Medication for social anxiety: Medication vs. CBT

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Here's how I think about medications vs. cognitive-behavioral therapy (CBT).

Maybe in time humans will come up with the perfect treatment for social anxiety i.e. one that works for all individuals all of the time. But at this point, that does not exist. But just because that does not exist, that doesn't mean we shouldn't be using the tools we humans have developed to try to help people achieve their goals and have a quality of life. So the tools we have now are basically drugs/medications and therapy. None of these have 100% success rate, but they do help many people. So when we look at studies, we're looking at which ones - and which combinations - have the highest success rate. Typically, the studies are looking at one of the medications alone, or CBT alone, or CBT in combination with one of the medications (or a category of medication like SSRI).

There are a lot of variables, hence a lot of studies. For example, doing CBT with therapists who have not been trained well in CBT brings down the success rate of CBT (so when we look at CBT studies we want to make sure the therapists are well-trained and experienced). There are a lot of different medications. There are also different flavors of CBT (CBT in groups, CBT in one-on-one therapy, CBT with desensitization/exposure, CBT with Acceptance and commitment therapy (ACT), Dialectical behavior therapy (DBT), etc.). In other words, there are many permutations!

My key take-aways from the social anxiety research:

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    Medications don't cure anything. They just mask symptoms. That can be very important! Medication can be what keeps you going to work or school. It can help people achieve their goals and increase their quality of life. Medications can also help people get into CBT. In short, it can be an important part of the treatment, but we just have to expect that it's probably not going to cure anxiety long-term.
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    There is a high relapse rate with medications. When you get off the medication, the symptoms come back.
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    There are side-effects with medications (especially the ones you take everyday like SSRIs/SNRIs, MAOIs, tricyclic antidepressants).
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    Medications are not as precise as we would like. Humans are still mapping all of the anxiety pathways in the brain and body. We're still not sophisticated enough in our science to say that this pill is going to target exactly what we want (anxiety), and not target other parts of the body that will have ill-effects.
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    CBT so far is the most effective therapy treatment for anxiety and depression. But individuals are unique, and some individuals may find more success with other approaches (this is a pretty good list of other approaches).
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    CBT has a lower relapse rate than medications. CBT is actually targeting some of the self-talk and behavior that is causing anxiety, and providing important strategies that you can use after therapy ends (unlike medication).
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    CBT typically takes 12-16-weeks. The "take every day" medications (like SSRIs/SNRIs, MAOIs, tricyclic antidepressants) may take 6 weeks to kick-in. So CBT may take a few weeks longer than those medications.
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    CBT combined with medications in many cases has been shown to be effective. It's especially helpful if you need medications to do CBT or the reasons in the first bullet. Once the individual goes off medication, in many cases relapse rate is lower (than medication alone) because CBT maintains the gains.
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    One note about CBT with medications. When you see gains from the combination therapy, you may attribute those gains to the medication and not to yourself. When in actuality, you have made some core changes in your thinking and behaviors that are making a difference in your life. Because you're attributing the change to the medication, you may may wonder "was it really me who made progress?" You may feel like you always need the prop - like a crutch. One of the goals of therapy will be for you to leave therapy knowing that you can enter a social situation more confident on your own without the medication.

Please comment or ask questions below!

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