2 Research recommendations

The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future.

2.1 Adults' uptake of and engagement with interventions for social anxiety disorder

What methods are effective in improving uptake of and engagement with interventions for adults with social anxiety disorder?

Why this is important

Effective interventions exist for social anxiety disorder but access to and uptake of services is limited and over 50% of people with social anxiety disorder never receive treatment; of those who do receive treatment many wait 10 years or more for it.

This question should be addressed by a programme of work that tests a number of strategies to improve uptake and engagement, including:

  • Development and evaluation of improved pathways into care, in collaboration with low users of services, through a series of cohort studies with the outcomes including increased uptake of and retention in services.

  • Adapting the delivery of existing interventions for social anxiety disorder in collaboration with service users. Adaptations could include changes to the settings for, methods of delivery of, or staff delivering the interventions. These interventions should be tested in a randomised controlled trial (RCT) design that reports short- and medium-term outcomes (including cost effectiveness) of at least 18 months' duration.

2.2 Specific versus generic CBT for children and young people with social anxiety disorder

What is the clinical and cost effectiveness of specific CBT for children and young people with social anxiety disorder compared with generic anxiety-focused CBT?

Why this is important

Children and young people with social anxiety disorder have commonly been treated with psychological interventions that cover a broad range of anxiety disorders, rather than interventions specifically focused on social anxiety disorder. This approach may be considered to be easier and cheaper to deliver, but emerging evidence suggests that children and young people with social anxiety disorder may do less well with these generic treatments than those with other anxiety disorders. There have, however, been no direct comparisons of treatment outcomes using generic compared with social anxiety-specific treatment programmes.

This question should be answered using an RCT design, reporting short- and medium-term outcomes (including cost-effectiveness) with a follow-up of at least 12 months. The outcomes should be assessed by structured clinical interviews, parent- and self-reports using validated questionnaires and objective measures of behaviour. The study needs to be large enough to determine the presence of clinically important effects, and mediators and moderators (in particular the child or young person's age) should be investigated.

2.3 The role of parents in the treatment of children and young people with social anxiety disorder

What is the best way of involving parents in the treatment of children and young people (at different stages of development) with social anxiety disorder?

Why this is important

There is very little evidence to guide the treatment of social anxiety disorder in children aged under 7 years. It is likely that treatment will be most effectively delivered either wholly or partly by parents. Parenting interventions have been effective in treating other psychological difficulties in this age group, and this guideline found emerging evidence that these approaches might be useful for the treatment of young socially anxious children.

Furthermore, when considering all age groups, parental mental health difficulties and parenting practices have been linked with the development and maintenance of social anxiety disorder in children and young people. This suggests that interventions targeting these parental factors may improve treatment outcomes. However, interventions for children and young people with social anxiety disorder have varied widely in the extent and manner in which parents are involved in treatment and the benefit of including parents in interventions has not been established.

This question should be addressed in 2 stages.

  • Parent-focused interventions should be developed based on a systematic review of the literature and in collaboration with service users.

  • The clinical and cost effectiveness of these interventions at different stages of development should be tested using an RCT design with standard care (for example, group CBT) as the comparison. It should report short- and medium-term outcomes (including cost effectiveness) with a follow-up of at least 12 months. The outcomes should be assessed by structured clinical interviews, parent- and self-reports using validated questionnaires and objective measures of behaviour. The study needs to be large enough to determine the presence of clinically important effects, and mediators and moderators (in particular the child or young person's age) should be investigated.

2.4 Individual versus group CBT for children and young people with social anxiety disorder

What is the clinical and cost effectiveness of individual and group CBT for children and young people with social anxiety disorder?

Why this is important

The majority of systematic evaluations of interventions for social anxiety disorder in children and young people have taken a group approach. Studies with adult populations, however, indicate that individually-delivered treatments are associated with better treatment outcomes and are more cost effective.

This question should be addressed using an RCT design comparing the clinical and cost effectiveness of individual and group-based treatments for children and young people with social anxiety disorder. It should report short- and medium-term outcomes (including cost effectiveness) with a follow-up of at least 12 months. The outcomes should be assessed by structured clinical interviews, parent- and self-reports using validated questionnaires and objective measures of behaviour. The study needs to be large enough to determine the presence of clinically important effects, and mediators and moderators (in particular the child or young person's age and familial and social context) should be investigated.

2.5 Combined interventions for adults with social anxiety disorder

What is the clinical and cost effectiveness of combined psychological and pharmacological interventions compared with either intervention alone in the treatment of adults with social anxiety disorder?

Why this is important

There is evidence for the effectiveness of both CBT and medication, in particular SSRIs, in the treatment of social anxiety disorder. However, little is known about the effects of combined pharmacological and psychological interventions despite their widespread use. Understanding the costs and benefits of combined treatment could lead to more effective and targeted combinations if they prove to be more effective than single treatments. The study will also provide important information on the long-term benefits of medication.

This question should be addressed in a large-scale 3-arm RCT comparing the clinical and cost effectiveness of combined individual CBT and SSRI treatment with individual CBT or an SSRI alone. Trial participants receiving medication should be offered it for 1 year. The study should report short- and medium-term outcomes (including cost effectiveness) with a follow-up of at least 24 months. The primary outcome should be recovery, with important secondary outcomes being retention in treatment, experience and side effects of medication, and social and personal functioning. The study needs to be large enough to determine the presence of clinically important effects, and mediators and moderators should be investigated.

  • National Institute for Health and Care Excellence (NICE)