Clouded Aspirations: The Cost of Anxiety
Part 2 of my daughter's story
During her first year at college, my daughter struggled making friendships in her freshman dorm, she hated her first roommate and had conflicts with the resident advisor. That year, she played lots of beer pong and joined a sorority. She also saw a psychologist at the campus health center weekly for her generalized anxiety disorder.
She called me frequently about her failed friendships and ongoing clashes with other students. She always asked for more money. Our phone conversations were quarrelsome, as she related to me the same sorts of traumatic issues repeatedly. She seemed unable to focus on why she was having such difficult interpersonal situations, and I never felt able to help her. Nothing I said seemed reassuring. Only spending money on new clothes made her happy. Despite those clashes, she received decent grades in her first two years in college. She moved into the sorority house and seemed to enjoy living alone in a solo dorm room.
I believe that her marijuana use increased during her junior year of college when she shared an apartment with a girl who used weed daily, but I was unaware that she was “self-medicating” for anxiety. I was also unaware that her anxiety disorder had worsened. She was majoring in psychology and still getting good grades, however. During the summer between junior and senior years, she returned home to attend a child-development center internship. She attended that internship sporadically, missed several appointments and teaching sessions, and often smelled of marijuana. Some days she slept in for hours and berated me for trying to get her up and out of the house. Of course, the faculty member refused to give her any credit for that internship.
Her senior year in college was a disaster. She told us that she was depressed, and despite antianxiety medication, she still felt very anxious. Her grades plunged. After the first semester of her senior year the college asked her not to return - they sent a letter indicating that her professors had no confidence in her ability to complete her course work. She had essentially failed her first semester. One assistant dean, who believed that she could do the work, helped her write a letter outlining how she was planning to redeem herself. It was a very detailed letter, full of promises and good intentions, so much so that the college took her back. Nevertheless, she failed all her classes again.
Looking back and writing this, it seems impossible that we did not recognize her excessive marijuana use along with her behavioral instability. It was not until I visited her in a new apartment, living with that same pot-smoking roommate, that I finally figured out that she was using marijuana several times each day. Her psychologist and I convinced her to enroll in an outpatient rehabilitation program in Salem, and she completed the required eight-week program. She began smoking weed again almost immediately afterwards. We allowed her to live in Salem another year to try to obtain some community college credits. She wanted to prove to her college that she could finish her degree. These efforts failed, and we finally forced her to return home to Austin.
She lived at home with us for two years, which was a nightmare. She bounced from job to job, seldom maintaining employment for more than several months at a time. Her mood swings, impulsive behavior, emotional, angry outbursts, self-harm, and unstable relationships were immensely difficult to tolerate. Once I considered putting her out on the street. Her college failure caused her feelings of extremely low self-worth, and several times she voiced suicidal ideations. We finally insisted that she move into an apartment (and paid her rent), and we also pressed her into another outpatient rehab program. This one also failed to stick.
Our daughter was ultimately diagnosed with Borderline Personality Disorder (BPD). She improved greatly on a higher dose of a mood stabilizing drug. In addition, completing a course in Dialectical Behavioral Therapy (DBT) helped her immensely. She continued to see her original psychiatrist for medication management and psychotherapy (CBT - see below). During this period, different antianxiety medications seemed to help, and she felt depressed less often.
Our daughter had additional conditions that exacerbated her instability (these are called co-morbidities). These were ADHD (diagnosed in childhood), a generalized anxiety disorder, depression, and substance use disorder.
Why tell this personal story
My daughter and I discussed relating her story here. My goal was to alert other parents to the possibility of anxiety and depression, as well as BPD, as a distinctly different entity from ordinary rebellious and impulsive teenage behavior.
Admirably, my daughter’s goal was to reduce the stigma of mental illness. She felt strongly that talking and writing openly about mental health reduces shame and normalizes these conditions among teenagers and young adults. Those are our intentions in recounting this experience.
A recent national survey
You may be aware that anxiety disorders and depression are increasing among teenagers and young adults today. A recent Harvard report, On Edge: Understanding and Preventing Young Adults’ Mental Health Challenges, is based on a nationally representative survey of 396 young adults (ages 18–25), 709 teens (ages 14-17), and parents conducted in December 2022. That survey found that thirty-six percent (36%) of young adults reported anxiety compared to 18% of teens. Twenty-nine percent (29%) of young adults reported depression compared to 15% of teens.
Mental health conditions in adolescents and young adults
The most common mental illnesses in adolescents are anxiety, mood, attention, and behavior disorders. Fully one-half (50%) of all lifelong mental illness begins by age 14, and 75% begin by age 24. Moreover, suicide is currently the 2nd leading cause of death among people aged 10-14 years.
The National Alliance on Mental Health (NAMI) reports that one in six youth aged 9–17 years currently has a diagnosable mental health disorder that causes some degree of impairment. Sadly, ten percent of young people have a disorder that causes significant impairment.
Causes for anxiety and depression in teens and young adults
When Harvard researchers questioned them about the things that negatively influenced their mental health, teens and young adults described these stressors:
a lack of “meaning or purpose” in their lives (58%)
“not knowing what to do with my life” (50%)
financial worries (56%)
achievement pressures (51%)
a general sense “that things are falling apart” (45%)
lack of meaningful relationships (44%)
a sense of not mattering to others (44%)
loneliness (34%)
gun violence in schools (42%)
climate change (34%)
political leaders are incompetent or corrupt (30%).
A typical response was, “I just wish I was able to calm down literally ever. I always feel on edge, everything scares me…If I could just find some way to calm down a little it would work miracles.”
Parents are often unaware that their teen or young adult might be developing a mental health condition. It helps to know what to look for.
