Anxiety and Depression in Today’s Youth: A Current Look into Assessment and Treatment

Abstract

Following the COVID-19 pandemic, the American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association declared a national emergency in child and adolescent mental health. Rates of anxiety and depression in youth continue at unprecedented levels, contributing to rising numbers of suicide attempts and lowered school attendance. Though many medical providers are trained to assess and provide recommendations for anxiety and depression, many report feeling ill-equipped to address these concerns in a timely, feasible, and effective manner. We review the existing literature on screening for anxiety and depression in the medical setting and provide evidence-based tools for providers to support patients, with acknowledgments of special populations. Additionally, we review multi-disciplinary models of treatment, such as one used by the Depression and Anxiety in Youth (DAY) program at Children’s Mercy Kansas City.

Prevalence of Anxiety and Depression in Youth

The prevalence of youth with clinically-elevated depression and anxiety has been increasing. In 2015, worldwide estimates indicated 7% of youth had clinically elevated symptoms of anxiety and 7.5% reported elevated symptoms of depression.^1,2 In 2021, Racine and colleagues estimated a staggering 20.5% of youth experienced elevated symptoms of anxiety, and 25.2% of youth reported elevated symptoms of depression globally.² Meta-analyses demonstrate that depression is associated with numerous negative outcomes, including academic underachievement, unemployment, early parenthood, suicidal behavior, and substance use.³ Similarly, anxiety disorders in adolescence are predictive of future mental health symptoms, substance use, physical health problems, self-harm, employment difficulties, and negative financial outcomes.⁴ Depressive disorders are typically considered when youth experience suicidal ideation, with nearly 30% of youth with major depressive disorder having reported suicidal ideation within the past year and over 10% having reported a suicide attempt.¹ Surprising to some, 9% of adolescents with anxiety disorders have also contemplated suicide, while 6% have made suicide attempts.⁵

Youth with adverse childhood experiences,⁶ those with lower socioeconomic status (SES),^7,8 and youth who identify with minority groups report increased rates of depression, anxiety, and suicide. For example, 67% of youth who identify as lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual or aromantic, or with other sexual orientations and gender identities (LGBTQIA+) report symptoms of anxiety, 54% report symptoms of depression, and LGBTQIA+ youth are more likely to die by suicide than those who do not identify as LGBTQIA+.⁹ Further, although the proportion of Black and Hispanic youth who report clinically-elevated anxiety or depression symptoms is lower than that of White peers, rates of suicide have been steadily increasing for Black and Hispanic youth (ages 10–24) over time, with estimates indicating Black children (ages five to 12) are twice as likely to die by suicide as their White peers.^10–14 Additionally, Black, Indigenous, and people of color (BIPOC) youth are directly and indirectly, and negatively impacted by racism and intersectionality with other marginalized identities. For example, youth who identify as both Black and LGBTQIA+ are more at risk due to intersecting identities.^15,16

Barriers to Accessing Mental Health Treatment

Despite high rates of depression and anxiety, more than 50% of youth do not receive needed behavioral health treatment.^11,17 This disparity is even more pronounced for youth who identify with racial/ethnic minority groups, those with low SES,^11,18 or those who identify as LGBTQIA+.¹⁹ Hoffmann and colleagues’ (2022) review demonstrates that Black and Hispanic youth are less likely to be seen by a behavioral health provider than other racial/ethnic groups, have fewer visits, and are less likely to receive evidence-based behavioral health treatments or psychotropic medications.¹¹ The literature indicates that many complex systemic factors prevent youth from accessing needed behavioral health services.²⁰

Behavioral Health Care in Medical Settings

Barriers to accessing traditional behavioral health services contribute to approximately 16% of primary care visits addressing a mental health concern.²¹ To meet patients’ mental health needs, integrated behavioral health care (IBHC) models have been developed and implemented to improve the identification and treatment of behavioral health symptoms in medical settings.^22,23 IBHC models broadly integrate medical and behavioral health providers into collaborative teams to coordinate patient care and address behavioral health symptoms.²⁴ In this model, medical providers address anxiety and depression symptoms via medication, while behavioral health providers use behavioral or cognitive approaches to assist patients in reducing symptoms. Empirical findings support the effectiveness of IBHC models in treating adolescent anxiety and depression.²⁵ Essential to addressing youth behavioral health symptoms within medical settings are evidence-based screening and treatment practices.

