Imipramine plus cognitive-behavioral therapy in the treatment of school refusal

Objective: To investigate the efficacy of 8 weeks of imipramine versus plac ebo in combination with cognitive-behavioral therapy (CBT) for the treatmen t of school-refusing adolescents with comorbid anxiety and major depressive disorders. Method: This was a randomized. double-blind trial with 63 subje cts entering the study and 47 completing. Outcome measures were weekly scho ol attendance rates based on percentage of hours attended and anxiety and d epression rating scales. Results: Over the course of treatment, school atte ndance improved significantly for the imipramine group (z = 4.36, p < .001) but not for the placebo group (z = 1.26, not significant). School attendan ce of the imipramine group improved at a significantly faster rate than did that of the placebo group (z = 2.39, p = .017). Over the 8 weeks of treatm ent, there was a significant difference between groups on attendance after controlling for baseline attendance; mean attendance rate in the final week was 70.1% +/- 30.6% for the imipramine group and 27.6% +/- 36.1% for the p lacebo group (p < .001). Defining remission as 75% school attendance, 54.2% of the imipramine group met this criterion after treatment compared with o nly 16.7% from the placebo group (p = .007). Anxiety and depression rating scales decreased significantly across treatment for both groups, with depre ssion on the Children's Depression Rating Scale-Revised decreasing at a sig nificantly faster rate in the imipramine group compared with the placebo gr oup (z = 2.08, p = .037). Conclusions: Imipramine plus CBT is significantly more efficacious than placebo plus CBT in improving school attendance and decreasing symptoms of depression in school-refusing adolescents with comor bid anxiety and depression.