What is the first‑line pharmacologic treatment for social anxiety disorder?

Best Medicine for Social Anxiety

Selective serotonin reuptake inhibitors (SSRIs)—specifically escitalopram, sertraline, paroxetine, or fluvoxamine—are the first-line pharmacologic treatment for social anxiety disorder, with venlafaxine extended-release (75–225 mg daily) as an equally effective alternative. 1

First-Line Pharmacologic Options

Preferred SSRIs

• Escitalopram and sertraline are the top-tier first-line agents because they have the lowest potential for drug-drug interactions, the smallest discontinuation-symptom burden, and established efficacy for social anxiety disorder. 1

• Paroxetine and fluvoxamine demonstrate comparable efficacy but are recommended as second-tier SSRIs due to higher rates of discontinuation symptoms and greater potential for drug interactions. 1

• All SSRIs as a class show robust efficacy with a number needed to treat (NNT) of approximately 4.7, meaning roughly one in five patients will respond to SSRIs who would not have responded to placebo. 1

SNRI Alternative

• Venlafaxine extended-release (75–225 mg daily) is an effective first-line alternative when SSRIs are ineffective or not tolerated after an adequate 8–12 week trial at therapeutic doses. 1, 2

• Venlafaxine requires blood pressure monitoring at baseline and with each dose increase due to dose-dependent risk of treatment-emergent hypertension. 1

Expected Timeline for Response

• Statistically significant symptom improvement begins by week 2 of SSRI therapy, with clinically meaningful improvement typically evident by week 6, and maximal therapeutic benefit reached by week 12 or later. 1

• Early response by week 4 is the strongest predictor of a favorable 12-week outcome, so patience during the initial titration phase is crucial. 1

Dosing Strategy

Starting and Titrating SSRIs

• Begin with lower doses to minimize initial anxiety or agitation: sertraline 25–50 mg daily or escitalopram 5–10 mg daily. 1

• Titrate by 25–50 mg increments for sertraline or 5–10 mg increments for escitalopram every 1–2 weeks as tolerated, targeting therapeutic doses of sertraline 50–200 mg/day or escitalopram 10–20 mg/day. 1

• Full response may take 12+ weeks, so do not escalate doses too quickly—allow 1–2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window. 1

Combination with Psychotherapy

• Combining an SSRI with individual cognitive-behavioral therapy (CBT) yields superior outcomes compared with medication or therapy alone for patients with moderate to severe social anxiety disorder. 1

• Individual CBT specifically designed for social anxiety disorder (such as the Clark & Wells or Heimberg models) is preferred over group therapy due to superior clinical effectiveness and cost-effectiveness. 1

• When face-to-face CBT is unavailable or declined, self-help CBT with professional support is a viable alternative. 1

Common Side Effects and Safety Monitoring

• Most adverse effects—including nausea, headache, insomnia, sexual dysfunction, dry mouth, and dizziness—emerge within the first few weeks and typically resolve with continued treatment. 1

• All SSRIs carry a boxed warning for suicidal thinking and behavior in individuals up to age 24, with pooled absolute rates of 1% versus 0.2% for placebo; close monitoring is essential, especially in the first months and following dose adjustments. 1

Treatment Duration

• After achieving remission, continue SSRI treatment for a minimum of 9–12 months to prevent relapse, with reassessment monthly until symptoms stabilize, then every 3 months. 1

• For recurrent social anxiety disorder, longer-term or indefinite treatment may be beneficial to reduce relapse risk. 1

Management of Inadequate Response

• If no clinically meaningful improvement occurs after 8–12 weeks at therapeutic doses despite good adherence, switch to a different SSRI or SNRI (e.g., from sertraline to escitalopram or to venlafaxine XR). 1

• Add individual CBT if not already implemented, as combined treatment provides superior outcomes. 1

• Approximately 50% of patients do not achieve full remission with first-line pharmacotherapy alone, underscoring the need for adjunctive strategies. 1

Medications to Avoid

• Beta-blockers (atenolol, propranolol) are deprecated by Canadian guidelines for social anxiety disorder treatment based on negative evidence, though propranolol may be used off-label for acute performance anxiety in musicians and public speakers. 1

• Benzodiazepines should be reserved for short-term use only (days to a few weeks) due to risks of dependence, tolerance, cognitive impairment, and withdrawal. 1

Clinical Pitfalls to Avoid

• Do not abandon treatment prematurely—full response requires 12+ weeks, and early symptom improvement by week 6 predicts eventual success. 1

• Avoid combining multiple serotonergic agents without careful monitoring for serotonin syndrome (mental status changes, autonomic hyperactivity, neuromuscular abnormalities). 1

• Do not discontinue SSRIs abruptly—taper gradually over 10–14 days to avoid discontinuation syndrome (dizziness, paresthesias, anxiety, irritability). 1

• Approximately one-third of adults with social anxiety disorder have comorbid conditions such as depression or substance-use disorders, which require concurrent management. 1