inhibitors are first-line choices based on their efficacy and tolerability profiles. The nonselective monoamine oxidase inhibitor, phenelzine, may be more potent than these two drug classes, but because of its food and drug interaction liabilities, its use should be restricted to patients not responding to selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors. There are other medication classes with demonstrated efficacy in social phobia (benzodiazepines, antipsychotics, alpha-2-delta ligands), but due to limited published clinical trial data and the potential for dependence and withdrawal issues with benzodiazepines, it is unclear how best to incorporate these drugs into treatment regimens. There are very few clinical trials on the use of combined medications. Cognitive behavior therapy appears to be more effective than other evidence-based psychological techniques, and its effects appear to be more enduring than those of pharmacotherapy. There is some evidence, albeit limited to certain drug classes, that the combination of medication and cognitive behavior therapy may be more effective than either strategy used alone. Generalized social phobia is a chronic disorder, and many patients will require long-term support and treatment.
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Affiliation(s)
- John Canton
- Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Kate M Scott
- Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Paul Glue
- Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Abstract
Given the enormous contribution of anxiety disorders to the burden of disease, it is key to optimize their prevention and treatment. In this critical review we assess advances in the pharmacotherapy of anxiety disorders, as well as remaining challenges, in recent decades, the field has seen rigorous clinical trial methods to quantify the efficacy and safety of serendipitously discovered agents, more focused development of medications with selective mechanisms of action, and the gradual translation of insights from laboratory research into proof-of-principle clinical trials. On the positive side, a considerable database of studies shows efficacy and relative tolerability of the selective serotonin reuptake inhibitors in the major anxiety disorders, and secondary analyses of such datasets have informed questions such as optimal definition of response and remission, optimal dose and duration, and comparative efficacy of different agents. Significant challenges in the field include barriers to appropriate diagnosis and treatment of anxiety disorders, failure of a significant proportion of patients to respond to first-line pharmacotherapy agents, and a limited database of efficacy or effectiveness studies to guide treatment in such cases.
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Affiliation(s)
- Nastassja Koen
- Department of Psychiatry and Mental Health, University of Cape Town, South Africa
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Crits-Christoph P, Newman MG, Rickels K, Gallop R, Gibbons MBC, Hamilton JL, Ring-Kurtz S, Pastva AM. Combined medication and cognitive therapy for generalized anxiety disorder. J Anxiety Disord 2011; 25:1087-94. [PMID: 21840164 PMCID: PMC3196054 DOI: 10.1016/j.janxdis.2011.07.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 07/11/2011] [Accepted: 07/11/2011] [Indexed: 11/15/2022]
Abstract
The current study assessed efficacy of combined cognitive behavioral therapy (CBT) and venlafaxine XR compared to venlafaxine XR alone in the treatment of generalized anxiety disorder (GAD) within settings where medication is typically offered as the treatment for this disorder. Patients with DSM-IV-diagnosed GAD who were recently enrolled in a long-term venlafaxine XR study were randomly offered (n=77), or not offered (n=40), the option of adding 12 sessions of CBT. Of those offered CBT, 33% (n=26) accepted and attended at least one treatment session. There were no differences between the combined treatment group and the medication only group on primary or secondary efficacy measures in any of the sample comparisons. Many patients who present in medical/psychopharmacology settings seeking treatment for GAD decline the opportunity to receive adjunctive treatment. Of those that receive CBT, there appears to be no additional benefit of combined treatment compared to venlafaxine XR alone.
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Affiliation(s)
- Paul Crits-Christoph
- Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104, United States.