Screening for Youth Anxiety and Depression in Medical Settings

The United States Preventive Services Task Force (USPSTF) recommends that health care providers screen youth ages eight to 18 years for anxiety and youth ages 12 to 18 years for major depressive disorder.²⁶ Screening for behavioral health symptoms in medical settings is positively associated with identifying symptoms, referring to services, and following up with medical providers.^27–29 Screening includes the administration of standardized questionnaires during routine or specialty care visits by medical or behavioral health providers. According to the USPSTF,²⁶ best practices for youth depression screening include caregivers completing the nine-item Patient Health Questionnaire (PHQ-9)³⁰ or youth completing the PHQ modified for adolescents (PHQ-A).³¹ These questionnaires include one item that assesses for suicidal ideation. However, one study found that depression screeners alone failed to detect one-third of youth at risk for suicide.³² Therefore, the AAP recommends providers complete a suicide screening measure, (e.g., The Ask Suicide-Screening Questions), in addition to depression screening. The USPSTF also recommends using standardized questionnaires, including the Screen for Child Anxiety-Related Disorders (SCARED), to assess symptoms of anxiety.³³ Another brief measure used to screen for symptoms of generalized anxiety disorder (GAD) is the GAD-7.³⁴ These questionnaires provide clinical cutoff scores that indicate the severity of youths’ symptoms, which can inform providers’ clinical decision-making. Most (92.1%) caregivers support routine mental health screening in primary care, preferring to review results with a professional. They also report feeling more comfortable completing caregiver-report questionnaires than having their child completing self-report measures.³⁵

Treatment of Anxiety and Depression in Medical Settings

Once a youth is screened for mental health symptoms, providers should be prepared to provide treatment recommendations based on the youth’s presenting concerns and screening results. Treatment for major depressive disorder and anxiety disorders may include pharmacotherapy, psychotherapy, collaborative care, psychosocial support interventions, and complementary and alternative medicine approaches.¹ To determine the best course of treatment, stepped-based care models, in addition to providers’ clinical judgment, should be used to determine which interventions are least resource-intensive and most beneficial for youth.³⁶ The literature commonly describes two-stepped care models. The progressive model indicates patients benefit when they receive brief behavioral health interventions regardless of symptom severity^37,38 Whereas the stratified model triages youth into the appropriate level of care based on their symptom severity and functional impairment.³⁶ Treatment recommendations within the stratified model can include watchful waiting, self-help, clinician-guided self-help, brief interventions, individualized therapies, and specialist and inpatient services.^{39 37,38}

Pharmacotherapy for Depressive Disorders in Youth

The Treatment for Adolescents with Depression Study (TADS), published in 2004, is an often-cited multicenter randomized controlled trial examining the effectiveness of fluoxetine and cognitive behavioral therapy (CBT) in treating depression in adolescents.⁴⁰ The study concluded that treatment with fluoxetine only, CBT only, as well as the combination of fluoxetine and CBT led to significant improvement in depression symptoms, but the combination treatment had the best response and resulted in better functioning and quality of life.

Selective serotonin reuptake inhibitors (SSRIs) are the mainstay of pharmacotherapy in the treatment of depression in youth. Within this class of medication, fluoxetine is approved by the US Food and Drug Administration (FDA) for use in the treatment of major depressive disorder in children eight years and older, while escitalopram is approved in adolescents 12 years and older.^41,42 Providers may prescribe other medications to address depression in children and adolescents, and off-label prescribing within this population is common and consistent with general practice. A notable exception to this is the SSRI medication paroxetine, which carries a higher risk of suicidal thinking and behavior in adolescents when compared to other medications in this class, and therefore is not a recommended treatment option for this population.⁴³

