Treatment of Social Phobia in Individuals with Depression

Despite the high frequency and clinical severity of the co-occurrence of social phobia and major depression, many studies have excluded depression in clinical trials. For example, a meta-analysis of30 cognitive and/or behavioral treatments of social phobia, published from 1996 to 2002, found that only 11 studies included patients with social phobia and comorbid depression (Lincoln & Rief, 2004). In this meta-analysis, the impact of comorbid depression could be examined only by comparing studies that did or did not exclude comorbid depression. The results indicated that inclusion of at least some patients with comorbid depression appeared to make little difference in the overall study findings, with near identical estimates of mean pre- to posttreatment effect sizes for studies that did (d = 0.91) or did not (d = 0.92) exclude patients with depression.

Clinical trials examining the impact of comorbid depression on the treatment of social phobia have produced equivocal results. Van Velzen, Emmelkamp, and Scholing (1997) found that comorbid anxiety or depression did not affect treatment outcome of exposure treatment for social phobia. Their comprised sample 18 patients with social phobia, with either comorbid anxiety or depression, compared to 43 individuals without these comorbidities. Likewise, Turner, Beidel, Wolff, Spaulding, and Jacob (1996) found no differences in treatment outcomes for social phobia treatment among 13 patients with social phobia with Axis I comorbidity (dysthymia, generalized anxiety disorder, or simple phobia) and 8 patients without comorbidity. These promising results, based on small studies that did not differentiate between anxiety and mood comorbidity, received additional support from a larger scale (N = 141) study by Erwin, Heimberg, Juster, and Mindlin (2002). The authors compared the response to 12 sessions of cognitive-behavioral group therapy (CBGT) in three groups of patients with social phobia: those with a primary diagnosis of social phobia and no comorbid diagnoses, those with a primary diagnosis of social phobia and an additional anxiety disorder diagnosis, and those with a primary diagnosis of social phobia and an additional mood disorder diagnosis. Their findings showed that patients with social phobia and comorbid mood disorders, but not comorbid anxiety disorders, were more severely impaired than patients with no comorbid diagnosis, both before and after CBGT. However, the rate of improvement in therapy was the same in both groups.

In contrast to these studies, the negative impact of depression on social phobia treatment outcome was shown in studies by Chambless, Tran, and Glass (1997) and Scholing and Emmelkamp (1999). Chambless et al. (1997) examined the prognostic value ofpretreatment depression, as well as personality disorder traits, patients' expectations of treatment, clinician-rated breadth and severity of impairment, and frequency of negative thoughts for CBGT of 62 outpatients with social phobia. The findings indicated that pretreatment depression was the most consistent predictor of poorer treatment outcome for measures of anxious apprehension and anxiety. Scholing and Emmelkamp (1999), in a partial replication of the Chambless et al. (1997) study, examined the role of pretreatment depression, personality disorder traits, clinician-rated severity of impairment, and frequency of negative self-statements during social interactions among 50 patients with generalized social phobia and 26 patients with somatic fears in social situations. In agreement with Chambless et al., they found a significant correlation between pretreatment depression and residual gain scores (r = .20,p < .05). At an 18-month follow-up assessment, however, depression had no significant predictive value for treatment outcome.

An additional perspective on the influence of comorbidity on social phobia treatment is provided by studies offering more detailed analyses of changes in symptoms across treatment. For example, Persons, Roberts, and Zalecki (2003) examined session-by-session symptom changes in anxiety and depression among 58 outpatients who received individual CBT for a variety of anxiety and mood disorders, although not specifically for social phobia. The authors showed that self-reported symptoms of anxiety and depression were highly predictive of one another and correlated more strongly when measured in the same session than when measured at different session-by-session time points. Based on these findings, the authors argued that anxiety and depression change together during the course of CBT, and that these nosologically distinct diagnoses may actually represent variants of a unitary, underlying disorder.

Preliminary evidence against this hypothesis comes from a more recent study that also investigated the interactive process of changes in social anxiety and depression during treatment (Moscovitch et al., 2005). This study examined the effects of CBT for social phobia on changes in depression. The authors gathered weekly measures of anxiety and depression in 66 adult outpatients with social phobia who participated in CBGT. Multilevel mediation analyses revealed that improvements in social anxiety mediated 91% of the improvements in depression over time. Conversely, decreases in depression only accounted for 6% of the decreases in social anxiety over time. Moreover, changes in social anxiety fully mediated changes in depression during the course of treatment. These findings suggest that in patients with social phobia, secondary symptoms of depression are ameliorated via effective CBT that targets primary symptoms of social anxiety. In other words, in patients with social phobia, secondary symptoms of depression are ameliorated via effective CBT that targets primary symptoms of social anxiety. It is possible that social anxiety blocks the path to positive reinforcement of attachment relationships (Eng, Heimberg, Hart, Schneier, & Liebowitz, 2001) and reducing social anxiety may lead to improvements in depression through the mechanism of increased positive reinforcement in interpersonal domains. Therefore, depending on the level of depressive symptoms, it might not be necessary to target depression initially or simultaneously when treating social phobia. Instead, we recommend that clinicians first target the principal social phobia diagnosis of individuals with mild to moderate depression, then reassess the depression status after a successful social phobia treatment.

In summary, studies suggest that outpatients with social phobia and comorbid depression are likely to present with more severe symptoms at pretreatment and to retain some of this severity at posttreatment, but in general they are likely to improve at the same rate as their nondepressed counterparts. Also, response to treatment of social phobia may well drive improvement in comorbid depression. Accordingly, these data provide clinicians with some confidence that for patients with comorbid social phobia and depression, brief CBT targeting social phobia has a good chance of success despite the presence of depression.

Natural Depression Cures

Natural Depression Cures

Are You Depressed? Heard the horror stories about anti-depressants and how they can just make things worse? Are you sick of being over medicated, glazed over and too fat from taking too many happy pills? Do you hate the dry mouth, the mania and mood swings and sleep disturbances that can come with taking a prescribed mood elevator?

Get My Free Ebook


Post a comment