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Phenelzine plus cognitive behavioral therapy best for social anxiety disorder

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – In treating social anxiety disorder, phenelzine combined with cognitive behavioral group therapy achieves a higher response rates than either treatment alone or placebo, according to a report in the Archives of General Psychiatry for March.

“Medication and cognitive behavioral therapy are the best established treatments for social anxiety disorder, yet many individuals remain symptomatic after treatment,” lead author Dr. Carlos Blanco, from New York State Psychiatric Institute, New York, and colleagues note.

To determine if combining medical therapy with cognitive behavioral group therapy would improve response and remission rates, the authors randomized 128 patients to receive one or both treatments, or neither (placebo).

During the course of the study, phenelzine was gradually increased from 15 mg/d to up to 90 mg/d as needed and tolerated. Group therapy consisted of 12 weekly 2.5-hour sessions with 4 to 6 participants. The main outcome measures were scores on the Liebowitz Social Anxiety Scale and on the Clinical Global Impression scale at 12 and 24 weeks.

Liebowitz Social Anxiety Scale scores improved most with combined treatment, followed by either medication or group therapy alone, and then by placebo (p < 0.01), the researchers report. At 12 weeks, Clinical Global Impression scale response rates were 71.9% with combined treatment, 54.3% with phenelzine, 47.1% with the group therapy, and 33.3% with placebo (p < 0.01). The corresponding remission rates were 46.9%, 22.9%, 8.8%, and 7.4% (p < 0.01). The response and remission rates at 24 weeks showed a similar pattern. At week 12, the mean daily dose of phenelzine was roughly 62-66 mg regardless of assignment to the drug-only group or the combined treatment group. Even so, the combined treatment group had higher rates of insomnia, dry mouth, and weight gain. Phenelzine monotherapy had the highest rates of lightheadedness, constipation, and anorgasmia. Nervousness was most common in the placebo group. “This study is the first, to our knowledge, to provide an empirical rationale for the use of combined treatment for social anxiety disorder,” the authors conclude. “Future studies should prospectively examine whether the combination of a selective serotonin reuptake inhibitor plus behavioral therapy or cognitive behavior therapy is superior to either treatment alone and the acceptability, efficacy, and cost-effectiveness of combined vs. sequentially administered or augmented treatments.” Reference:
Arch Gen Psychiatry 2010;67:286-295.