# Understanding the Internalizing Pathway in Adolescent Cannabis Use > **Author:** Benjamin Caplan, MD (ABFM Board Certified, MA Lic. #240562, NPI: 1962722637) > **Publisher:** CED Clinic (https://cedclinic.com) > **Canonical URL:** https://cedclinic.com/internalizing-pathway-cannabis-use-adolescents-anxiety/ > **Published:** 2026-05-12T22:54:08-04:00 | **Last Modified / Clinically Audited:** 2026-09-28T11:54:10-04:00 > **Clinical Summary:** Explore the internalizing pathway cannabis use adolescents face, linking anxiety and depression to increased cannabis use risk in youth. --- Table of Contents - [Clinical Takeaway](#Clinical_Takeaway) - [#17 Anxiety, depression and risk of cannabis use: Examining the internalising pathway to use among Chilean adolescents.](#17_Anxiety_depression_and_risk_of_cannabis_use_Examining_the_internalising_pathway_to_use_among_Chilean_adolescents) - [What This Study Teaches Us](#What_This_Study_Teaches_Us) - [Why This Matters Clinically](#Why_This_Matters_Clinically) - [Study Snapshot](#Study_Snapshot) - [Where This Paper Deserves Skepticism](#Where_This_Paper_Deserves_Skepticism) - [Dr. Caplan’s Take](#Dr_Caplan8217s_Take) - [Clinical Bottom Line](#Clinical_Bottom_Line) - [Related](#Related) #### Clinical Takeaway Adolescents with higher levels of depression and anxiety symptoms were more likely to initiate and increase cannabis use over an 18-month follow-up period, supporting the internalizing pathway hypothesis. This longitudinal finding suggests that untreated mental health symptoms in adolescents may drive substance use as a coping mechanism. Clinicians should screen for depression and anxiety in adolescent patients as part of broader substance use prevention efforts. ### #17 Anxiety, depression and risk of cannabis use: Examining the internalising pathway to use among Chilean adolescents. **Citation:** Stapinski Lexine A et al. *Anxiety, depression and risk of cannabis use: Examining the internalising pathway to use among Chilean adolescents.* Drug and alcohol dependence. 2016. PMID: 27427415. **Study type:** Journal Article, Randomized Controlled Trial  |  **Topic area:** Pediatrics  |  **CED Score:** 11 Design: 5 Journal: 0 N: 4 Recency: 0 Pop: 3 Human: 1 Risk: -2 **Quality Gate Alerts:** - Preclinical only **Abstract:** BACKGROUND: Adolescents who experience internalising symptoms may be susceptible to the use of alcohol and other substances in an attempt to alleviate or cope with these symptoms. We examined the hypothesised internalising pathway from symptoms of depression, generalised anxiety, social anxiety and panic, to incidence and frequency of cannabis use 18 months later. METHOD: Longitudinal cohort study of participants (n=2508; 45% female; mean age 14.5 years) recruited from the 9th grade at 22 low-income secondary schools in Santiago, Chile. Baseline internalising symptoms were assessed using the Beck Depression Inventory and the Revised Child Anxiety and Depression Scale. Frequency of cannabis was assessed at baseline, 6 month and 18 month follow-up. RESULTS: High rates of use were observed in this sample, with 40.3% reporting cannabis use at least once over the study period. Adjusted for baseline cannabis use, symptoms of depression, panic and generalised anxiety were associated with greater cannabis use frequency 18 months later. When all predictors were considered simultaneously, only generalised anxiety symptoms showed an independent association with subsequent cannabis use frequency (OR: 1.23, 95% CI: 1.08-1.41). Generalised anxiety symptoms were also associated with a 25% increased risk of transitioning from non-user to use of cannabis during the study (OR: 1.25, 95% CI: 1.09-1.44). CONCLUSIONS: Internalising symptoms, and in particular symptoms of generalised anxiety, increase risk of cannabis use during adolescence. Targeted interventions that promote adaptive [anxiety management](https://cedclinic.com/cannabis-and-ptsd-treatment-memory-loss-benefits/) among high-risk adolescents may represent a promising strategy to prevent uptake of cannabis use during adolescence. ### What This Study Teaches Us Adolescents with generalized anxiety symptoms are at significantly higher risk of initiating cannabis use and using it more frequently over time. When depression, panic, and generalized anxiety are all measured together, only generalized anxiety independently predicts future cannabis use. ### Why This Matters Clinically Clinicians evaluating anxious adolescents should recognize cannabis use as a potential maladaptive coping strategy, not just a behavioral risk. This finding suggests that targeted anxiety management might actually reduce cannabis initiation in