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QUESTION: Do the benefits of exposure therapy and sertraline for social phobia last after treatment has ceased?
Randomised controlled trial with allocation concealment. Physicians and patients were blind to pharmacological treatment allocation (but not psychosocial treatment).
Norway and Sweden; timeframe not specified.
375 people aged 18–65 years with generalised social phobia of at least 1 year duration (DSM-IV criteria) rated as moderately ill (score of 4 or greater on overall severity item of the Clinical Global Impression - Social Phobia scale, severity sub-scale). Participants were recruited from 41 primary care centres in Norway and Sweden and from advertisements in newspapers and other media. 61% were female; mean age was 40 years; mean age at symptom onset was 16 years; mean duration of illness was 24 years. People with comorbid dysthymia or specific phobias were eligible. People with panic disorder with onset before social phobia or any other current anxiety or major depressive disorder were excluded, as were people with substance misuse, eating disorder or a history of bipolar disorder or psychosis.
Participants received sertraline or placebo for 24 weeks, with or without 8 short sessions of exposure therapy provided by general practitioners (2 x 2 design). After treatment was discontinued, participants entered a 28 week follow up period where additional treatment could be provided at the clinicians’ discretion. About 20% received treatment with sertraline during the follow up period, 8% received exposure treatment and 7% referral to a psychologist or psychiatrist. Participants were evaluated at baseline, at the completion of treatment and 52 weeks after inclusion (follow up rate 87%).
Main outcome measures
The main outcome measure was change in symptoms and severity scores using the 36-item Short Form Health Survey and the Clinical Global Impression - Social Phobia scale. General practitioners evaluated their own patients at 24 and 52 weeks.
During the treatment period, sertraline, exposure therapy, and combined treatment with sertraline and exposure therapy were all associated with reduced social phobia scores. Treatment with exposure therapy alone was associated with subsequent improvement, whereas people who received sertraline had a tendency towards deterioration after medication ceased. People who received exposure therapy had improved social phobia scores during follow up (mean change in overall severity score 0.45, 95% CI 0.16 to 0.65, P <0.01). At 52 weeks, those receiving sertraline alone or sertraline plus exposure therapy had a greater deterioration on the 36-item Short Form Health Survey compared with exposure therapy alone.
Exposure therapy alone may have ongoing benefits for people with social phobia. There was a tendency towards deterioration after completing treatment with sertraline alone or exposure therapy combined with sertraline. The authors conclude that exposure therapy administered alone is more effective in the long term than when combined with sertraline.
Social phobia (or social anxiety disorder) is one of the most common mental health problems in the community. It develops early in life and is a risk factor in the development of major depression and substance abuse. Effective pharmacological and psychological treatments are available, but few studies directly compare these forms of treatment.
This large well designed study provides important information about treatment for social phobia in primary care. The authors compared one of the most widely used pharmacological treatments (SSRI antidepressant) with a brief psychosocial treatment - eight 20 minute sessions of exposure therapy. After 24 weeks of treatment, all participants receiving active treatment improved compared with placebo. The greatest improvement was observed in those receiving sertraline. There was no advantage to participants receiving sertraline plus exposure therapy. By the end of the 28 week follow up period, there was some continued improvement in the exposure group and some deterioration in participants who received sertraline (on some measures at least), with an overall advantage to patients assigned to exposure therapy plus placebo. Differences were measured using patient self ratings and global ratings by the physician (who was blind to the pharmacological treatment condition but not blind to psychosocial treatment).
These findings are consistent with previous studies suggesting better long term outcome for exposure-based treatment. The results are even more impressive considering that an economical form of psychosocial treatment was used (8 brief sessions) and treatment was provided by primary care physicians who received only brief training. The study raises questions about the often recommended practice of routinely combining pharmacological and psychological treatments. Combining treatments increases the cost, but may not improve long term outcomes. It would be helpful to extend this research, with a treatment cell involving psychosocial treatment without placebo and psychosocial treatment with a broader range of components or higher dose of treatment. Additional research on the maintenance or loss of gains after discontinuing treatment would also be useful.
Source of funding: Pfizer Inc.
For correspondence: TT Haug, Haukeland University Hospital, 0021 Bergen, Norway.
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