Talk therapy is better than pills for social anxiety

"The good news from our study is that social anxiety is treatable. Now that we know what works best, we need to improve access to psychotherapy for those who are suffering," says Evan Mayo-Wilson. (Credit: Marc Wathieu/Flickr)

A form of talk therapy beats antidepressants in treating social anxiety disorder and, unlike the medication, can remain effective long after treatment has stopped, a study shows.

Cognitive behavioral therapy, a type that helps a patient focus on relationships between thoughts, feelings, and behaviors, led all treatments in an analysis of 101 clinical trials comparing multiple types of medication and talk therapy. The results are published online in the Lancet Psychiatry.

“Social anxiety is more than just shyness,” says study leader Evan Mayo-Wilson, a research epidemiologist at the Johns Hopkins University Bloomberg School of Public Health. “People with this disorder can experience severe impairment, from shunning friendships to turning down promotions at work that would require increased social interaction.

“The good news from our study is that social anxiety is treatable. Now that we know what works best, we need to improve access to psychotherapy for those who are suffering.”

Social anxiety disorder is characterized by intense fear and avoidance of social situations; it affects up to 13 percent of Americans and Europeans. Most never receive treatment. For those who do, medication is a more accessible treatment because there is a shortage of trained psychotherapists.

Irrational fears

The study involved researchers from Johns Hopkins, Oxford University, and University College London, where Mayo-Wilson formerly worked. They analyzed data from 13,164 participants in 101 clinical trials.

All had severe and longstanding social anxiety. Approximately 9,000 received medication or a placebo; more than 4,000 received a psychological intervention. Few of the trials looked at combining medication with talk therapy, and there was no evidence that combined therapy was better than talk therapy alone.

The data compared several different types of talk therapy and found individual cognitive behavioral therapy the most effective. CBT helps people challenge irrational fears and overcome their avoidance of social situations, Mayo-Wilson says.

Therapy vs. meds

For people who don’t want talk therapy, or who have no access to CBT, the most commonly used antidepressants—selective serotonin reuptake inhibitors (SSRIs)—are effective, the researchers found.


But the medication can be associated with serious adverse effects and doesn’t work at all for many people, the researchers say. Improvements in symptoms do not last after people stop taking the pills, they add.

Medication remains an important tool, but should be used as a second-line therapy for people who do not want or don’t respond to psychological therapy, the researchers say.

The study has already led to new treatment guidelines guidance in the United Kingdom and, Mayo-Wilson says, could have a significant impact on policymaking and the organization of care in the United States.

Access to treatment

Social anxiety disorder typically begins in adolescence or early adulthood and can severely impair a person’s daily functioning by impeding the formation of relationships, negatively affecting performance at work or school, and reducing overall quality of life.

Because it strikes at critical times in patients’ social and educational development, it can have important and lasting consequences.

“Greater investment in psychological therapies would improve quality of life, increase workplace productivity, and reduce health care costs,” Mayo-Wilson says. “The health care system does not treat mental health equitably, but meeting demand isn’t simply a matter of getting insurers to pay for psychological services.

“We need to improve infrastructure to treat mental health problems as the evidence shows they should be treated.

“We need more programs to train clinicians, more experienced supervisors who can work with new practitioners, more offices, and more support staff.”

The National Institute for Health and Care Excellence in England and Wales funded the study.

Source: Johns Hopkins