Antidepressant medication: is it a viable and valuable adjunct to cognitive-behavioral therapy for school refusal?

Cognitive-behavioral therapy (CBT) is an evidence-based treatment for school refusal. However, some youth do not respond to CBT. The serious risks associated with school nonattendance call for novel approaches to help those who do not respond to CBT. Because school refusal is commonly associated with anxiety disorders, and the combination of CBT and antidepressant medication enhances outcomes in the treatment of anxiety disorders, combined treatment may be effective for school refusal. This narrative review evaluates the current evidence base for adding antidepressant treatment to CBT for school refusal. Six randomized controlled trials (RCTs), two open trials, six case studies/series, and one observational study were identified and reviewed. There is support for combined CBT and imipramine, but this medication is not typically used due to the risk of concerning side effects. Two recent RCTs failed to provide evidence for the superiority of combined CBT and fluoxetine. Further research in this area is required because the extant studies have a number of methodological limitations. Recommendations are provided for clinicians who consider prescribing antidepressant medication or referring for adjunctive antidepressant treatment for school refusal.