| | - Michelle G. Newman
- Department of Psychology, Pennsylvania State University, 111 Moore Building, University Park, PA 16802
| | - Karl Rickels
- Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104
| | - Robert Gallop
- Department of Mathematics, West Chester University, 25 University Avenue, West Chester, PA 19383
| | | | - Jessica L. Hamilton
- Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104
| | - Sarah Ring-Kurtz
- Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104
| | - Amy M. Pastva
- Department of Psychology, Villanova University, 800 Lancaster Avenue, Villanova, PA 19085
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Abstract
Patients with personality disorders are prescribed psychotropic medications with greater frequency than almost any other diagnostic group. Prescribing practices in these populations are often based on anecdotal evidence rather than rigorous data. Although evidence-based psychotherapy remains an integral part of treatment, Axis II psychopathology is increasingly conceptualized according to neurobiological substrates that correspond to specific psychopharmacological strategies. We summarize the best available evidence regarding medication treatment of personality disordered patients and provide optimal strategies for evidence-based practice. Most available evidence is concentrated around borderline and schizotypal personality disorders, with some additional evidence concerning the treatment of avoidant and antisocial personality disorders. Although maladaptive personality symptoms respond to antidepressants, antipsychotics, mood stabilizers, and other medications, evidence-based pharmacotherapy is most useful in treating circumscribed symptom domains and induces only partial improvement. Most available evidence supports use of medication in reducing impulsivity and aggression, characteristic of borderline and antisocial psychopathology. Efforts have also begun to reduce psychotic-like symptoms and improve cognitive deficits characteristic of schizotypy. Indirect evidence is also provided for psychopharmacological reduction of social anxiety central to avoidant personality disorder. Evidence-based practice requires attention to domains of expected clinical improvement associated with a medication, relative to the potential risks. The development of future rational pharmacotherapy will require increased understanding of the neurobiological underpinnings of personality disorders and their component dimensions. Increasing efforts to translate personality theory and social cognitive neuroscience into increasingly specific neurobiological substrates may provide more effective targets for pharmacotherapy.
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Bower P, Knowles S, Coventry PA, Rowland N. Counselling for mental health and psychosocial problems in primary care. Cochrane Database Syst Rev 2011; 2011:CD001025. [PMID: 21901675 PMCID: PMC7050339 DOI: 10.1002/14651858.cd001025.pub3] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The prevalence of mental health and psychosocial problems in primary care is high. Counselling is a potential treatment for these patients, but there is a lack of consensus over the effectiveness of this treatment in primary care. OBJECTIVES To assess the effectiveness and cost effectiveness of counselling for patients with mental health and psychosocial problems in primary care. SEARCH STRATEGY To update the review, the following electronic databases were searched: the Cochrane Collaboration Depression, Anxiety and Neurosis (CCDAN) trials registers (to December 2010), MEDLINE, EMBASE, PsycINFO and the Cochrane Central Register of Controlled Trials (to May 2011). SELECTION CRITERIA Randomised controlled trials of counselling for mental health and psychosocial problems in primary care. DATA COLLECTION AND ANALYSIS Data were extracted using a standardised data extraction sheet by two reviewers. Trials were rated for quality by two reviewers using Cochrane risk of bias criteria, to assess the extent to which their design and conduct were likely to have prevented systematic error. Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals (CI). Continuous data from different measuring instruments were transformed into a standard effect size by dividing mean values by standard deviations. Sensitivity analyses were undertaken to test the robustness of the results. Economic analyses were summarised in narrative form. There was no assessment of adverse events. MAIN RESULTS Nine trials were included in the review, involving 1384 randomised participants. Studies varied in risk of bias, although two studies were identified as being at high risk of selection bias because of problems with concealment of allocation. All studies were from primary care in the United Kingdom and thus comparability was high. The analysis found significantly greater clinical effectiveness in the counselling group compared with usual care in terms of mental health outcomes in the short-term (standardised mean difference -0.28, 95% CI -0.43 to -0.13, n = 772, 6 trials) but not in the long-term (standardised mean difference -0.09, 95% CI -0.27 to 0.10, n = 475, 4 trials), nor on measures of social function (standardised mean difference -0.09, 95% CI -0.29 to 0.11, n = 386, 3 trials). Levels of satisfaction with counselling were high. There was some evidence that the overall costs of counselling and usual care were similar. There were limited comparisons between counselling and other psychological therapies, medication, or other psychosocial interventions. AUTHORS' CONCLUSIONS Counselling is associated with significantly greater clinical effectiveness in short-term mental health outcomes compared to usual care, but provides no additional advantages in the long-term. Participants were satisfied with counselling. Although some types of health care utilisation may be reduced, counselling does not seem to reduce overall healthcare costs. The generalisability of these findings to settings outside the United Kingdom is unclear.