About 60% of children and adolescents will respond to initial treatment with SSRI medication. Of those who do not initially respond, another 55% will respond to another SSRI medication or a serotonin and norepinephrine reuptake inhibitor (SNRI) medication along with CBT.⁴⁴ Currently no definitive empirical guidelines exist regarding how to switch from one medication to another, but providers use two common approaches. The most conservative approach consists of tapering the initial medication until it is discontinued prior to starting the second medication. Of note, fluoxetine does not require tapering, considering its extended half-life and unlikelihood of withdrawal symptoms. The other approach to switching medications is to cross-taper, where one medication is tapered gradually while the second medication is started and optimized over weeks to months. This approach minimizes the risk of clinical decompensation and is less time-consuming. However, this approach also increases the potential interactions and associated side effect burden with two medications being taken at the same time.⁴⁵ Once a pharmacotherapeutic approach is determined to be successful through the resolution of depressive symptoms, youth and their caregivers may be interested in coming off their medication. The risk of symptom relapse may be elevated when treatment is discontinued and therefore it is recommended that youth remain on their medication for at least six to nine months once they have experienced a resolution of their depression. Based on the timeline and severity of depressive symptoms, the provider may choose to slowly lower the dose of the medication and monitor the patient’s mood closely over the following several months, or choose to discontinue the medication completely.⁴⁶

SSRI medications are generally well tolerated, though mild side effects are common and may include dry mouth, nausea, diarrhea, heartburn, headache, somnolence, insomnia, dizziness, change in appetite, weight loss or gain, fatigue, nervousness, tremors, bruxism, or diaphoresis. Serious side effects are rare but have been reported, including suicidal thinking and behaviors, behavioral activation, hypomania or mania, sexual dysfunction, seizures, abnormal bleeding, or serotonin syndrome. All medications that treat depression, including SSRIs, carry a black box warning for suicidal thoughts and behaviors in adolescents and young adults up to age 24. This warning was implemented in 2004 and unsurprisingly has led to alarm for many prescribers and patients. It is important to note that no suicide deaths were reported in the cases that were studied. Additionally, meta-analysis determined that suicidal thoughts and behaviors increased by 3% in adolescents and young adults on antidepressant medications, while they also increased by 2% in those on a placebo pill.^47,48 A troubling trend that has been observed since the FDA implemented its black-box warning on antidepressants is that the prescribing of these medications decreased, leaving many patients with depressive symptoms untreated. It is clear that untreated depression carries a much greater risk for suicidal behaviors than the risk associated with antidepressant medications. The morbidity and mortality risk of utilizing medication to treat depressive symptoms is further mitigated with close monitoring of treatment response and tolerability by a prescribing provider.⁴⁹

Pharmacotherapy for Anxiety Disorders in Youth

The Child/Adolescent Anxiety Multimodal Study (CAMS) published in 2010 was a large multicenter randomized controlled trial that showed that both CBT and sertraline treatment for anxiety in children and adolescents ages seven to 17 significantly reduced the severity of anxiety symptoms. However, similar to TADS, the combination of psychotherapy and pharmacotherapy proved to be the most beneficial.⁵⁰

Several disorders are classified under the Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition (DSM-5) anxiety umbrella. SSRI medications are considered safe and effective in the treatment of generalized anxiety disorder, social anxiety disorder, separation anxiety disorder, and panic disorder in children and adolescents. This class of medications would be considered the first-line pharmacologic option for youth with anxiety disorders, with escitalopram receiving FDA approval for the treatment of generalized anxiety disorder for children aged seven to 17 years. SNRI medications have also been shown to improve primary anxiety symptoms. Within this class, duloxetine also has FDA approval for the treatment of generalized anxiety disorder for children aged seven to 17 years. As with the treatment of depression, providers may prescribe other medications to address anxiety symptoms in children and adolescents, and off-label prescribing within this population is common and consistent with general practice.⁴²

