What is the best first‑line selective serotonin reuptake inhibitor (SSRI) for an adult with social anxiety disorder who has no major medical contraindications, is not pregnant or nursing, and is not taking interacting medications such as mono‑amine oxidase inhibitors?

Best SSRI for Social Anxiety Disorder

Escitalopram or sertraline should be your first choice for treating social anxiety disorder in adults, as these agents combine the strongest efficacy evidence with the lowest risk of discontinuation symptoms and drug interactions. 1

First-Line SSRI Selection

Escitalopram and sertraline are recommended as top-tier first-line agents because they demonstrate:

• Established efficacy with moderate to high strength evidence for social anxiety disorder 1
• The most favorable side effect profiles among SSRIs 1
• The lowest risk of discontinuation symptoms compared to paroxetine and fluvoxamine 1
• Minimal drug-drug interaction potential, particularly escitalopram which has the least effect on CYP450 enzymes 1

Escitalopram Dosing

• Start at 5-10 mg daily to minimize initial anxiety or agitation 1
• Titrate by 5-10 mg increments every 1-2 weeks as tolerated 1
• Target therapeutic dose: 10-20 mg/day 1
• Meta-analysis shows significant superiority over placebo at all doses (5mg, 10mg, and 20mg) with treatment differences of -9.2 to -10.1 points on the LSAS 2

Sertraline Dosing

• Start at 25-50 mg daily 1, 3
• Titrate by 25-50 mg increments every 1-2 weeks 1
• Target therapeutic dose: 50-200 mg/day 1, 3
• FDA-approved for social anxiety disorder with demonstrated superiority over placebo on multiple validated scales 3

Second-Tier SSRIs (Reserve for First-Line Failures)

Paroxetine and fluvoxamine are equally effective but should be reserved as second-tier options due to:

• Higher rates of discontinuation symptoms when stopping treatment 1
• Greater potential for drug-drug interactions 1
• Paroxetine carries higher risk of discontinuation syndrome and potentially increased suicidal thinking compared to other SSRIs 1

Despite these limitations, paroxetine (20-60 mg/day) has robust efficacy data and FDA approval for social anxiety disorder 4, 5.

Expected Response Timeline

• Week 2: Statistically significant improvement may begin 1
• Week 6: Clinically significant improvement expected 1
• Week 12: Maximal therapeutic benefit achieved 1
• Do not abandon treatment prematurely; full response requires patience with gradual dose escalation 1

Alternative First-Line: Venlafaxine XR

If SSRIs are contraindicated or ineffective after 8-12 weeks at therapeutic doses, switch to venlafaxine extended-release:

• Dose: 75-225 mg/day 1, 6
• NNT of 4.94, nearly identical to SSRIs (NNT = 4.70) 6
• Requires blood pressure monitoring due to risk of sustained hypertension 1
• Comparable dropout rates to placebo, indicating good tolerability 6

Critical Monitoring Requirements

• Assess response at 4 and 8 weeks using standardized scales (LSAS, CGI-S) 6
• Monitor for suicidal ideation, especially in the first months and after dose adjustments 6
• Common side effects include nausea, sexual dysfunction, headache, insomnia, which typically emerge within the first few weeks and often resolve with continued treatment 1
• Never discontinue abruptly—taper gradually over at least 10-14 days to avoid discontinuation syndrome 6

Combination Treatment for Optimal Outcomes

Combining medication with individual cognitive behavioral therapy (CBT) provides superior outcomes compared to either treatment alone, particularly for moderate to severe social anxiety:

• Individual CBT is prioritized over group therapy due to superior clinical and cost-effectiveness 1, 6
• CBT specifically designed for social anxiety disorder (Clark and Wells model or Heimberg model) should be offered 1
• Combination therapy has moderate strength of evidence for enhanced symptom reduction and functional improvement 1

Common Pitfalls to Avoid

• Do not use beta-blockers (propranolol, atenolol) for chronic social anxiety disorder—Canadian guidelines explicitly deprecated these agents based on negative evidence 6
• Do not escalate doses too quickly—allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window 6
• Do not use benzodiazepines as first-line treatment—reserve only for short-term use due to risks of dependence, tolerance, and withdrawal 1
• Do not rely on medication alone—integrating CBT yields superior outcomes 1, 6

Treatment Duration

• Continue effective medication for a minimum of 9-12 months after achieving remission to prevent relapse 1
• Patients maintained on sertraline in long-term studies experienced significantly lower relapse rates compared to placebo substitution 3