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Affiliation(s)
- Peter Bower
- University of ManchesterHealth Sciences Research Group, Manchester Academic Health Science CentreWilliamson BuildingOxford RoadManchesterUKM13 9PL
| | - Sarah Knowles
- University of ManchesterHealth Sciences Research Group, Manchester Academic Health Science CentreWilliamson BuildingOxford RoadManchesterUKM13 9PL
| | - Peter A Coventry
- University of ManchesterHealth Sciences Research Group, Manchester Academic Health Science CentreWilliamson BuildingOxford RoadManchesterUKM13 9PL
| | - Nancy Rowland
- British Association for Counselling and PsychotherapyBACP House15 St.John's Business ParkLutterworthUKLE17 4HB
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Roshanaei-Moghaddam B, Pauly MC, Atkins DC, Baldwin SA, Stein MB, Roy-Byrne P. Relative effects of CBT and pharmacotherapy in depression versus anxiety: is medication somewhat better for depression, and CBT somewhat better for anxiety? Depress Anxiety 2011; 28:560-7. [PMID: 21608087 DOI: 10.1002/da.20829] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Revised: 04/09/2011] [Accepted: 04/18/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Little is known about whether cognitive behavioral therapy (CBT) or pharmacotherapy is relatively more advantageous for depressive versus anxiety disorders. METHODS We conducted a meta-analysis wherein we searched electronic databases and references to select randomized controlled studies comparing CBT and pharmacotherapy, with or without placebo, in adults with major depressive or anxiety disorders. The primary effect size was calculated from disorder-specific outcome measures as the difference between CBT and pharmacotherapy outcomes (i.e., positive effect size favors CBT; negative effect size favors pharmacotherapy). RESULTS Twenty-one anxiety (N = 1,266) and twenty-one depression (N = 2,027) studies comparing medication to CBT were included. Including all anxiety disorders, the overall effect size was.25 (95% CI: -0.02, 0.55, P =.07). Effects for panic disorder significantly favored CBT over medications (.50, 95% CI: 0.02, 0.98). Obsessive-compulsive disorder showed similar effects-sizes, though not statistically significant (.49, 95% CI: -0.11, 1.09). Medications showed a nonsignificant advantage for social anxiety disorder (-.22, 95% CI: -0.50, 0.06). The overall effect size for depression studies was.05 (95% CI: -0.09, 0.19), with no advantage for medications or CBT. Pooling anxiety disorder and depression studies, the omnibus comparison of the relative difference between anxiety and depression in effectiveness for CBT versus pharmacotherapy pointed to a nonsignificant advantage for CBT in anxiety versus depression (B =.14, 95% CI: -0.14, 0.43). CONCLUSIONS On balance, the evidence presented here indicates that there are at most very modest differences in effects of CBT versus pharmacotherapy in the treatment of anxiety versus depressive disorders. There seems to be larger differences between the anxiety disorders in terms of their relative responsiveness to pharmacotherapy versus CBT.
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de Menezes GB, Coutinho ESF, Fontenelle LF, Vigne P, Figueira I, Versiani M. Second-generation antidepressants in social anxiety disorder: meta-analysis of controlled clinical trials. Psychopharmacology (Berl) 2011; 215:1-11. [PMID: 21181129 DOI: 10.1007/s00213-010-2113-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2010] [Accepted: 11/22/2010] [Indexed: 11/28/2022]
Abstract
RATIONALE A growing number of controlled clinical trials suggest that different second-generation antidepressants (SGA) may be effective in the treatment of social anxiety disorder (SAD). OBJECTIVES The aim of the present study is to evaluate the effectiveness of SGA in SAD and to investigate possible differences in their efficacy. METHODS We performed a systematic review and meta-analysis of all double-blind, randomized, controlled clinical trials involving second-generation antidepressants in adult patients with SAD published on PubMed/MEDLINE, PsycINFO, and Current Controlled Trials databases until July 2009. Our analyses were based on changes in Liebowitz Social Anxiety Scale (LSAS), Clinical Global Impression (CGI), and standardized mean difference (SMD). RESULTS Twenty-seven controlled clinical trials, comprising ten different SGA, were selected. When comparing the reduction of LSAS scores, the group receiving active drugs showed a significantly greater reduction compared to those observed in the placebo group [pooled weighted mean -11.9 (IC 95% -14.5 to -9.4)]. The combined relative risk (RR) for the different drugs revealed a 62% increase in treatment response (final CGI ≤2) for those using SGAs, compared to those receiving placebo [RR 1.62 (95% CI 1.44-1.81)]. The combined SMD for the SGAs was -0.43 (IC 95% -0.49 to -0.37). CONCLUSION Second-generation antidepressants are efficacious treatment for patients with SAD. However, our results do not suggest differences of efficacy among different drugs.