SNRI medications tend to be well tolerated, like SSRIs, but as a class, they have an elevated risk for side effects when compared to SSRIs. Common side effects may include dry mouth, nausea, diarrhea, headache, tremor, insomnia, somnolence, appetite changes, weight gain or weight loss, and diaphoresis. Due to their impact on norepinephrine, SNRIs are also associated with risk for elevated blood pressure and heart rate. Similar to SSRIs, SNRIs carry a black box warning for suicidal thinking and behavior in adolescents and young adults. Venlafaxine has been linked to higher rates of discontinuation syndrome and elevated suicidal thinking and behavior in this population when compared to other SNRIs.⁵¹

Behavioral Treatments for Depression and Anxiety in Youth

CBT has consistently demonstrated positive effects in decreasing youth anxiety and depressive symptoms.^52,53 Indeed, a meta-analysis of 42 RCTs found that CBT proved to be a possibly efficacious treatment for childhood depression and a well-established treatment for adolescent depression.⁵⁴ For anxiety, individual CBT therapy and several other modalities, (e.g., exposure-based treatments), are well-established treatments for adolescents.⁵⁵ CBT interventions for youth are typically short-term and focus on teaching youth and their parents specific skills based on how youths’ cognitions, feelings, and behaviors influence each other.⁵⁶ CBT interventions have also been adapted to be delivered to groups, as abbreviated behavioral health interventions, via electronic resources, or as phone applications.⁵⁷ Acceptance and Commitment Therapy (ACT) and Interpersonal Psychotherapy for Adolescents (IPT-A) have been shown to have positive effects in treating anxiety and depression in youth.^58,59 In sum, medical providers should seek to refer youth to resources that reference these modalities.

Case Example: Depression and Anxiety in Youth Clinic

To demonstrate how these recommendations support youth in outpatient settings, we will look at a new multidisciplinary outpatient clinic at Children’s Mercy Hospital designed to offer short-term, evidence-based treatment to youth ages 12–17. For context, Children’s Mercy Hospital is located in the Kansas City, Missouri, metro area and serves youth from a variety of socioeconomic and cultural backgrounds across Kansas and Missouri. Upon referral to the clinic, potential patients are verbally screened for anxiety and depression symptoms, as well as common comorbid conditions that may lead to differences in treatment model needs, e.g., autism spectrum disorder. As a treatment team, representatives from medical and therapy disciplines discuss the “fit” of potential patients within the clinic treatment model, as well as identify recommendations for the best treatment course, (e.g., medication first), then therapy once at a therapeutic level of medication.

Screening measures, i.e., GAD-7 and PHQ-9, are first administered at the intake appointment to assess baseline levels of anxiety and depression in youth. These measures are repeated minimally every two months, in addition to clinical information and observation within the sessions, to assess response to treatment and adjust individualized treatment program for youths as needed. Additionally, following the intake appointment, further screening for other conditions that may be either comorbid with anxiety and depression or underlying anxiety and depression is considered and completed when appropriate. For example, the Child and Adolescent Trauma Screen⁶⁰ or the UCLA PTSD Reaction Index⁶¹ may be administered to assess symptoms of trauma, while the Vanderbilt⁶² or Conners-4⁶³ may be used to assess for symptoms of attention deficit hyperactivity disorder.

Based on a patient’s wants, needs, and goals identified collaboratively with the family and treatment team, a treatment plan is identified, which may include medication management, e.g., initiation of SSRI, individual therapy (using CBT or ACT frameworks, with additional Dialectical Behavior Therapy, exposure therapy, executive functioning skills, and mindfulness skills), and skills-based group therapy. Given the treatment plan identified, as well as other factors, such as time of year entering the program, patients participate in simultaneous services, when possible, though adjustments may be made to the timeline for clinical reasons. For example, for youth and families who want to complete a combination treatment of medication and therapy, a course of treatment may be recommended that begins with medication and then starts therapy approximately six to eight weeks later, to better align benefits from medication with momentum in therapy. Additionally, some youth or families may enter the DAY Clinic, preferring to start with just one modality of treatment, i.e., therapy or medication, and later, with the support of their treatment team, decide to include a second modality of treatment.

