College students and anxiety: a psychiatrist's guide to the first semester

I spent part of my career as a psychiatrist at the University of South Carolina's Counseling and Psychiatric Services, and I now work with medical students as a dean. The first semester of college is the single most common time I see a young adult develop an anxiety disorder, or discover one that had been managed at home without anyone naming it. Here is what I tell students and parents before move-in day.

Why the first semester

Almost everything that holds anxiety in check at home disappears at once. Sleep schedule, meals at regular times, a parent who notices, a bedroom that is yours, friends you have known for a decade, a teacher who knows your name. In their place: a roommate, a dining hall, a 300-person lecture, a syllabus that assumes you can manage your own time, and a social world that has to be built from scratch. Add caffeine, alcohol, and a phone that compares you to everyone, and the first eight weeks are a stress test. National surveys such as the Healthy Minds Study consistently find anxiety among the most commonly reported mental health concerns on American campuses, and most campus counseling centers see their demand spike in October and again before finals.

Normal adjustment versus an anxiety disorder

Some anxiety in the first semester is expected and healthy. Homesickness, nerves before the first exam, awkwardness in a new social group. These usually improve by Thanksgiving. I become concerned when I hear the following:

• Worry that is present most days, about many things, and hard to turn off, for weeks at a time. That is the pattern of generalized anxiety disorder.
• Panic attacks: sudden surges of fear with a pounding heart, shortness of breath, dizziness or a sense of unreality, peaking within minutes. Students often go to the emergency department convinced it was their heart. One attack is not a disorder. Repeated attacks plus fear of the next one is panic disorder.
• Avoidance. Skipping classes that involve participation, eating alone to avoid the dining hall, not going to office hours, not joining anything. Social anxiety disorder is common and under-recognized, because the student who avoids is invisible.
• Sleep that will not come because the mind will not stop.
• Physical symptoms with no medical explanation: stomach problems, headaches, muscle tension, fatigue.
• Using alcohol or cannabis to get through social situations or to fall asleep.

Anxiety and depression travel together. A student who starts with anxiety and then stops caring, stops going to class, and stops getting out of bed has moved into territory that needs attention quickly.

What I tell students before they leave

Know where the counseling center is before you need it. Walk past it during orientation. Most centers offer same-day urgent appointments and short-term counseling at no additional cost. Many also have a psychiatrist or psychiatric nurse practitioner on staff or a referral list.

If you have a diagnosis, bring the paperwork. Register with the disability services office in the first weeks, not after the first failed exam. Under the Americans with Disabilities Act and Section 504 of the Rehabilitation Act, colleges must provide reasonable accommodations, and an anxiety disorder qualifies with documentation. Common accommodations include extended time on exams, a reduced-distraction testing room, and flexibility on attendance. Accommodations are not retroactive. Having them in place and never using them is far better than needing them and having none.

If you take medication, do not let it lapse. Bring a 90-day supply if your insurance allows, know which pharmacy near campus is in network, and know who will write the next prescription. A psychiatrist can only treat you in a state where they hold a license, which matters for telehealth. I am licensed in South Carolina, North Carolina, Georgia and Florida; a student who goes to school in another state may need a local prescriber, and that handoff should be arranged before the semester starts.

Protect sleep. Keep a consistent wake time even on weekends. Stop caffeine by early afternoon. Energy drinks and anxiety are a bad combination; I have seen more than one panic attack that was mostly caffeine.

Move your body daily. Twenty to thirty minutes of anything that raises your heart rate. The evidence that regular exercise reduces anxiety is consistent, and campus recreation is already paid for.

Join one thing. Not five. One club, one intramural team, one faith group. A single standing commitment gives you a place to be and people who notice if you are not there.

What I tell parents

Your access changes legally on the first day. Under FERPA, the college cannot share your student's grades or records without permission. Under HIPAA, a campus clinician cannot talk to you without a signed release. Ask your student to sign both before they leave, with the understanding that you will use them only if you are worried. Most students agree when it is framed as a safety net rather than surveillance.

Agree on a check-in rhythm. A short call at a set time each week tells you far more than daily texts. Listen for the pattern I described above: avoidance, sleep, physical complaints, alcohol. If you hear them, say so directly and suggest the counseling center by name. Do not fly in to fix the problem unless there is a safety issue. Do point your student toward the resources already on campus, and offer to help with the phone call if that is the barrier.

How I treat first-semester anxiety

When a student comes to me, I evaluate before I prescribe. I want to rule out thyroid disease, excessive caffeine, stimulant misuse, and substance use, all of which produce anxiety and are common on campuses. I screen for depression and ADHD, because untreated ADHD in a student who has lost the structure of home often presents as anxiety about work that is not getting done.

For generalized anxiety, social anxiety and panic, cognitive behavioral therapy is the first-line treatment and often all that is needed. For moderate to severe symptoms, or when therapy alone has not been enough, SSRIs such as sertraline and escitalopram, several of which are FDA-approved for specific anxiety disorders in adults, have the best evidence. They take four to six weeks to work, which I tell students up front, because the temptation to stop at week two is strong. I use benzodiazepines rarely and briefly. They work immediately, which is exactly the problem: they teach the brain that the only way through a feared situation is a pill, and they carry real risks when combined with alcohol.

Most students I treat for first-semester anxiety are doing well by spring. The ones who struggle longest are the ones who waited until the damage to their grades and relationships was done before telling anyone. The first semester is hard. It is also the easiest point at which to intervene.

More from Dr. Williams

• How I evaluate a child for ADHD, and why I will not diagnose from a questionnaire alone2026-06-09
• Teen depression: what parents see first and what to do in the first two weeks2026-07-07
• Stimulants, non-stimulants and the decision I make with every family2026-09-01

Educational content and not a substitute for evaluation. If you are in crisis, call or text 988.