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Affiliation(s)
- Gabriela Bezerra de Menezes
- Programa de Ansiedade e Depressão, Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro (IPUB/UFRJ), Niterói, Rio de Janeiro, Brazil
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Abstract
INTRODUCTION Social anxiety disorder (SAD) is one of the most common psychiatric disorders, with a lifetime prevalence of 5-12%. Fears of scrutiny and embarrassment in social and public situations are accompanied by anxiety symptoms, avoidance behavior, and impairment in social and work functioning. Several classes of medication, as well as cognitive-behavioral therapies, have evidence for efficacy in the treatment of SAD, but only a minority of individuals with the disorder receives treatment. AREAS COVERED This review focuses on the evidence-based treatment of SAD with medications including serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, monoamine oxidase inhibitors, other antidepressants, benzodiazepines, alpha-delta calcium-channel agents, and beta-adrenergic blockers. It discusses clinical considerations in the selection and monitoring of treatments, including issues of safety, duration of treatment, comorbidity, and integration of medication with psychotherapeutic treatment. For this review, a PubMed literature search was conducted during July, 2010. EXPERT OPINION Medications in several classes have been demonstrated efficacious in the treatment of SAD. Treatment selection and implementation require attention to clinical diagnosis, patient education, and appropriate monitoring.
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Affiliation(s)
- Franklin R Schneier
- Columbia University College of Physicians and Surgeons, and Research Psychiatrist, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, USA.
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Goljevscek S, Carvalho LA. Current management of obsessive and phobic states. Neuropsychiatr Dis Treat 2011; 7:599-610. [PMID: 22003299 PMCID: PMC3191872 DOI: 10.2147/ndt.s17032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Indexed: 12/05/2022] Open
Abstract
Obsessional states show an average point prevalence of 1%-3% and a lifetime prevalence of 2%-2.5%. Most treatment-seeking patients with obsessions continue to experience significant symptoms after 2 years of prospective follow-up. A significant burden of impairment, distress, and comorbidity characterize the course of the illness, leading to an increased need for a better understanding of the nature and management of this condition. This review aims to give a representation of the current pharmacological and psychotherapeutic strategies used in the treatment of obsessive-compulsive disorder. Antidepressants (clomipramine and selective serotonin reuptake inhibitors) are generally the first-line choice used to handle obsessional states, showing good response rates and long-term positive outcomes. About 40% of patients fail to respond to selective serotonin reuptake inhibitors. So far, additional pharmacological treatment strategies have been shown to be effective, ie, administration of high doses of selective serotonin reuptake inhibitors, as well as combinations of different drugs, such as dopamine antagonists, are considered efficacious and well tolerated strategies in terms of symptom remission and side effects. Psychotherapy also plays an important role in the management of obsessive-compulsive disorder, being effective for a wide range of symptoms, and many studies have assessed its long-term efficacy, especially when added to appropriate pharmacotherapy. In this paper, we also give a description of the clinical and psychological features likely to characterize patients refractory to treatment for this illness, with the aim of highlighting the need for greater attention to more patient-oriented management of the disease.
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Abstract
AbstractThis article provides an overview of the role of psychopharmacotherapy in common emotional disorders for cognitive behaviour therapists. We consider some of the philosophical difference between CBT and medication, when medication might interfere with CBT, when it may enhance outcome and when it might be safely discontinued. We highlight how to differentiate side-effects and symptoms of discontinuation of antidepressants from that of the underlying disorder. The scope of this article is confined to common emotional disorders and does not discuss the interaction of CBT with medication in, e.g. schizophrenia, bipolar disorder or dementia.
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Ganasen KA, Ipser JC, Stein DJ. Augmentation of cognitive behavioral therapy with pharmacotherapy. Psychiatr Clin North Am 2010; 33:687-99. [PMID: 20599140 DOI: 10.1016/j.psc.2010.04.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
There has long been interest in combining pharmacotherapy with psychotherapy, including cognitive behavioral therapy (CBT). More recently, basic research on fear extinction has led to interest in augmentation of CBT with the N-methyl Daspartate (NMDA) glutamate receptor partial agonist D-cycloserine (DCS) for anxiety disorders. In this article, the literature on clinical trials that have combined pharmacotherapy and CBT is briefly reviewed, focusing particularly on the anxiety disorders. The literature on CBT and DCS is then systematically reviewed. A series of randomized placebo-controlled trials on panic disorder, obsessive-compulsive disorder, social anxiety disorder, and specific phobia suggest that low dose DCS before therapy sessions may be more effective compared with CBT alone in certain anxiety disorders. The strong translational foundation of this work is compelling, and the positive preliminary data gathered so far encourage further work. Issues for future research include delineating optimal dosing, and demonstrating effectiveness in real-world settings.
