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

Social anxiety disorder (SAnD) is a con­ dition in which the individual experi­ ences 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). Esti­ mates of the prevalence of social pho­ bia vary markedly (Fehm et al., 2005; Furmark, 2002; Somers et al., 2006). However, the condition is clearly com­ mon in many western countries, with nationally representative samples yield­ ing Diagnostic and Statistical Manual of Mental Disorders (DSM) lifetime and 12­month 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 preva­ lent of the anxiety disorders (Bijl et al., 1998; Kessler et al., 2005b; McEvoy et al., 2011). SAnD typically emerges in child­ hood 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 disor­ ders (Furmark, 2002). It is more preva­ lent 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 develop­ ment of major depressive disorder, and is associated with substance mis­ use (Stein and Stein, 2008) and increased levels of suicidality, even in the absence of comorbid depression (Fehm et al., 2005). SAnD is also asso­ ciated with significant societal costs; for example, one study reported that 22% of SAnD participants were on dis­ ability 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 signifi­ cant physical illness such as diabetes and heart disease (Alonso et al., 2004). Sub­threshold 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 assess­ ment of the condition (Filho et al., 2010). Despite the distressing nature of SAnD, the availability of effective psy­ chopharmacological 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 high­income countries sampled in the World Mental Health Survey, only 20.8% of individuals with SAnD reported seek­ ing 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 cal­ culated that with 70% and 100% cov­ erage using optimal current treatments for SAnD, this currently very low level of disability prevention could be increased to 34% and 49%, respec­ tively (Andrews et al., 2004). Thus, there is a clear need to promote helpseeking and access to evidence-based treatments among individuals with SAnD. However, to date, SAnD has been rel­ egated to the role of Cinderella com­ pared to depressive disorders, with public awareness campaigns focused almost exclusively on promoting help­ seeking for depression.