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PSYCHOPHARMACOLOGICAL TREATMENT OF SOCIAL PHOBIA (SP)

PSYCHOPHARMACOLOGICAL TREATMENT OF SOCIAL PHOBIA (SP). Professor Jiří Raboch, M.D. Psychiatric Department 1 st . Medical Faculty Charles University Prague. TREATMENT OPTIONS. CBT MONOAMINE OXIDASE INHIBITORS BENZODIAZEPINES BETA-BLOCKERS SSRIs DUAL REUPTAKE INHIBITORS

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PSYCHOPHARMACOLOGICAL TREATMENT OF SOCIAL PHOBIA (SP)

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  1. PSYCHOPHARMACOLOGICAL TREATMENT OF SOCIAL PHOBIA (SP) Professor Jiří Raboch, M.D. Psychiatric Department 1st. Medical Faculty Charles University Prague

  2. TREATMENT OPTIONS • CBT • MONOAMINE OXIDASE INHIBITORS • BENZODIAZEPINES • BETA-BLOCKERS • SSRIs • DUAL REUPTAKE INHIBITORS • OTHER/NEWER AGENTS

  3. RANDOMIZED CONTROLLED TRIALS RESPONSE RATE clinically significant reduction of symptoms Clinical Global Impression Scale-Improvement (CGI-I) – „very much“ or „much improved“ 50 % drop in the Liebowitz Social Anxiety Scale (LSAS)

  4. MONOAMINE OXIDASE INHIBITORS

  5. PHENELZINE - controlled studies + stat. sign. better than placebo

  6. MOCLOBEMIDE – controlled studies + stat. sign. better than placebo

  7. BENZODIAZEPINES – controlled studies + stat. sign. better than placebo

  8. BUSPIRONE – controlled studies

  9. BETA-BLOCKERS – controlled studies

  10. SSRIs

  11. FLUVOXAMINE – controlled studies * CR – controlled-release + p=0,05 +++ p=0,001

  12. PAROXETINE – controlled studies * CR – controlled-release + p=0,05 +++ p=0,001

  13. SERTRALINE – controlled studies ++ p=0,01 +++ p=0,001

  14. FLUOXETINE – controlled studies + p=0,05

  15. s-CITALOPRAM – controlled studies + p=0,05 ++p=0,01 +++ p=0,001

  16. WHAT DOSAGE? + p=0,05 +++ p=0,001

  17. SNRI

  18. VENLAFAXINE ER – controlled studies + p=0,05 ++ p=0,01 +++ p=0,001

  19. WHICH IS BETTER? • Few methodologically fair head to head comparisons • Lader et al., 2004 20 mg s-citalopram better (p=0,01) than 20 mg paroxetine • Liebowitz et al., 2005 paroxetine 20-50 mg/d and venlafaxine ER 75-225 mg - similar effects

  20. OTHER DRUGS

  21. ANTIEPILEPTIC DRUGS -controlled studies + stat. sign. better than placebo

  22. ATYPICAL ANTIPSYCHOTICS Barnet et al., 2003

  23. COMPARISON OF DRUG CLASSES FOR TREATMENT OF SF Adapted from Westenberg, 2004

  24. SP – first choice TREATMENT • SSRIs – s-citalopram, fluvoxamine (CR), paroxetine (CR), sertraline, (fluoxetine) • SNRI – venlafaxine ER • COMBINATION – CBT + ANTIDEPRESSANTS – few data (sequencing)

  25. SP – second choice TREATMENT and future alternatives • MAOIs (phenelzine) • Moclobemide • Clonazepam • Performance anxiety – beta-blockers – propranolol, atenolol • Anticonvulsants, atypical antipsychotics

  26. CONCLUSION • THERE ARE NUMBER OF EMPIRICALLY VALIDATED ACUTE TREATMENTS FOR SOCIAL PHOBIA • THE GOAL OF TREATMENT NEEDS TO BE REFOCUSED FROM ACHIEVING RESPONSE TO ACHIEVING REMISSION IN A LONGER PERSPECTIVE (CONTINUATION AND MAINTENANCE PHASES IN THE TREATMENT)

  27. THANK YOU FOR YOUR ATTENTION!

  28. HOW LONG? • Stein et al., 2003 • 112 patients with SAD, improved after 12 weeks treatment with sertraline CR (100 – 300 mg/day) • 24 weeks extension phase • Subjects continued to improve compared to placebo treated, although changes were smaller

  29. TREATMENT PHASES acute 6 – 12 (or longer) weeks continuation up to 1 year maintenance

  30. CONTINUATION TREATMENT? • Walker et al., 2000 • 50 patients with generalized social phobia much or very much improved after 20 weeks of treatments with sertraline (50-200 mg/day) • Randomly assigned to sertraline or placebo for another 6 months • Relapse rate: placebo group 36 %, sertraline group 4 % (p=0,01)

  31. MAINTENANCE TREATMENT? • Versiani et al., 1996 • 58 patients-responders with SF treated 2 years with moclobemide (600-750 mg/day) • After 2 years moclobemide was withdrawn • Relapse rate 88 %

  32. Pharmacological treatment of SF: a meta-analysis Blanco et al., 2003 CI – confidence interval

  33. PREDICTORS OF TREATMENT RESPONSE • Alcohol abuse • Comorbid personality disorder • Earlier age of onset • Higher heart rate and blood pressure • Elevated baseline measures of anxiety and depression

  34. TREATMENT RESISTENCE • Switching – venlafaxine, phenelzine • Augmentation – buspirone, pindolol, benzodiazepines (clonazepam), atypical antipsychotics (olanzapine, risperidone), tiababine

  35. TREATMENT RESISTENCEcontrolled studies

  36. CONTINUATION TREATMENT? • Stein et al., 2002 • … patients with SAD improved after 12 weeks treatment with paroxetine (20-50 mg/day) • Randomly assigned to paroxetine or placebo for another 6 months • Relapse rate: placebo group 40 %, sertraline group 14 % (p=0,0001)

  37. REMISSION CRITERIA • No longer satisfying diagnostic criteria • CGI-I very much improved • LSAS > 70 % reduction, < 30 • SDS < 5

  38. COMPARISON OF DRUG CLASSES FOR TREATMENT OF SF Adapted from Westenberg, 2004

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