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Affiliation(s)
- K A Ganasen
- Department of Psychiatry, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa.
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Blanco C, Heimberg RG, Schneier FR, Fresco DM, Chen H, Turk CL, Vermes D, Erwin BA, Schmidt AB, Juster HR, Campeas R, Liebowitz MR. A placebo-controlled trial of phenelzine, cognitive behavioral group therapy, and their combination for social anxiety disorder. ACTA ACUST UNITED AC 2010; 67:286-95. [PMID: 20194829 DOI: 10.1001/archgenpsychiatry.2010.11] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
CONTEXT Medication and cognitive behavioral treatment are the best-established treatments for social anxiety disorder, yet many individuals remain symptomatic after treatment. OBJECTIVE To determine whether combined medication and cognitive behavioral treatment is superior to either monotherapy or pill placebo. DESIGN Randomized, double-blind, placebo-controlled trial. SETTING Research clinics at Columbia University and Temple University. PARTICIPANTS One hundred twenty-eight individuals with a primary DSM-IV diagnosis of social anxiety disorder. INTERVENTIONS Cognitive behavioral group therapy (CBGT), phenelzine sulfate, pill placebo, and combined CBGT plus phenelzine. MAIN OUTCOME MEASURES Liebowitz Social Anxiety Scale and Clinical Global Impression (CGI) scale scores at weeks 12 and 24. RESULTS Linear mixed-effects models showed a specific order of effects, with steepest reductions in Liebowitz Social Anxiety Scale scores for the combined group, followed by the monotherapies, and the least reduction in the placebo group (Williams test = 4.97, P < .01). The CGI response rates in the intention-to-treat sample at week 12 were 9 of 27 (33.3%) (placebo), 16 of 34 (47.1%) (CBGT), 19 of 35 (54.3%) (phenelzine), and 23 of 32 (71.9%) (combined treatment) (chi(2)(1) = 8.76, P < .01). Corresponding remission rates (CGI = 1) were 2 of 27 (7.4%), 3 of 34 (8.8%), 8 of 35 (22.9%), and 15 of 32 (46.9%) (chi(2)(1) = 15.92, P < .01). At week 24, response rates were 9 of 27 (33.3%), 18 of 34 (52.9%), 17 of 35 (48.6%), and 25 of 32 (78.1%) (chi(2)(1) = 12.02, P = .001). Remission rates were 4 of 27 (14.8%), 8 of 34 (23.5%), 9 of 35 (25.7%), and 17 of 32 (53.1%) (chi(2)(1) = 10.72, P = .001). CONCLUSION Combined phenelzine and CBGT treatment is superior to either treatment alone and to placebo on dimensional measures and on rates of response and remission.
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Affiliation(s)
- Carlos Blanco
- Department of Psychiatry, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University,1051 Riverside Dr, Box 69, New York, NY 10032, USA.
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Stewart RE, Chambless DL. Cognitive-behavioral therapy for adult anxiety disorders in clinical practice: a meta-analysis of effectiveness studies. J Consult Clin Psychol 2010; 77:595-606. [PMID: 19634954 DOI: 10.1037/a0016032] [Citation(s) in RCA: 263] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The efficacy of cognitive-behavioral therapy (CBT) for anxiety in adults is well established. In the present study, the authors examined whether CBT tested under well-controlled conditions generalizes to less-controlled, real-world circumstances. Fifty-six effectiveness studies of CBT for adult anxiety disorders were located and synthesized. Meta-analytic effect sizes are presented for disorder-specific symptom measures as well as symptoms of generalized anxiety and depression for each disorder, and benchmarked to results from randomized controlled trials. All pretest-posttest effect sizes for disorder-specific symptom measures were large, suggesting that CBT for adult anxiety disorders is effective in clinically representative conditions. Six studies included a control group, and between-groups comparisons yielded large effect sizes for disorder-specific symptoms in favor of CBT. Benchmarking indicated that results from effectiveness studies were in the range of those obtained in selected efficacy trials. To test whether studies that are more representative of clinical settings have smaller effect sizes, the authors coded studies for 9 criteria for clinical representativeness. Results indicate an inverse relationship between clinical representativeness and outcome, but the magnitude of the relationship is quite small.
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Affiliation(s)
- Rebecca E Stewart
- Department of Psychology, University of Pennsylvania, Solomon Laboratories, Philadelphia, PA 19104, USA.
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