The life of a teenager can be tough. Their bodies and brains are changing quickly at a time when parents, teachers and peers expect a lot from them. Every teen has a passing case of “the blues” when a friendship hits a bump or she feels anxious facing exams or college applications. At times, however, these emotional ups and downs mean more is going on  than just typical teenage stress.

Silent Suffering

It’s not always easy for parents to distinguish between normal teen angst and a serious mental health issue such as an anxiety or depressive disorder. Teens with anxiety and depression often suffer in silence. They tend not to create problems in the classroom or at home. They are often quiet and try to fly below the radar. Teachers, parents and friends who notice that the teen is out of sorts may attribute what they observe to just being a teenager. “He’s okay, he’s just grouchy.” Or, “She’s just stressed right now.” This means that many teens with anxiety and depressive disorders may go unnoticed for several months before parents or teachers ask how they are feeling.

Anxiety and Depressive Disorders

Many teens develop anxiety or depressive disorders during this critical period and some develop both. Anxiety disorders are the most common mental health issue for teens. Perhaps 25% of teens and 30% of all teen girls suffer with an anxiety disorder. Depressive disorders are common in adolescence too. About 6-8% of teens experience serious depression, and by mid-adolescence girls are twice as likely to suffer with a mood disorder than boys. Furthermore, it appears that up to 75% of youth in some clinical samples who suffer primarily from anxiety or depression also have a concurrent diagnosis of the other disorder, (meaning they are suffering from both anxiety and depression simultaneously) although anxiety disorders in depressed youth (20-50%) is higher than depressive disorders in anxious youth (10-15%).

It’s not always easy to tell whether teens are struggling with an anxiety or depressive disorder. Teens who are depressed can look quite different than adults who are depressed. Depressed teens may not necessarily look sad. Instead, they may seem irritable or slowed down. They may also be  extremely sensitive to criticism because they feel bad about themselves. They may complain about aches and pains, or complain when asked to do homework or jobs at home. Depressed teens may withdraw from some people but, unlike adults, they usually keep some friendships, although they may socialize with friends less frequently. Other signs of depression in teens could include loss of appetite or weight gain and trouble sleeping. By the time parents and teachers notice their lack of interest in things, particularly in social activities with peers, it’s likely the teen has been depressed for some time.

Teens with anxiety disorders often do not come to the attention of adults, particularly teachers, if they continue to perform well in school. Teens with anxiety disorders often seek reassurance from parents or ask to be excused from tasks or activities that make them anxious. Anxiety disorders typically occur earlier in childhood than depressive disorders, and parents are often unaware that their teen has been anxious, worried or stressed. As many as10-12% of teens have social anxiety disorder, making it the most common anxiety disorder in adolescence. Some social anxiety about relationships with peers is normal during adolescence because of the perceived importance of fitting in with peers. However, social anxiety disorder can limit teenagers’ social success in general and is much more than personality traits like shyness or introversion.

Chicken or Egg

We don’t know why some teens are both anxious and depressed. Furthermore, we don’t really know why some teens develop anxiety and some develop depressive disorders and others do not. Most researchers suggest that it is a combination of nature and nurture. For example, genetic studies suggest that people who develop emotional disorders inherit a higher degree of emotional sensitivity or reactivity. That is, teens with anxiety and depressive disorders have emotional systems that react to events more intensely, more rapidly, and remain aroused longer than teens without emotional disorders. Emotional reactivity appears to be hard-wired and inherited. A teen with an anxiety disorder is more likely to have a parent with a history of an anxiety or depressive disorder too.

Anxiety disorders are more likely to occur without depression than depression without anxiety, but over time, many teens with anxiety disorders become depressed. For example, a teen with social anxiety disorder may avoid connecting with peers because she worries that her peers may view her as weird or boring. The socially anxious teen then withdraws from friends and social activities more and more, even though connecting with other teens is very important to her. At some point, the socially anxious teen becomes depressed. Teens who worry excessively about their grades may disengage from the fun things in their lives in order to keep up their grades. They then can become depressed as their lives fill with all work and no play.

Teens with depressive disorders can become anxious too. Because they are depressed, they have trouble concentrating, they may be hopeless and no longer see the point of school or life. Their energy is low and they fall behind because homework and even paying attention in class seems to require too much effort. Parents and teachers may think the teen is lazy or oppositional, rather than depressed, and blame them for their poor school performance. As they fall farther and farther behind, they become more anxious and distressed about their failing grades. Furthermore, living with a depressive disorder is stressful. Everything is more difficult: getting out of bed, getting to school, completing homework. It is all overwhelming and anxiety provoking for depressed teens.

