Nonsocial Comorbid Anxiety Reduces Efficacy of Cognitive Therapy

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mental health professional
Cognitive therapy outcomes in individuals with major depressive disorder plus social, other, or no comorbid anxiety was compared.

Patients receiving cognitive therapy for major depressive disorder experienced poorer outcomes related to depression and anxiety if they described having nonsocial comorbid anxiety disorders. Patients with comorbid social anxiety found cognitive therapy effective but with heightened social avoidance, according to a study published in the Journal of Affective Disorders.

The investigators of this double-blind study sought to compare cognitive therapy outcomes among adults with major depressive disorder who had comorbid social anxiety disorder, other (nonsocial) comorbid anxiety disorders, or no anxiety disorders. Findings were used to differentiate social anxiety from other anxiety disorders in predicting the efficacy of cognitive therapy.

The study included 523 outpatients who met criteria for recurrent major depressive disorder, including 87 participants who also had social anxiety disorder and 110 with other comorbid anxiety disorders. Participants received acute-phase cognitive therapy for 12 weeks. Following the acute-phase protocol, high-risk responders (n=241) were randomly assigned to receive 8 months of continuation-phase cognitive therapy (n=86), fluoxetine medication (n=86), or placebo pills (n=69). Low-risk responders (n=49) were assessed for 32 months without receiving additional treatment. Following the continuation phase, patients entered a 24-month follow-up period in which depressive symptoms, anxiety, and social avoidance measures were evaluated every 4 months.

Overall, participants who had a type of anxiety disorder vs participants with no anxiety disorder reported more depressive symptoms, anxiety, and social avoidance throughout the acute phase of cognitive therapy. Among patients with anxiety, results varied with the type of disorder. Those with social anxiety disorder showed greater social avoidance but no significant increase in depression or anxiety, whereas patients with nonsocial anxiety disorders showed a significant increase in depression and anxiety, but not social avoidance.

The investigators further tested the ability of pre-acute-phase anxiety disorders to predict outcomes from cognitive therapy. Anxiety disorders that were nonsocial predicted an increase in depression- and anxiety-related symptoms during and after acute-phase cognitive therapy. Social anxiety disorders predicted an improvement in anxiety and depressive symptoms but elevated social avoidance during and after receiving therapy.

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Limitations of the study included a brief anxiety symptom measure, which was assessed only before acute-phase treatment and not again after cognitive therapy response. The sample population did not allow for finer differentiation between different types of anxiety disorders and generalizability to other patient populations or interventions is unknown.

Patients with nonsocial comorbid anxiety disorders showed reduced efficacy of acute-phase cognitive therapy for major depressive disorder with poorer outcomes relative to patients with social anxiety or no anxiety disorders. Presence of comorbid social anxiety disorders predicted improved outcomes during acute-phase cognitive therapy, but these patients may require additional treatment for social avoidance.

This study was sponsored by the National Institute of Mental Health. See source article for a full list of authors’ disclosures.


Vittengl JR, Clark LA, Smits JAJ, Thase ME, Jarrett RB. Do comorbid social and other anxiety disorders predict outcomes during and after cognitive therapy for depression?  J Affect Disord. 2018; 242: 150–158.