Abstract
Social anxiety disorder (SAD) is a common and disabling disorder. Crome and colleagues provide an important update on several aspects of the epidemiology of SAD from the latest National Survey of Mental Health and Wellbeing together with implications for changes to the diagnostic criteria in DSM5. Among their conclusions, the authors point to the high prevalence but low rates of treatment seeking among adults with SAD. This combination of high prevalence and low treatment seeking underlies the significant societal burden and the public health significance of this mental health disorder. In this commentary we discuss this significance and set out a research agenda that holds potentially important directions for Australia’s mental health initiatives.
People with SAD, as described by Crome and colleagues, have one of the lowest rates of treatment seeking of any mental disorder. Moreover, even when treatment is sought, it is typically delayed from disorder onset by several decades. It is believed that the nature of SAD, particularly the significant fears of negative evaluation and uncertainty, may underlie delayed treatment seeking. Fortunately, recent developments suggest three avenues that may help to overcome some of the barriers to treatment for adults with SAD: early intervention, improved recognition by general practitioners, and remotely delivered psychological treatments, for example, treatments delivered via the internet or workbook.
Improved understanding of the aetiology of SAD has led to recent development of prevention and early intervention programs. Because SAD has its mean onset in the early-to-mid teens, with many cases beginning far earlier, prevention and early intervention programs must be directed toward this age group. One of the most extensively evaluated programs, Cool Little Kids, provides brief education for parents of inhibited preschool children and long-term evaluations reveal significantly reduced anxiety, especially SAD, at ages 7 and 15, along with reductions in comorbid mood disorder at age 15 (Rapee, 2013; Rapee, et al., 2010). Other promising research has evaluated the possibility of reducing SAD through early intervention with school age children (Sportel et al., 2013). Despite this promising potential of early intervention for SAD, considerably more research is needed to maximise the efficacy of and increase access to these interventions.
Crome and colleagues report that the majority of Australians who seek treatment for SAD first present to their general practitioner. Importantly, because SAD is a risk factor for the development of additional mental disorders, targeted assistance to GPs in the recognition and management of SAD will translate to decreased social burden. Fortunately, several brief, easy to administer and empirically evaluated screening measures have now been developed and are freely available for use in routine practice. One example is the Mini-SPIN, which contains three questions and has excellent diagnostic specificity (Seeley-Wait et al., 2009). The development of online assessment and treatment services, such as the MindSpot Clinic (www.mindspot.org.au), now also offer treatment for people who might not access face-to-face services. These online treatments can be integrated with face-to-face services provided directly by the GP or a mental health professional. However, the most effective and efficient combination of online and face-to-face service delivery remains an empirical question requiring careful evaluation.
Finally, the delivery of psychological treatments via internet or bibliotherapy represent treatment models that can reduce barriers to treatment, particularly for those reluctant or unable to access face-to-face services (Andersson and Titov, 2014). For example, one research trial has shown that combining printed bibliotherapy materials with traditional group-based face-to-face cognitive behaviour therapy (CBT) for SAD reduced the therapist time by 25% (Rapee et al., 2007). Recent developments in internet-delivered psychological treatment programs are now allowing for even more efficient delivery and considerably greater access. For example, several studies now indicate that CBT for SAD can be delivered entirely via the internet with clinical outcomes comparable with those achieved via traditional face-to-face treatment (Andrews et al., 2011). In Australia and other countries the growing number of online services are extending the provision of services to traditionally hard-to-reach people in rural and remote regions as well as providing improved efficiency to meet overwhelming demand. Notwithstanding these promising findings, numerous research imperatives remain in this area and, given the early onset of SAD, one critical target for future research is the continued development of online interventions for young people.
As highlighted by Crome and colleagues, in this volume, SAD is a cause of significant societal burden in Australia due to its high prevalence, significant impact and the low rates of treatment seeking. Surprisingly, Crome et al. report that the prevalence of this disorder has not decreased in the decade between the first and second National Surveys. Several directions of research promise to improve our ability to reduce the burden from SAD including prevention and early intervention, development of assistance to general practitioners and the growing availability of remotely delivered psychological treatments. A number of research questions remain in all of these areas and further investment in research into these directions will pay off in reduced disease burden.
See Research by Crome et al., 2015, 49(3): 227–235.