What Can Help

There is help for teens with anxiety and depressive disorders, although 80% of youth with an anxiety disorder and 60% with a depressive disorder are not receiving appropriate treatment, and many are not diagnosed at all. There are three treatment options for teens with anxiety and depressive disorders: psychotherapy, pharmacotherapy (medications), or both. Cognitive-behavior therapy is the psychological treatment of choice for adolescents with an anxiety disorder and includes teaching skills to manage anxiety as well as assisting the teen to systematically face the objects, activities and situations that evoke fear and anxiety. Similarly, cognitive-behavior therapy is effective for teens with depressive disorders too, and includes skills to correct thinking that contributes to depression as well as getting depressed teens re-engaged in pleasant activities. To find qualified cognitive behavior therapists in your community, check www.abct.org, www.apa.org, or www.academyofct.org.

Pharmacotherapy or medications for anxiety and depressed disorders can help anxious and depressed teens, particularly when their symptoms are moderate or severe. Serotonin-selective reuptake inhibitors (SSRI) are the first-line medication treatments for anxiety and depressive disorders. Most children and adolescents tolerate this class of medications well. Some youth experience upset stomach, diarrhea, insomnia, or weight gain but most times these side effects decrease over time, or decrease by reducing the dose or by changing to a different SSRI. In 2004, the Food and Drug Administration issued a black box warning on antidepressant medications prescribed for depression in children and adolescents. Drug manufacturers add black box warnings on labels for prescription drugs when there is reasonable evidence of an association of a serious hazard with the drug. In the case of SSRI medications for depression in youth, the warning notes an increased risk of suicidal thinking and behavior in some youth. When considering medication for your teen, first speak to your teen’s pediatrician and then seek a prescriber with experience treating depressed teens with SSRI medications. Furthermore, there are a number of medical conditions, such as an under-active or over-active thyroid that can contribute to anxiety and depression in youth, and your teen’s pediatrician can rule these out and discuss medications that might help your anxious and depressed teen.

How You Can Help

Whether your teen is anxious, depressed, or both, here are a few things that you can do to help:

Help your teen talk. Speak to your teen about what you’ve noticed and wonder aloud what might be going on. Listen, validate how your child is feeling, and don’t lecture or ask too many questions. Give your teen time and space to talk and tell your teen that you are ready to do whatever you can to help. Some parents worry that talking about depression will make it worse, but your support and attention will only help your teen to feel more hopeful, particularly when you remind your teen that no matter the problem, there is something you can do to help. At times, anxious and depressed teens do not always want to talk and will push you away. Persist in a calm and gentle way, checking in from time to time while you wait for an opening. Don’t try to talk your teen out of feeling anxious or depressed. Don’t say that these are growing pains when they may be more than that. Don’t say that things aren’t so bad when things feel terrible to your teen. You want your teen to feel like you understand and that you are ready to talk with them when they are ready to share.

Help your teen connect. Anxious and depressed teens often pull away from friends, either because they worry what their friends think of them or because they no longer have the energy or interest to hang out. Help your teen set up dates with friends, either to do something at home or to go to a movie or shopping. Ask permission to invite other families with teens to parties at your home. It’s okay to go slow. If your teen tells you that a day of shopping is too much, suggest an hour. As your teen feels better, she or he may want to spend a bit more time with friends.

Help your teen with the basics. Sleep, nutrition and exercise are the basics of good mental health and anxious, and depressed teens tend to have trouble with all of these. For example, anxious and depressed teens benefit from any physical activity. Encourage your teen to walk the dog, to kick a soccer ball around or dance around the house. Arrange meet-ups for your teen with friends to do something physical, such as walking around the mall. Also, screen time tends to increase when teens are anxious and depressed. Set limits around screen use while encouraging and arranging face-to-face time with you and your teen’s friends.

Help your teen relax. Whether your teen is anxious, depressed or both, relaxation can help. Encourage your teen to practice simple progressive muscle relaxation, belly breathing, yoga or mindfulness meditation. Anxious and depressed teens may have trouble relaxing. Anxious teens may complain that they do not have time to relax. Depressed teens may complain that nothing will help, that it takes too much effort or that they are not anxious. Explain to your teen that finding time to relax will help them feel better in the moment and better for hours after too. Start small, perhaps just 5 minutes can help, and extend the time over several weeks. In fact, practice with your teen.

Help your teen journal. Encourage your teen to journal. Journaling helps teens sort through their thoughts and feelings. Often, writing down what troubles them provides some emotional distance which can help them feel less overwhelmed and put problems into perspective. Gratitude journals are a great way to feel a little better. Encourage your teen to record the small things for which they are grateful: a call from a friend, the magnolia tree in bloom, the taste of chocolate milk or a hug from you. Remind your teen that it’s okay to keep the journal private, if they like, or to share it with you if it helps.