Teen Angst, Adolescent Anguish: Could It Be Mental Illness?

Across the country, bus drivers are dropping off buses full of adolescents at school, saying, “Have a great day, and remember these are the best years of your life!” Among the approximately 72 students on a school bus, there are statistically 10 to 15 who would probably disagree.^1,2

In 2019, the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children’s Hospital Association collectively declared child and adolescent mental health a national emergency.³ Across the US, more than 5.3 million adolescents have been diagnosed with mental or behavioral health conditions, and approximately 20% have undiagnosed mental health disorders.¹ Many adults think back to their middle and high school years and can empathize.

Among adolescent females, anxiety is more common than in males (20.1% vs 12.3%). Females are also more likely to experience depression (10.9% vs 6% in males).¹ Adolescents who report adverse childhood experiences, come from lower socioeconomic status homes, or identify with minority groups are at greatest risk.^4-6 The third most common mental illness in this population is behavior or conduct disorder, with males more likely to be diagnosed than females (8.2% vs 4.3%).¹ Youths who have mental health problems are often unengaged in school, may be troubled or troublesome students, are frequently absent from school, or may deal with bullying. These youths experience isolation because they have trouble making or keeping friends.¹

Collaboration Is Crucial

Many adolescents are diagnosed in primary care settings, so primary care providers must have evidence-based screening and treatment approaches that ask important questions and include feedback from caregivers.^7,8 Like adults, youths with mental health disorders need 2 types of treatment: Behavioral health providers use behavioral or cognitive programs to help patients develop coping skills and reduce symptoms, whereas medical providers are the team’s prescribers.^7,8

Steps in Treatment

Once youth are diagnosed, providers need to work with them and their caregivers to determine an acceptable path back to good mental health. In youths whose symptoms are less severe, the health care provider, child, and child’s family may choose watchful waiting, self-care, brief interventions, or therapy crafted for the individual.^9-11 In adolescents whose symptoms need immediate intervention, psychotherapy, psychosocial support, and sometimes inpatient admission provide the underpinning for pharmacotherapy to work.^9-11 Ample evidence indicates that combining medication with counseling and psychotherapy is more effective than any single approach.¹² In patients who have conduct disorder, most experts recommend management training for caregivers that helps them use positive reinforcement and increase parental warmth, patience, and understanding.¹³

Selection of the appropriate pharmacotherapy must consider the patient’s preferences and symptom constellation. Not all mental health medications haven been approved for this age group, and prescribers may need to rely on recommendations from professional organizations, recent research, or their experience. The Table^12-15 provides guidance about medications that have evidence supporting their use.

Counseling in the Pharmacy

Since the FDA applied a boxed warning to antidepressants concerning suicidality, many people are hesitant to have children and adolescents take these medications. Pharmacists need to stress that youths are at far higher risk of suicidal behaviors when they are depressed than when they are taking antidepressants. Careful monitoring of their behavior and good interdisciplinary support ensure the best outcomes.¹⁴ Pharmacists need to monitor young patients closely for adverse effects and adherence, remembering that many adolescents can be oppositional or think they do not need the medication. Using the lowest effective dose for the shortest period of time is an excellent approach. It is also notable that many states allow youths to seek mental health care without parental permission.¹⁶

Conclusion

Mental health disorders among children and adolescents continue to be more prevalent than ever, and early intervention is critical. Using a combination of cognitive behavioral therapy and medication can help youths believe that their middle and high school years really are some of the best years of their life.

REFERENCES

1. Sappenfield O, Alberto C, Minnaert J, Donney J, Lebrun-Harris L, Ghandour R. National Survey of Children’s Health Data Briefs [Internet]. Health Resources and Services Administration; 2018. Accessed August 13, 2025. https://www.ncbi.nlm.nih.gov/books/NBK608531/

2. Mental health of adolescents. World Health Organization. October 10, 2024. Accessed August 13, 2025. https://www.who.int/news-room/fact-sheets/detail/adolescent-mental-health

3. AAP-AACAP-CHA declaration of a national emergency in child and adolescent mental health. American Academy of Pediatrics. Updated October 19, 2021. Accessed August 13, 2025. https://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/?srsltid=AfmBOoqxE8VH-tv_rnVXJaszpdqXWanX2j5fLYQ6m3MZDi1DlUZpVFvH

4. Johnson KF, Cheng S, Brookover DL, Zyromski B. Adverse childhood experiences as context for youth assessment and diagnosis. J Counsel Dev. 2023;101(2):236-247. doi:10.1002/jcad.12460

5. Valle-Palomino N, Talledo-Sebedón DL, Fernández-Mantilla MM, et al. Symptom scale for anxiety and depression disorders (ESTAD): psychometric properties and sociodemographic profile in Peruvian university students. BMC Psychol. 2024;12:765. doi:10.1186/s40359-024-02272-w

6. Reiss F, Meyrose AK, Otto C, Lampert T, Klasen F, Ravens-Sieberer U. Socioeconomic status, stressful life situations and mental health problems in children and adolescents: results of the German BELLA cohort-study. PLoS One. 2019;14(3):e0213700. doi:10.1371/journal.pone.0213700

7. Asarnow JR, Rozenman M, Wiblin J, Zeltzer L. Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: a meta-analysis. JAMA Pediatr. 2015;169(10):929-937. doi:10.1001/jamapediatrics.2015.1141

8. Arrojo MJ, Bromberg J, Walter HJ, Vernacchio L. Pediatric primary-care integrated behavioral health: a framework for reducing inequities in behavioral health care and outcomes for children. Pediatr Clin North Am. 2023;70(4):775-789. doi:10.1016/j.pcl.2023.04.004

9. Boyd L, Baker E, Reilly J. Impact of a progressive stepped care approach in an improving access to psychological therapies service: an observational study. PLoS One. 2019;14(4):e0214715. doi:10.1371/journal.pone.0214715

10. Bower P, Kontopantelis E, Sutton A, et al. Influence of initial severity of depression on effectiveness of low intensity interventions: meta-analysis of individual patient data. BMJ. 2013;346:f540. doi:10.1136/bmj.f540

11. Berger M, Fernando S, Churchill AM, et al. Scoping review of stepped care interventions for mental health and substance use service delivery to youth and young adults. Early Interv Psychiatry. 2022;16(4):327-341. doi:10.1111/eip.13180

12. Compton SN, Walkup JT, Albano AM, et al. Child/adolescent anxiety multimodal study (CAMS): rationale, design, and methods. Child Adolesc Psychiatry Ment Health. 2010;4:1. doi:10.1186/1753-2000-4-1

13. Garland AF, Hawley KM, Brookman-Frazee L, Hurlburt MS. Identifying common elements of evidence-based psychosocial treatments for children’s disruptive behavior problems. J Am Acad Child Adolesc Psychiatry. 2008;47(5):505-514. doi:10.1097/CHI.0b013e31816765c2

14. Friedman RA. Antidepressants’ black-box warning—10 years later. N Engl J Med. 2014;371(18):1666-1668. doi:10.1056/NEJMp1408480

15. Ortega I. Evidence for clinicians: a typical antipsychotics for disruptive behaviour disorders in children and youths. Paediatr Child Health. 2019;24(2):125-127. doi:10.1093/pch/pxy156

16. Privacy, please: health consent laws for minors in the information age. California Health Care Foundation. January 2013. Accessed August 13, 2025. https://www.chcf.org/wp-content/uploads/2017/12/PDF-PrivacyPleaseHealthConsentMinors.pdf