Initial pharmacotherapy for social anxiety disorder in adults and young people
Follow the approach to managing social anxiety disorder in adults and young people.
Treat social anxiety disorder in adults and young people with psychosocial interventions. Consider pharmacotherapy as an adjunct to psychotherapy, or as an alternative if psychosocial interventions are not available, not effective or not preferred.
If an antidepressant is indicated for social anxiety disorder, initial choice should be informed by:
- the drug’s adverse effect profile, potential for drug interactions and safety in overdose
- the patient’s comorbidities
- the patient’s age:
- older people are more likely to have multiple comorbidities or be more sensitive to antidepressant adverse effects (eg hyponatraemia with selective serotonin reuptake inhibitors [SSRIs])
- young people are more susceptible to developing activation and suicidal thoughts when starting treatment with an antidepressant; this effect has been most often observed with SSRIs. Despite this, SSRIs remain a first-line option when antidepressant therapy is indicated; paroxetine, however, should be avoided because it has been associated with an increased risk of suicidal thoughts and behaviours, and other serious adverse events
- the patient’s response to previous treatments and family history of response to treatments
- tolerability when stopping treatment
- whether a patient is planning pregnancy or is pregnant or breastfeeding (also see Considerations in managing anxiety disorders during the perinatal period).
SSRIs (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline) are first-line drugs for the treatment of social anxiety disorder. The serotonin noradrenaline reuptake inhibitors (SNRIs) (desvenlafaxine, duloxetine, venlafaxine) are effective for social anxiety disorder but there is less evidence for their use than for SSRIs.
If an SSRI or SNRI is considered appropriate for social anxiety disorder, individualise the choice of drug (see above). Lower doses may be needed in older people; consult a source of drug information. Use:
1 citalopram 20 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 40 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing social anxiety disorder (adult) citalopram citalopram citalopram
OR
1 escitalopram 10 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 5 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 20 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing social anxiety disorder (adult) escitalopram escitalopram escitalopram
OR
1 fluoxetine 20 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 60 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing social anxiety disorder (adult) fluoxetine fluoxetine fluoxetine
OR
1 fluvoxamine 50 mg orally, at night. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 300 mg is reached. Doses above 150 mg daily may be given in 2 divided doses for better tolerability. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing social anxiety disorder (adult) fluvoxamine fluvoxamine fluvoxamine
OR
1 paroxetine 20 mg orally, in the morning1. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 50 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing social anxiety disorder paroxetine paroxetine paroxetine
OR
1 sertraline 50 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 200 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing social anxiety disorder (adult) sertraline sertraline sertraline
OR
2 desvenlafaxine 50 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 50 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 200 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing social anxiety disorder desvenlafaxine desvenlafaxine desvenlafaxine
OR
2 duloxetine 60 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 30 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 120 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing social anxiety disorder duloxetine duloxetine duloxetine
OR
2 venlafaxine modified-release 75 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 37.5 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 300 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing. social anxiety disorder venlafaxine venlafaxine venlafaxine