Pharmacotherapy for social anxiety disorder: An evidence-based treatment review

Social anxiety disorder (SAD) is a common and often chronic psychiatric illness characterized by persistent fear of social or performance situations and associated functional impairment and avoidance. Although multiple pharmacologic treatments have been studied, questions remain regarding optimal sequencing of therapies, long-term treatment strategies, and the management of partial or treatment-resistant illness. This narrative review synthesizes the evidence for pharmacologic treatments for SAD across medication classes, including antidepressants, benzodiazepines, monoamine oxidase inhibitors, GABA-related agents, second-generation antipsychotics, and emerging interventions. It also examines as-needed (PRN) interventions and steroid-based approaches, deprescribing and proposes a definition of treatment-resistant SAD. Randomized controlled trials, open-label studies, and guideline recommendations were reviewed to provide a framework for pharmacologic decision-making. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) remain the best-supported first-line pharmacotherapies for SAD. Evidence supports switching within or across antidepressant classes and integrating pharmacotherapy with behavioral interventions in patients with incomplete response. Additional treatments, including benzodiazepines, monoamine oxidase inhibitors, pregabalin, and selected augmentation strategies, may be considered for patients with persistent symptoms, although the evidence base is more limited. Data regarding long-term outcomes and treatment-resistant populations remain relatively sparse. While serotonergic antidepressants remain the cornerstone of treatment, optimal management requires individualized sequencing of therapies, integration with behavioral interventions, and consideration of alternative mechanisms in patients with incomplete response. Future studies should prioritize comparative effectiveness, long-term outcomes, and interventions for treatment-resistant SAD.