Impact of depressive symptoms on the treatment of generalized social anxiety disorder
Ledley DR, Huppert JD, Foa EB, Davidson JRT, Keefe FJ and Potts NLS;
Commented by , 17 Jan 2006
Background
Although it is well known that social anxiety disorder (SAD) is often associated with depressive symptoms, the impact of depressive symptoms on the treatment of SAD has not been extensively investigated up to now.
Aims of the study
To investigate the impact of depressive symptoms on the treatment outcome of SAD.
Method
295 patients with SAD, without depressive symptoms or with depressive symptoms not meeting diagnostic criteria for major depressive disorder, were included in a randomized controlled study involving five treatments:
- fluoxetine
- comprehensive cognitive-behavioral therapy (CBT)
- fluoxetine and CBT
- CBT and pill placebo
- pill placebo
Fluoxetine was given at a dosage of 40 mg. CBT was provided in 14 weekly group sessions. Depressive symptoms were assessed using the Hamilton Rating Scale for Depression (HRSD) and the 21 item version of the Beck Depression Inventory (BDI). Severity of social phobia was assessed using the Brief Social Phobia Scale (BSPS)
Results
Depressive symptoms were related to more severe social anxiety and to s change over time. Patients who were non-responders to treatment had higher pre-treatment depression scores than those who responded to treatment. Patients who dropped out of the study during treatment had higher pre-treatment levels of depressive symptoms than those who completed treatment.
Professor Pull's comments
SAD is a highly prevalent mental disorder. It interferes significantly with the person’s normal routine, occupational or academic functioning, or social activities or relationships, and/or is associated with considerable distress.
SAD is often associated with other mental disorders, including in particular depression, and the co-occurrence of SAD and depression is associated with greater impairment.
Both SAD and depression are amenable to treatment with either pharmacotherapy or CBT or a combination of both. Owing to the fact that patients with major depressive disorder are routinely excluded from studies exploring the efficacy of either treatment for SAD, little is known, however, about the impact of depression on the treatment of SAD.
This study provides some interesting information on this topic and raises a few questions that need to be addressed in future studies.
As shown by the results of the study, treatment of SAD is complicated by the presence of depressive symptoms. In particular, higher levels of depressive symptoms are related to more severe social anxiety overall and to less change in social anxiety symptoms during treatment by either pharmacotherapy or CBT.
This raises the question of whether patients with SAD and depressive symptoms might benefit from a treatment combining both an antidepressant and CBT. As shown by the results of the study, patients with depressive symptoms who received combined treatment did not do better than those receiving monotherapies.
Future studies on SAD with depressive symptoms should address the following questions:
- Explore treatments combing CBT with other serotonine reuptake inhibitors.
- Explore sequential treatments, using medication prior to beginning CBT
- Explore treatments combining CBT for depression and CBT for SAD, either in association or sequentially.