Additional Considerations for Depression and Anxiety Treatment

In addition to the evidence-based outpatient treatments discussed, many other interventions should be considered by medical providers who do not have access to multidisciplinary outpatient programs. For primary care providers, the Guidelines for Adolescent Depression in Primary Care (GLAD-PC) toolkit is highly recommended as it outlines specific collaborative care practices, (e.g., imbedded behavioral health providers), and treatment recommendations, (e.g., patient monitoring), based on symptom severity.⁶⁴ Additionally, evidence supports the positive treatment effects of single-session interventions (SSIs; i.e., interventions that include one visit or encounter with a clinic, provider, or program) on youth depression and anxiety.^65,66 SSIs take many forms and can include brief behavioral health visits or digital mental health interventions, e.g., phone applications.⁶⁷ These interventions can increase access to care by eliminating barriers, (e.g., transportation issues), that prevent families from receiving care or are good options for patients who do not need more intensive outpatient therapy.

Conclusion

Approximately 16% of primary care visits include addressing a mental health concern, highlighting the urgent need for primary care providers to address the rising rates of adolescent depression and anxiety.²¹ Medical providers can support the behavioral health needs of youth by screening for anxiety and depression routinely, providing referrals to behavioral or mental health professionals, consulting with specialty providers, (e.g., psychiatrists), and providing evidence-based pharmacotherapy or behavioral therapy interventions within medical clinics. See Table 1 for a quick reference guide of clinical resources to use in practice.

Table 1.

Resources Quick Reference Guide

Resource Type	Resource Name	Accessibility
Symptom Screeners
Depression Screener	Patient Health Questionnaire Modified for Adolescents - 9 (PHQ-A-9)	American Academy of Child and Adolescent Psychiatry
Generalized Anxiety Screener	Generalized Anxiety Disorder – 7 (GAD-7)	Anxiety and Depression Association of America
Global Anxiety	Screener Screen for Child Anxiety Related Emotional Disorders (SCARED)	American Academy of Child and Adolescent Psychiatry
Suicide Screener	Ask Suicide-Screening Questions (ASQ)	National Institute of Mental Health - Ask Suicide-Screening Questions (ASQ) Toolkit
Provider Treatment Resources
Pharmacotherapy guidelines	American Medical Association Pharmacotherapy Guidelines	American Medical Association Pharmacotherapy Guidelines
Guidelines for Addressing Adolescent Depression	Guidelines for Adolescent Depression in Primary Care	The Reach Institute – GLAD-PC
Practice Guidelines: Anxiety AACAP	Anxiety Resource Center	AACAP Anxiety Resource Center
Practice Guidelines: Depression	AACAP Depression Resource Center	AACAP Depression Resource Center
Anxiety and Depression Psychoeducation	Seattle Children’s Anxiety FAST Resource	Seattle Children’s Anxiety FAST Resource
Behavioral Health Tools: Primary Care	American Academy of Family Physicians – Six 5 minute tools	American Academy of Family Physicians
Brief Mental Health Interventions	Orygen – The National Center of Excellence for Youth Mental Health	Orygen – The National Center of Excellence for Youth Mental Health
Parenting Resources
Parent Anxiety Medication Guide	AACAP: Anxiety Disorders: Parents’ Medication Guide	American Academy of Child and Adolescent Psychiatry
Parent Depression Medication Guide	AACAP: Depression: Parents’ Medication Guide	American Academy of Child and Adolescent Psychiatry
Self-Help Resources
Crisis Hotline	988 text/call hotline	Suicide and Crisis Lifeline Missouri
Mental Health App Guide	Mobile Health Index and Navigation Database (MIND)	Mobile Health Index and Navigation Database (MIND)
Psychotherapy Referral Resources
Search for Behavioral Health providers	Psychology Today	Psychology Today
Certified Community Behavioral Health Centers	Missouri Behavioral Health Council – Find a Provider	Missouri Behavioral Health Council Find a Provider