high-risk youth, shifting prevention from scare tactics to clinical skill-building. ### Study Snapshot **Study Design**Longitudinal cohort study with baseline, 6-month, and 18-month follow-up assessments**Population**2,508 Chilean adolescents (45% female, mean age 14.5 years) recruited from 9th grade at 22 low-income secondary schools in Santiago**Intervention**None (observational study). Baseline internalizing symptoms (depression, anxiety) were measured; cannabis use was tracked over 18 months**Primary Outcome**Frequency of cannabis use at 18-month follow-up; secondary outcome was transition from non-user to cannabis user status**Key Result**Generalized anxiety symptoms independently associated with 23% increased odds of greater cannabis use frequency (OR 1.23) and 25% increased risk of transitioning to cannabis use (OR 1.25) at 18 months ### Where This Paper Deserves Skepticism This is an observational study, so we cannot infer causation; anxious adolescents might use cannabis for relief, or underlying factors might drive both anxiety and use. The population is entirely low-income Santiago youth, limiting generalizability to higher-income or non-Chilean populations. The abstract does not specify whether the investigators adjusted for other known predictors of [adolescent cannabis use](https://cedclinic.com/adolescent-cannabis-use-and-anxiety-research/) (peer influence, family history, conduct problems) or whether loss to follow-up was significant. Additionally, a 40% overall use rate in this cohort is notably high and may reflect local patterns not applicable elsewhere. ### Dr. Caplan’s Take This study aligns with what I see clinically: anxious adolescents often reach for cannabis as a self-medication strategy before we have a chance to offer structured coping skills. The specificity of generalized anxiety (rather than depression or panic alone) is interesting and worth exploring further in your own practice. That said, I read this as a signal to screen anxious teens for cannabis use and to prioritize evidence-based anxiety interventions, not as proof that cannabis causes the problem. The correlation is real; the direction of causality remains unclear. ### Clinical Bottom Line Screen adolescents with generalized anxiety for cannabis use, and consider that inadequate anxiety management may increase uptake. Prioritize teaching adaptive coping strategies as part of both [anxiety treatment](https://cedclinic.com/benzodiazepine-discontinuation-rates-medical-cannabis/) and cannabis prevention in high-risk youth.  |  [View on PubMed ↗](https://pubmed.ncbi.nlm.nih.gov/27427415/)[DOI ↗](https://doi.org/10.1016/j.drugalcdep.2016.06.032) [https://cedclinic.com/contact/](https://cedclinic.com/contact/) Physician-Led, Whole-Person Care A doctor who takes the time to truly understand you. Personal care that starts with listening and is guided by experience and ingenuity. 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[Learn More](https://cedclinic.com/internalising-symptoms-cannabis-use-risk-adolescents/) [Endocannabinoid System & Teen Mental Health: Clinical Insights](https://cedclinic.com/internalising-pathway-cannabis-use-teens-clinical-insights/) Clinical insights into how the endocannabinoid system influences cannabis use and mental health in teens. [Read Insights](https://cedclinic.com/internalising-pathway-cannabis-use-teens-clinical-insights/) [Endocannabinoid System Research: Cannabis & Teen Mental Health](https://cedclinic.com/internalising-symptoms-adolescent-cannabis-use-risk/) Research findings on the relationship between cannabis use, the endocannabinoid system, and adolescent mental health risks. [Explore Research](https://cedclinic.com/internalising-symptoms-adolescent-cannabis-use-risk/) ### Related --- ### Verification & Medical Governance - **Lead Clinical Author:** Benjamin Caplan, MD - **Credentials:** Board Certified in Family Medicine (ABFM), Founder & CMO CED Clinic & CED Foundation, Author of *The Doctor-Approved Cannabis Handbook* (Penguin Random House). - **Clinical Scale:** 350,000+ lifetime evaluations overseen; 81,008-patient Real-World Evidence Registry (`~/.ced_rwe_vault.db`); 125,000+ peer-reviewed study literature observatory (`http://localhost:8768/api/explorer/terminal`). - **License Verification:** Commonwealth of Massachusetts License #240562 (https://checkahealthlicense.mass.gov/). - **NPI Registry:** 1962722637 (https://npiregistry.cms.hhs.gov/provider-view/1962722637). - **Ethics & Data Privacy:** Clinical registry observations adhere strictly to HIPAA Safe Harbor de-identification (45 CFR § 164.514(b)) and criteria for secondary research exemption under 45 CFR § 46.104(d)(4).