What is the best medication for social anxiety disorder?

Best Medications for Social Anxiety Disorder

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line recommended medications for social anxiety disorder, with sertraline and escitalopram being the most effective options. 1, 2

First-Line Treatment Options

SSRIs

• Recommended as first-line treatment with strong evidence supporting their efficacy 1, 2
• Specific SSRIs with proven efficacy:
  • Sertraline (Zoloft): 50-200 mg/day 2, 3
  • Escitalopram (Lexapro): 20 mg/day 2
  • Paroxetine (Paxil): 20-50 mg/day 1, 2
  • Fluvoxamine: Effective but with potentially more side effects 1, 2

• SSRIs demonstrate high response rates with Number Needed to Treat (NNT) of 4.70 1
• Treatment response typically occurs within 4-6 weeks 2
• Higher doses of SSRIs within the therapeutic range are associated with greater treatment benefits 4

SNRIs

• Venlafaxine: Second-line option with similar efficacy to SSRIs (NNT = 4.94) 1, 2
• Dosage range: 75-225 mg/day
• May have more noradrenergic side effects (increased blood pressure, sweating) 2

Treatment Algorithm

1. Start with an SSRI (preferably sertraline or escitalopram) 2

   • Begin sertraline at 50 mg/day (can start at 25 mg/day for the first week to minimize side effects) 3
   • Titrate up to 50-200 mg/day based on response and tolerability 3, 5

2. If inadequate response after 4-6 weeks:

   • Increase SSRI dose (higher doses show better efficacy) 4
   • Continue for at least 12 weeks before determining treatment failure 5, 6

3. If SSRI is ineffective or not tolerated:

   • Switch to a different SSRI or
   • Switch to venlafaxine (SNRI) 1, 2

4. For breakthrough anxiety during initial treatment:

   • Consider short-term (1-4 weeks) benzodiazepine use while waiting for SSRI effect 2
   • Not recommended for long-term management due to dependence risk

Efficacy Evidence

• Sertraline demonstrated significantly greater reduction in Liebowitz Social Anxiety Scale (LSAS) scores compared to placebo (31.0 vs. 21.7 point reduction) 5
• Response rates (CGI-I score ≤2) for sertraline were approximately twice that of placebo (55.6% vs. 29% among completers) 5, 6
• In a 20-week study, sertraline showed 53% response rate compared to 29% for placebo 6
• Meta-analysis shows SSRIs have larger effect sizes compared to reversible monoamine oxidase inhibitors (RIMAs) 7

Treatment Duration and Follow-up

• Continue treatment for at least 24-28 weeks after initial response 2
• Premature discontinuation increases relapse risk 2
• Taper medication slowly when discontinuing to avoid withdrawal symptoms

Medications to Avoid

• Beta-blockers (atenolol, propranolol)
• Levetiracetam
• Quetiapine
• Tricyclic antidepressants
• These have shown negative evidence in SAD treatment 2

Common Pitfalls and Caveats

1. Inadequate dosing: Many clinicians underdose SSRIs; higher doses within the therapeutic range show better efficacy for social anxiety 4

2. Insufficient treatment duration: Treatment should continue for at least 24-28 weeks after response 2

3. Reliance on benzodiazepines: While effective for short-term relief, they should not be used as primary long-term treatment due to dependence risk 2

4. Overlooking side effects: Monitor for sexual dysfunction, gastrointestinal issues, and potential suicidal ideation, especially during initial treatment phase 2

5. Abrupt discontinuation: Always taper SSRIs gradually to avoid discontinuation syndrome 2