Antidepressants are the most commonly used treatment for social anxiety disorder but we know they don't work for many people and their efficacy goes down over time.

New research finds they are not even needed in many instances. 

Social anxiety disorder is a condition characterized by fear and avoidance of social situations. It affects as many as 13 percent of the Western world. For most people, it is not severe, and they never receive treatment for the disorder but those who do get treatment are usually assigned medication.

A network meta-analysis that collected and analyzed data from 101 clinical trials comparing multiple types of medication and talk therapy and results published in The Lancet Psychiatry found that cognitive behavioral therapy (CBT) is more effective and, unlike medication, can have lasting effects long after treatment has stopped. 

"Social anxiety is more than just shyness," says study leader Evan Mayo-Wilson, DPhil, a research scientist in the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health. "People with this disorder can experience severe impairment, from shunning friendships to turning down promotions at work that would require increased social interaction. The good news from our study is that social anxiety is treatable. Now that we know what works best, we need to improve access to psychotherapy for those who are suffering."

The research was a collaboration between the Johns Hopkins Bloomberg School of Public Health, Oxford University and University College in London, where Mayo-Wilson formerly worked.

For the study, Mayo-Wilson and his colleagues analyzed data from 13,164 participants in 101 clinical trials. The participants all had severe and longstanding social anxiety.

Approximately 9,000 received medication or a placebo pill, and more than 4,000 received a psychological intervention.

Few of the trials looked at combining medication with talk therapy, and there was no evidence that combined therapy was better than talk therapy alone.

The data compared several different types of talk therapy and found individual CBT was the most effective. CBT is a form of treatment that focuses on relationships between thoughts, feelings and behaviors. It helps people challenge irrational fears and overcome their avoidance of social situations, Mayo-Wilson says.

For people who don't want talk therapy, or who lack access to CBT, the most commonly used antidepressants -- selective serotonin reuptake inhibitors (SSRIs) -- are effective, the researchers found. But they caution that medication can be associated with serious adverse events, that it doesn't work at all for many people, and that improvements in symptoms do not last after people stop taking the pills.

The researchers acknowledge that medication remains important but say it should be used as a second-line therapy for people who do not respond to or do not want psychological therapy. The group's analysis has already led to new treatment guidelines guidance in the U.K. and, Mayo-Wilson says, it could have a significant impact on policymaking and the organization of care in the U.S.

Social anxiety disorder typically begins in adolescence or early adulthood, and it can severely impair a person's daily functioning by impeding the formation of relationships, by negatively affecting performance at work or school, and by reducing overall quality of life. Because it strikes people at critical times in their social and educational development, social anxiety disorder can have important and lasting consequences.

"Greater investment in psychological therapies would improve quality of life, increase workplace productivity, and reduce healthcare costs," Mayo-Wilson says. "The healthcare system does not treat mental health equitably, but meeting demand isn't simply a matter of getting insurers to pay for psychological services. We need to improve infrastructure to treat mental health problems as the evidence shows they should be treated. We need more programs to train clinicians, more experienced supervisors who can work with new practitioners, more offices, and more support staff."