Signs that may indicate mental illness in teens and young adults:
Sudden trouble in school,
intense mood swings,
lack of concentration,
absence of motivation,
isolating from friends and family,
poor hygiene,
irregular sleep schedule,
struggling to sleep,
no desire to eat,
changes in eating habits,
self-loathing,
excessive worrying,
low energy,
excessive anger or violence,
easily irritated,
defiance of authority,
unexplained physical injuries,
suicidal thoughts,
substance abuse.
Anxiety disorders in teens and young adults.
Anxiety disorders are the most common mental health issues in adolescents and young adults, with rates steadily rising over the past decade. The types of anxiety include Generalized Anxiety Disorder (GAD), Social Anxiety Disorder (SAD), Panic Disorder, Specific Phobias, and Separation Anxiety (more common in younger teens).
In youth with ADHD, anxiety disorders are among the most common co-morbidities. Recent AAP data from 2024 indicates that approximately 22% of pediatric ADHD patients also have an anxiety disorder. Co-morbid anxiety can exacerbate ADHD symptoms, leading to increased inattention, emotional dysregulation, and functional impairment. Anxiety can also mask ADHD symptoms, complicating diagnosis and potentially delaying appropriate treatment.
Over 30% of adolescents in high-income countries report significant anxiety symptoms. Most anxiety disorders begin before age 21, often by age 11–14. Untreated anxiety can lead to depression, substance use, and school/work impairment in early adulthood. Substance use often begins as a way to “self-medicate.” Anxiety disorders occur more often among females and gender-diverse youth. When LGBTQ+ teens develop anxiety, it is often linked to discrimination, family rejection, and bullying.
The relationship between anxiety and depression in teens and young adults.
Up to 60–70% of teens with depression also have an anxiety disorder, and vice versa. This co-occurrence often begins in early adolescence and is associated with more severe symptoms, longer duration of illness, greater functional impairment, and higher risk of suicide.
Anxiety often precedes depression. Children and early teens may start with GAD or social anxiety. Chronic anxiety can lead to hopelessness, withdrawal, and low self-worth - hallmarks of depression. My daughter’s story of ADHD and GAD leading to depression suggests this typical course. This trajectory is especially common in girls, LGBTQ+ youth, and youth exposed to trauma or chronic stress. Interestingly, there are shared biological mechanisms to explain anxiety and depression, such as dysregulation in the amygdala and serotonin pathways.
Treatment modalities available for teens and young adults:
Cognitive Behavioral Therapy (CBT) is first line therapy for both anxiety and depression. CBT is evidence-based and widely used as a structured, time-limited psychotherapy that helps individuals identify and change negative thought patterns (cognitions) and unhelpful behaviors that contribute to emotional distress.
It’s based on the principle that our thoughts, feelings, and behaviors are interconnected, and that changing one can influence the other. Teens learn how anxiety or depression work in their body - why they feel the way they do. CBT helps to normalize symptoms and reduce shame or stigma. They learn to identify automatic negative thoughts ("I'm a failure," "No one likes me") and to challenge and replace them with more realistic, balanced thoughts.
Most importantly, CBT provides training in coping skills, like problem-solving, relaxation techniques, and emotion regulation. CBT works well for teens because it is very structured and goal-oriented, which appeals to youth who want tools and practical strategies.
CBT can be provided in different formats, such as individual or group therapy, or family-involved CBT (for younger teens), and more recently in digital or online CBT platforms (apps, virtual therapy). CBT can be as effective as medication for many teens with mild to moderate symptoms, and even more effective when combined with medications for severe cases, like my daughter’s.
Medications, like the SSRIs - fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro) - are often used when symptoms are moderate to severe. Treating both anxiety and depression together and as early as possible is crucial. When left untreated, their interaction increases the likelihood of progressing into a chronic mental health disorder.
Best outcomes often result from combining both SSRIs + CBT
Just as in my daughter’s case, when severe or treatment-resistant anxiety and depression occur, combined therapy works best. The benefits of combination therapy are faster symptom reduction than either treatment alone. CBT addresses root cognitive/behavioral patterns, while SSRIs reduce biological intensity of symptoms, making therapy more effective. CBT reduces relapse risk over time.
Please see this downloadable pdf chart (above) comparing CBT to SSRIs for anxiety and depression in teens and young adults.
References
1. American Academy of Child and Adolescent Psychiatry (AACAP) Clinical Practice Guideline for Children and Adolescents with Anxiety Disorders. (2020) Journal of the American Academy of Child & Adolescent Psychiatry, 59(10), 1107–1124
This guideline emphasizes that both CBT and SSRIs are safe and effective short-term treatments for anxiety in children and adolescents. It highlights the importance of considering the individual needs of the patient.
2. American Psychological Association (APA) Depression Treatment Guideline across Three Age Cohorts (2024) American Psychologist, 74(8), 875–899.
The APA recommends CBT as a first-line treatment for depression in adolescents, with SSRIs considered when psychotherapy alone is insufficient. The guideline underscores the importance of monitoring and individualizing treatment.
3. American Family Physician (AAFP) Review (2020) The Lancet Psychiatry, 7(7), 581–601.
This review discusses evidence-based treatments for adolescent depression, noting that CBT and SSRIs are both effective. It also addresses considerations for initiating SSRIs in this population.
4. Meta-Analysis on Combining SSRIs and CBT (2021)
Combining selective serotonin reuptake inhibitors and cognitive behavioral therapy for youth with depression and anxiety: A meta-analysis. Journal of Affective Disorders, 287, 123–134.
This study found that combining SSRIs with CBT leads to superior outcomes in youth with depression and anxiety compared to either treatment alone.