There is some evidence that SSRIs can be effective at treating co-occurring SAD and AOD use disorders, although their effectiveness at reducing AOD use may be limited [1184, 1186, 1187]. In a double-blind, placebo-controlled trial, paroxetine was found to reduce symptoms of social anxiety and reliance on alcohol for self-medication of anxiety symptoms, but it did not reduce actual quantity and frequency of drinking [1186, 1187].
There is a large body of evidence demonstrating the efficacy of SSRIs, SNRIs, and MAOIs (in particular, phenelzine) for the treatment of SAD as a single disorder [1158]. Although comparative research is lacking, SSRIs and SNRIs are recommended by the RANZCP as first-line pharmacotherapies due to their superior safety and side-effect profiles relative to MAOIs. As mentioned previously, MAOIs may cause significant adverse effects and the person must adhere to strict dietary restrictions [1158]. Other medications that have demonstrated some level of effectiveness include pregabalin and gabapentin. It is recommended that beta blockers, buspirone and antipsychotics should be avoided [1158].
The RANZCP guidelines suggest that SSRIs or SNRIs may be considered as an alternative to CBT for cases in which the response to CBT has been inadequate or if the person has a preference for medication. Similarly, the combined use of CBT and an SSRI or SNRI may be considered in cases of severe SAD, or where the response to either CBT or pharmacotherapy alone has been insufficient. As mentioned previously, it is important that practitioners explain to clients prescribed SSRI or SNRI antidepressants that they may experience an initial exacerbation of anxiety [1158]. To reduce the likelihood of this occurring, it is recommended that clients start with a low dose and titrate slowly to a required therapeutic dose.
The RANZCP guidelines provide guidance on dose titration and switching within- and between- classes of anti-depressants and the other previously mentioned medications depending on treatment response. It is important to note however, that treatment response is typically slow (at least four weeks) and it is therefore important to allow time for appreciable effects to be discerned, which may be difficult for clients who are seeking immediate relief from their symptoms.