Towards a framework for increasing help-seeking for social anxiety disorder

Social anxiety disorder (SAnD) is a condition in which the individual experiences persistent, excessive fear in social and performance situations, leading to their avoidance, or intense distress and impaired role functioning, including social, educational and occupational, and routine functioning (American Psychiatric Association, 2000). Estimates of the prevalence of social phobia vary markedly (Fehm et al., 2005; Furmark, 2002; Somers et al., 2006). However, the condition is clearly common in many western countries, with nationally representative samples yielding Diagnostic and Statistical Manual of Mental Disorders (DSM) lifetime and 12-month prevalences of 8.7% (McEvoy et al., 2011) and 4.7%, respectively, in Australia (Slade et al., 2009), 7.8% and 4.8% in The Netherlands (Bijl et al., 1998) and 12.1% (Kessler et al., 2005a) and 6.8% (Kessler et al., 2005b) in the USA. SAnD is one of the most prevalent of the anxiety disorders (Bijl et al., 1998; Kessler et al., 2005b; McEvoy et al., 2011).
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\nSAnD typically emerges in childhood or adolescence with a reported median age of onset of 13 years in Australia (McEvoy et al., 2011) and 16 years in the USA (Magee et al., 1996). The condition involves a chronic course with a mean duration of at least 20 years (Canadian Psychiatric Association, 2006) and a high rate of comorbidity with other mental disorders (Furmark, 2002). It is more prevalent in women than men (Furmark, 2002; McEvoy et al., 2011; Somers et al., 2006). SAnD exerts a profound, negative impact on quality of life, is a significant risk factor for the development of major depressive disorder, and is associated with substance misuse (Stein and Stein, 2008) and increased levels of suicidality, even in the absence of comorbid depression (Fehm et al., 2005). SAnD is also associated with significant societal costs; for example, one study reported that 22% of SAnD participants were on disability or welfare benefits compared to 10% of controls (Furmark, 2002). At an individual level, the severity of disability associated with pure SAnD is as high as that associated with pure depression (Fehm et al., 2005). For example, the work loss index for SAnD adjusted for comorbidity is the same as for affective disorder and exceeds that for significant physical illness such as diabetes and heart disease (Alonso et al., 2004). Sub-threshold social anxiety is also associated with substantial disability, leading some researchers to propose the use of a dimensional rather than a categorical approach to the assessment of the condition (Filho et al., 2010).
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\nDespite the distressing nature of SAnD, the availability of effective psychopharmacological and psychological treatments for the condition, and its unremitting nature if left untreated, only a minority of individuals with SAnD seek professional treatment (Grant et al., 2005; Magee et al., 1996; Ormel et al., 2008; Schneier et al., 1992). Across the nine high-income countries sampled in the World Mental Health Survey, only 20.8% of individuals with SAnD reported seeking professional help (Ormel et al., 2008). Moreover, it has been reported that only 7% of people with SAnD receive ‘notionally effective treatment’ (Andrews et al., 2004). It has been calculated that with 70% and 100% coverage using optimal current treatments for SAnD, this currently very low level of disability prevention could be increased to 34% and 49%, respectively (Andrews et al., 2004). Thus, there is a clear need to promote help-seeking and access to evidence-based treatments among individuals with SAnD. However, to date, SAnD has been relegated to the role of Cinderella compared to depressive disorders, with public awareness campaigns focused almost exclusively on promoting help-seeking for depression.

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