What is the most effective pharmacological treatment and dosage for social anxiety disorder (SAD) or performance anxiety?

From the Guidelines

For performance anxiety or social anxiety disorder, fluvoxamine, paroxetine, and escitalopram are suggested as first-choice treatments, as they are covered by national health insurance for social anxiety disorder in Japan and have been reported to be effective and well-tolerated 1. These medications are selective serotonin reuptake inhibitors (SSRIs) and are typically considered first-line treatment for social anxiety disorder.

• The initial dose and gradual increase of these medications may vary, but they are generally started at a low dose and gradually increased as needed and tolerated.
• It's essential to consult with a healthcare provider before starting any medication, as they can assess your specific situation, medical history, and potential drug interactions to determine the most appropriate treatment approach.
• In addition to medication, cognitive-behavioral therapy (CBT) is also suggested as a treatment for social anxiety disorder, either through individual sessions or self-help with support based on CBT 1.
• The treatment should be individualized, and medication works best when combined with CBT, as it can help improve mood regulation and reduce physical anxiety symptoms.
• Other medications, such as sertraline and venlafaxine, may also be effective, but they are not covered by national health insurance for social anxiety disorder in Japan and should be used with caution and after careful consideration of the potential benefits and harms 1.

From the FDA Drug Label

Social anxiety disorder is a chronic condition that may require several months or longer of sustained pharmacological therapy beyond response to initial treatment Systematic evaluation of sertraline has demonstrated that its efficacy in social anxiety disorder is maintained for periods of up to 24 weeks following 20 weeks of treatment at a dose of 50 to 200 mg/day The recommended and initial dosage is 20 mg/day In clinical trials the effectiveness of PAXIL was demonstrated in patients dosed in a range of 20 to 60 mg/day. While the safety of PAXIL has been evaluated in patients with social anxiety disorder at doses up to 60 mg/day, available information does not suggest any additional benefit for doses above 20 mg/day

The best drug and dosage for social anxiety disorder is not explicitly stated, but based on the available information,

• Sertraline can be used at a dose of 50 to 200 mg/day 2
• Paroxetine can be used at a dose of 20 mg/day, with no additional benefit suggested for doses above 20 mg/day 3 It is recommended to start with the lowest effective dose and periodically reassess the need for continued treatment. Key points:
• The dosage of sertraline or paroxetine may need to be adjusted to maintain the patient on the lowest effective dose.
• Patients should be periodically reassessed to determine the need for long-term treatment.
• The efficacy of these medications in social anxiety disorder has been demonstrated in clinical trials, but the optimal duration of treatment is not well established.

From the Research

Treatment Options for Social Anxiety Disorder

• The first-line treatment for social anxiety disorder (SAD) is selective serotonin reuptake inhibitors (SSRIs) due to their efficacy, safety, and ability to treat co-morbid conditions 4, 5, 6, 7.
• Venlafaxine XR (extended release) may also be considered a first-line treatment for SAD 4, 5, 6.
• Second-line treatments include monoamine oxidase inhibitors (MAOIs), reversible inhibitors of monoamine oxidase A, benzodiazepines, and antiepileptics 4, 5, 6, 7.

Dosage and Treatment Duration

• The optimal length of treatment for SAD is not well established, but individuals who discontinue treatment after 12-20 weeks appear more likely to relapse than those who continue on medication 6, 7.
• Treatment with SSRIs, such as paroxetine, sertraline, or clonazepam, can be maintained for a longer period to prevent relapse 5.

Performance Anxiety

• Beta-blockers, such as propranolol and atenolol, may be beneficial for performance anxiety, but their benefits are limited to this specific type of anxiety 5.

Combination Therapies

• Combination treatments, such as cognitive-behavioral therapy (CBT) and medication, may be beneficial, but more research is needed to determine their effectiveness 5, 6, 8.
• CBT may be a helpful adjunct or alternative to pharmacological treatment for SAD, and it has been shown to be effective in reducing symptoms of SAD 8.