Nonresponse to initial pharmacotherapy for social anxiety disorder in adults and young people
Consider modifying treatment for social anxiety disorder in an adult or young person if symptoms persist despite:
- using an effective dose of at least 2 selective serotonin reuptake inhibitors (SSRIs) or serotonin noradrenaline reuptake inhibitors (SNRIs) as sequential monotherapy, each for a minimum of 4 weeks (full benefit may take 6 weeks or longer); and
- discounting alternative reasons for treatment nonresponse.
Options for treatment modification include:
- combining psychosocial interventions (if not already used) with pharmacotherapy
- referral to a psychiatrist or age-appropriate mental health service—psychiatrists may use clonazepam or phenelzine (see below)
- a trial of clonazepam (see below).
For treatment considerations for females of childbearing potential, including advice on contraception, preconception planning and psychotropic use, see here.
For considerations in managing anxiety disorders such as social anxiety disorder during the perinatal period, see here or for considerations in partners, see here.
There is some evidence for clonazepam in social anxiety disorder. However, benzodiazepines should not be used as first-line pharmacotherapy because of potential harms (including increased risk of falls, memory problems, motor vehicle accidents, daytime sedation and dependence). These risks are of particular concern in older people and people with a history of problem substance use (particularly problem alcohol use); in these people, harms of benzodiazepine use may outweigh benefits.
Benzodiazepine use is usually restricted to acute crises and short-term initial therapy. In treatment resistance, they may be considered for maintenance therapy, ideally in consultation with a psychiatrist. Follow the principles of benzodiazepine use in anxiety disorders.
If a benzodiazepine is considered appropriate for social anxiety disorder, a suitable regimen in adults and young people is:
clonazepam 0.25 mg orally, twice daily. 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 500 micrograms every 2 to 4 weeks, as tolerated, until an acceptable response is achieved or a daily dose of 4 mg is reached. If there is an acceptable response, continue the same dose for 6 to 12 months, then consider deprescribing. social anxiety disorder clonazepam clonazepam clonazepam
Psychiatrists may use phenelzine (a monoamine oxidase inhibitor [MAOI]) for treatment-resistant social anxiety disorder. Although phenelzine has strong evidence of efficacy for social anxiety disorder, dietary restrictions hinder its usefulness (see Principles of using irreversible nonselective monoamine oxidase inhibitors [MAOIs]). Lower doses may be needed in older people; consult a source of drug information. If phenelzine is considered appropriate for social anxiety disorder, a suitable regimen in adults and young people is:
phenelzine 15 to 30 mg orally, daily in 2 divided doses (the last dose each day should be given no later than early afternoon to minimise insomnia)1 . 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 15 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 90 mg is reached. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing. social anxiety disorder phenelzine phenelzine phenelzine
If symptoms recur when reducing the dose or stopping therapy, patients may need ongoing pharmacotherapy.