Augmenting Cognitive Behavior Therapy for School Refusal with Fluoxetine: A Randomized Controlled Trial


This study investigates whether the augmentation of cognitive behavior therapy (CBT) with fluoxetine improves outcomes in anxious school refusing adolescents (11–16.5 years). Sixty-two participants were randomly allocated to CBT alone, CBT + fluoxetine or CBT + placebo. All treatments were well tolerated; with one suicide-attempt in the CBT + placebo group. All groups improved significantly on primary (school attendance) and secondary outcome measures (anxiety, depression, self-efficacy and clinician-rated global functioning); with gains largely maintained at 6-months and 1-year. Few participants were anxiety disorder free after acute treatment. During the follow-up period anxiety and depressive disorders continued to decline whilst school attendance remained stable, at around 54 %. The only significant between-group difference was greater adolescent-reported treatment satisfaction in the CBT + fluoxetine group than the CBT alone group. These results indicate the chronicity of school refusal, and the need for future research into how to best improve school attendance rates.

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The authors acknowledge the National Health and Medical Research Council (545968), beyondblue The National Depression Initiative and Financial Markets Foundation for Children. The authors thank A/Prof Neville King (retired) who made a substantial contribution to establishment of this study, the team of clinicians, Slade Pharmacy for preparation of the fluoxetine and placebo and all the participating adolescents and their families.

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Corresponding author

Correspondence to Glenn A. Melvin.

Additional information

This trial is registered with the Australian New Zealand Clinical Trials Registry (; Trial Number: ACTRN12606000103561; Trial Name: Treatment of School Refusal).

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Melvin, G.A., Dudley, A.L., Gordon, M.S. et al. Augmenting Cognitive Behavior Therapy for School Refusal with Fluoxetine: A Randomized Controlled Trial. Child Psychiatry Hum Dev 48, 485–497 (2017).

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  • School refusal
  • Anxiety disorders
  • Cognitive behavior therapy
  • Fluoxetine