January 23, 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 Constance J. Salhany, PhD, A-CBT, representing NSAC Staten Island, NY and examines the article, The Effect of Depression on Treatment Outcome in Social Anxiety Disorder: An Individual-level Meta-analysis.

People with Social Anxiety Disorder (SAD) often have comorbid depression. However, the empirical findings on the effects of depression on Cognitive Behavioral Therapy (CBT) and pharmacotherapy for SAD are mixed. To further complicate the matter, consideration is needed for differences in modality of treatment. In prior studies, patients were treated with CBT by group (CBGT), individual, or internet-delivered CBT (I-CBT), and variations in pharmacotherapies have also been cited.

In some studies, pre-treatment depression was correlated with poorer outcomes in CBT, and poorer response in pharmacotherapy. Yet, other research did not yield similar results. In fact, in some studies there was no difference in treatment outcomes among those participants who had comorbid depression as compared to those who did not have comorbid depression. An interesting finding in other studies was a positive association between comorbid Major Depressive Disorder (MDD) and outcome. Some people who had SAD and MDD had greater improvement as compared to those who had SAD alone. Examination of severity of depression demonstrated inconsistent outcomes across studies.

Intrigued by the research literature, Rozen and Aderka (2022) conducted an initial meta-analysis prior to their current study. In that meta-analysis, they found a small but positive relationship between depression and improvement in SAD, and that face-to-face CBT predicted better outcomes. However, they determined that a limitation was the use of study-level data in that it could lead to aggregation bias. Therefore, they decided to conduct the present study using individual-level data.

In the current study, Rozen and Aderka (2022) conducted a meta-analysis using effect sizes based on individual-level data that they gathered directly from the original researchers. They included 41 studies and 46 treatment conditions. In terms of results, they found participants with SAD and elevated levels of depression at pretreatment had greater decreases in social anxiety symptoms at post treatment. Duration of follow-up was not found be significant as a moderator of depression-outcome association at follow-up. The findings were significant for CBT and ICBT, but not for CBGT or pharmacotherapy. Based on the findings of their study, the authors concluded, “depression does not negatively affect treatment outcome in SAD and may even lead to improved outcomes in some treatment formats.” The authors speculated that reduction in depression early in treatment may increase motivation and alliance, but caution in interpreting the findings due to the effect size.

For clinicians: What experiences do you have in treating people with SAD and comorbid depression? What do you think might account for the pre-treatment depression leading to better outcomes for some people?

Rozen, Naama & Aderka, Idan M. The effect of depression on treatment outcome in social anxiety disorder: An individual-level meta-analysis. Cognitive Behaviour Therapy, May, 2022, vol. 51, no. 3, pp. 185-216.

Constance J. Salhany, PhD, A-CBT
Representing NSAC Staten Island (Cognitive Therapy Staten Island)