March 7, 2023

Dear Colleagues,

The National Social Anxiety Center (NSAC) provides information about relevant and current research in service of disseminating and promoting evidence-based treatment. This month’s summary is written by Suma Chand, PhD, representing NSAC St. Louis, and examines the article, Long-term outcomes of cognitive behavioral therapy for social anxiety disorder: A meta-analysis of randomized controlled trials.

Social Anxiety Disorder (SAD) has high prevalence rates and also high rates of comorbidity with disorders like depression and generalized anxiety disorder. Cognitive-behavioral therapy (CBT) has been established as the ‘‘gold-standard’ treatment for SAD and previous meta-analyses have reported its efficacy at post-treatment assessment. However, there is not enough research on the long-term efficacy of CBT in treating SAD or on the comorbid disorders.

The current meta-analysis operationalized long term as 12 months after treatment cessation and the authors identified 25 relevant studies through a systematic literature search.

The meta-analysis had three aims: 1. to evaluate the efficacy of CBT randomized controlled trials (RCTs) on the long-term disorder-specific outcomes of SAD; 2. to examine the effects of CBT for SAD on long-term, subsyndromal secondary outcomes, including depression, general anxiety, quality of life, and self-esteem; and 3. to assess whether differences in treatment model, format, and features affect treatment outcomes.

The meta-analysis results indicated that CBT interventions showed moderate improvement in social anxiety symptoms at the end of treatment, but showed a further improvement 12 months after treatment cessation.

The results indicate that restricting assessment of outcomes to immediately post treatment underestimates the ultimate level of change achieved by CBT. The lag effect was noted across all CBT interventions and formats. This suggests that CBT is a robust treatment despite its varied procedures, and that there is flexibility in CBT treatment options.

CBT was found to produce a moderate effect size for reducing depressive and general anxiety symptomatology immediately after treatment and the gains were maintained one year after treatment cessation. Quality of life was assessed in the i-CBT studies and it was found to improve at cessation of treatment and continued to improve after end of treatment.

There was little indication that treatment-specific moderating variables influenced treatment efficacy.

The authors have acknowledged potential limitations in their meat-analysis, such as the studies not retaining control groups to be assessed in the long term, effect estimates being possibly distorted in meta-analyses due to lack of power and the methodological quality. The findings are nevertheless very encouraging to clinicians who are invested in using evidence-based treatments like CBT to help their clients with SAD.

For clinicians: Have you had cases that have reported significantly more improvement in their social anxiety symptoms when you have had later follow-up visits? What did they identify as factors that contributed to their continued improvement?

Kindred R., Bates G. W., McBride N. L. Long-term outcomes of cognitive behavioral therapy for social anxiety disorder: A meta-analysis of randomized controlled trials. Journal of Anxiety Disorders, vol. 92, December 2022.

Suma Chand, PdD, A-CBT
Representing NSAC St. Louis
(The Cognitive Behavior Therapy Program of SLUCare Adult Psychiatry Services)