A drawing of anxiety by a 12 year old girl, from Huffington Post
In this real-world study, it barely mattered whether treatment started with therapy or medication
STUDY: Peterson BS et al, Am J Psychiatry 2026
STUDY TYPE: Randomized clinical trial (pragmatic sequential multiple assignment randomized trial, single-blind)
FUNDING: Patient-Centered Outcomes Research Institute
Background
Both CBT and SSRIs help pediatric anxiety in short trials, but which should we start with? This trial tested that in a diverse, community-based sample.
The Study
- 316 youths, ages 8 to 17, with anxiety disorders, recruited from primary care and community mental health clinics; 64% Hispanic or Latino, 56% on Medicaid, high comorbidity (67% depression, 46% ADHD).
- Randomized to 12 weeks of fluoxetine or weekly CBT.
- Nonremitters at week 12 were randomized again to optimize that treatment, or optimize it while adding the other one, for 12 more weeks.
- Primary outcome: change in youth-reported anxiety (SCARED) at week 24.
Results
Starting with CBT or fluoxetine gave about the same result by week 24, though fluoxetine worked faster early on. Adding the untried treatment for nonremitters did not work better than simply optimizing what they were already on.
Overall, anxiety fell by about 30% in both groups. Remission was rare: 4 of 316 youths by week 12, and 14 more by week 24.
Side Effects
Appetite loss (44% on fluoxetine versus 32% on CBT). No suicidality related to treatment.
Limitations
No placebo or waitlist comparator. Outcomes relied on self-report, not blinded clinician ratings. The trial ran during the pandemic, with most sessions by telehealth.
Youths who added fluoxetine after starting CBT had only 12 weeks to titrate the dose versus 24 for those on medication throughout, which may have understated that sequence’s benefit.
Practice Implications
- Unfortunately, full remission by six months is rare even with this rigorous protocol.
- Either fluoxetine or CBT is a reasonable starting point based on access, cost, and family preference.
- If a child hasn’t responded by week 12, optimizing what you’re already using works as well as adding the other modality.
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
