No: Efforts to relieve human suffering deserve rewards

Abstract

The US News and World Report cover story, “How Shy Is Too Shy?” captured the debate about the pharmaceutical industry's role in bringing social anxiety disorder to the forefront of public awareness. Drug companies have been accused of fabricating this disorder to boost sales of selective serotonin reuptake inhibitors (SSRIs). This is untrue and does a great disservice to patients. In fact, the pharmaceutical industry was a reluctant participant in this area, funding studies in the mid-1990s only on the repeated urging of the academic research community. Social anxiety disorder is a chronic, debilitating condition that has long been trivialized and even ignored. The high prevalence of social anxiety disorder became apparent after publication of the National Comorbidity Survey (NCS) data in 1994.1 This congressionally mandated survey measured the presence of psychiatric diagnoses in more than 8,000 randomly selected American adults living in the community. As a result of this landmark study, social anxiety disorder was recognized as a condition to be taken seriously. The NCS study found that social anxiety disorder has a lifetime prevalence of 13.3%. It is the third most common disabling psychiatric disorder, after major depression (17.1%) and alcohol dependence (14.1%), and is the single most common disabling anxiety disorder in the United States. Persons with social anxiety disorder dread scrutiny and embarrassment in social and performance situations. Symptoms are often so severe that they either avoid interpersonal interactions or endure them with dread. This leads to academic underachievement, poor performance at work, and isolated, lonely living. Social anxiety disorder is a persistent, lifelong condition with an insidious onset in childhood or adolescence. The development of social anxiety disorder in a child or teenager is a harbinger of a lifetime of suffering and comorbidity. Most persons with social anxiety disorder later develop major depression, and many will abuse or become dependent on alcohol. The combination of social anxiety disorder and depression is particularly deadly and is associated with a 6-fold greater risk of suicide attempts.2 Dysfunction and missed opportunities are hallmark sequelae of social anxiety disorder. Compared with control subjects, individuals with social anxiety disorder are 8.4% less likely to graduate from college, 14.5% less likely to secure a professional, technical, or managerial job, and will earn wages that are 14% lower.3 The good news is that social anxiety disorder is treatable. Monoamine oxidase inhibitors are effective,4 but concerns about adverse effects limit their use. It was not until late in the past decade that the SSRIs were shown to be a safe and effective treatment.5 The need for early recognition and intervention is clear and compelling. Yet, why is this condition so overlooked and undertreated? There are numerous barriers to care. Social anxiety disorder, by definition, makes patients hesitant to seek treatment for this disability. Many have had symptoms for decades and believe that this is the way life is supposed to be. Physicians and other health care professionals do not actively look for social anxiety disorder and often do not take it seriously. Following the Food and Drug Administration's approval of the use of paroxetine for the treatment of social anxiety disorder, the pharmaceutical industry went to great lengths to educate the mental health community, primary care providers, and the public about this disorder. For this, they are to be applauded, not condemned. Medical luddites, in failing to embrace scientific advances, and even obstructing them, only perpetuate human suffering and contribute to scientific malfeasance. We should economically reward any successful effort to relieve human suffering, not disparage it. It will encourage others to invest more in finding effective treatments for medical illnesses. This is a more successful and a more compassionate strategy.