Paroxetine reduces social anxiety in individuals with a co-occurring alcohol use disorder
Book SW, Thomas SE, Randall PK, Randall CL;
Commented by , 31 Jul 2007
Aim of the study
The aim of the study was to see if paroxetine successfully treated social anxiety disorder in individuals with an alcohol use disorder. This is an important question as social anxiety is the most common psychiatric disorder found in young people – especially men – who abuse alcohol, yet its treatment is often overlooked or made secondary to that of the drinking behaviour.
Method
Participants were eligible to participate if they met the DSM-IV criteria for current Social Anxiety Disorder (SAnD) and Alcohol Use Disorder (abuse or dependence); had a Leibowitz Social Anxiety Scale score >=60; >=15 standard drinks in the previous 30 days; and used alcohol to cope with social situations. Exclusion criteria included: history of seeking treatment for alcohol abuse/dependence; severely abnormal liver function; current use of other psychotropic medication.
Eligible participants were randomly assigned to either the placebo (n = 22) or paroxetine (mean dose: 45 mg/day; n = 20) group. Treatment was continued for 16 weeks. The main outcome measure was total LSAS score at 16 weeks.
Results
Analysis was conducted on an intention-to-treat basis. Only 4 participants did not provide data at week 16. The paroxetine group showed increasingly lower LSAS scores over the first 6 weeks compared with the placebo group, and this difference was maintained over the following 10 weeks (treatment group x week interaction, p= 0.0004). At study completion, the paroxetine group showed a mean reduction of 53% in total LSAS scores compared with a mean reduction of 32% in the placebo group (p=0.02).
Dr Hood's and Prof Nutt's comments
This study extends the evidence of paroxetine effectiveness in social anxiety disorder to people with comorbid alcohol use disorders. As the authors mention, comorbid alcohol use is seen in roughly one in five persons seeking treatment for social anxiety and thus represents an important subgroup to examine (ref. 1). The magnitude of effect appeared to be very comparable to that seen in prior SAnD studies (ref. 2), thus comorbid alcohol use did not seem to hinder treatment with this medication.
One ideal outcome from this study would be a reduction in both social anxiety and alcohol use with one treatment, negating the need for polyprescribing and/or multiple treatment modalities. The authors of this study claim that the details of alcohol use related outcomes will be the focus of a subsequent paper, however they report here that the comorbid alcohol use problems did not improve with paroxetine therapy.
It will be interesting to see whether context-specific alcohol use (e.g. use of alcohol to cope in social situations) is related to successful paroxetine treatment, even if global alcohol abuse/dependence criteria are still met.
There are some minor methodological concerns worthy of mention. As subjects who had a history of either "medical detoxification or treatment seeking for alcohol problems" were excluded from this study, this may have excluded patients with more severe alcohol comorbidity.
The use of riboflavin (vitamin B2) urinalysis to assess pill compliance was an interesting strategy; however it was not clear if these subjects (who had a co-occurring alcohol use disorder) were also taking multivitamin supplements, which are usually very high in B vitamin content.
It is pleasing to see the publication of studies looking at a broader subject base than that routinely required for licensing purposes. One of the most frequent criticisms of the research literature of anxiety psychopharmacology is that the types of patients seen routinely at the clinical coalface are not represented, hindering real-world clinical application of the data.
It is not necessarily the case that more naturalistic research provides lower-level evidence than RCT's (ref. 3), yet we have been generally reticent to open up our research methodologies to contemplate more real-world participants.
References
1. Morris EP, Stewart SH, Ham LS. The relationship between social anxiety disorder and alcohol use disorders: a critical review. Clinical Psychology Review 2005; 25 (6); 734-760
2. Robinson H, Hood S. Social Anxiety Disorder - A Review of Pharmacological Treatments. Current Psychiatry Reviews 2007; 3; 95-122
2. Leichsenring F. Randomized controlled versus naturalistic studies: a new research agenda. Bulletin of the Menninger Clinic 2004; 68 (2); 137-151