Pharmacotherapy of social anxiety disorder: what does the evidence tell us?

The treatment goals for social anxiety disorder (SAD) are to reduce fear, avoidance, physical distress, disability, and comorbidity. This review illustrates some of the primary studies used to evaluate efficacy of treatments for SAD. The selective serotonin reuptake inhibitors (SSRIs) paroxetine, sertraline, fluoxetine, fluvoxamine, and escitalopram and the serotonin-norepinephrine reuptake inhibitor venlafaxine are effective treatments. They have the additional benefit of being able to treat comorbid conditions. For people who do not respond to serotonin reuptake inhibitors, treatment options include benzodiazepines (clonazepam, alprazolam, and bromazepam), alpha2delta calcium-channel blockers (gabapentin and pregabalin), reversible inhibitors of monoamine oxidase A (moclobemide, although agents in this class are not available in the United States), antiepileptics (levetiracetam), and atypical antipsychotics (olanzapine). The irreversible monoamine oxidase inhibitor phenelzine can be considered an effective third-line therapy. Combination treatments may be beneficial, but more research is needed. Benefits of beta-blockers (propranolol and atenolol) are limited to performance anxiety. Botulinum toxin A may be an effective augmentation treatment option for severe axillary hyperhidrosis in patients with SAD. Studies show that patients with SAD who are maintained on paroxetine, sertraline, or clonazepam have a low relapse rate.