Youth Mental Health Anxiety and Depression

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This clinical tool helps primary care providers (PCPs) detect and manage anxiety and depression, two of the most common mental health disorders in youth aged 12-24 years.¹ The tool was developed to help guide conversations with patients and families over a series of visits, as appropriate.

Screening / Assessment

Screen patients aged 12-24 routinely for anxiety and depression. Use questions such as those in the Modified Patient Health Questionnaire (PHQ-4), below,^2-5 to help determine the need for further assessment. Current evidence does not indicate a recommended screening interval for anxiety and depression. It may be appropriate to screen opportunistically.² More frequent screening may be considered for patients with risk factors/red flags; signs and symptoms; and history of anxiety and/or depression.

A positive result on an initial screening tool does not necessarily indicate need for treatment.² Further assessment is required.
As appropriate,* engage parent/legal guardian. For example, ask: “Is child withdrawing from or avoiding their usual activities?”⁷
Create a supportive space for all youth (see LGTBQ+ friendly environment for tips)

*See Resources for more information on when to involve parents/legal guardians

Modified Patient Health Questionnaire (PHQ-4)

Begin or schedule time to conduct further assessment of anxiety or depressive symptoms and to evaluate symptom severity as well as the potential for self-harm (Further Assessment)^{2, 7}

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Further assessment

Consent and confidentiality: when to involve parents/legal guardians?

Is the youth a mentally competent adult or a ”mature minor”?²⁹

A mature minor has the mental capacity to consent to treatment, understands the nature of the treatment, its intended effect and the consequences of refusing it.
To assess, try the “teach-back technique”: ask the youth to rephrase what they have been told and invite them to ask questions. Note that if a youth is deemed capable to consent to a specific treatment, e.g., SSRIs, this does not mean they are automatically deemed competent to consent to all treatments.
Can a child provide consent?²⁹

Yes, youth is a mentally competent adult or a “mature minor”

Youth may consent to treatment, without parental/legal guardian involvement.
PCP requires explicit permission from the youth to share confidential information with their parents/legal guardians or to engage them in treatment decisions³¹
Family support can help improve treatment success, so encourage youth to involve their parents/legal guardians or other trusted family member.

No, youth is not a mentally competent adult or a “mature minor”

Parents/legal guardians must be involved in treatment decisions and the PCP can share the youth’s confidential information with parents/legal guardians.
If the PCP feels that the parent/legal guardian’s decisions are putting the youth’s health at risk, they must involve child protective services.³¹

Conduct diagnostic assessment ^8,9

Do a clinical interview to determine patient history⁸
- Onset and intensity of symptoms
- Functional impairment
- Past episodes
- Psychosocial stressors (e.g., current/past trauma, abuse, and bullying)
DSM-5 criteria (Anxiety / Depression)
Mental status exam

Additional assessment

Risk of suicide or harm to self/others⁹
- Consider using Ask Suicide Screening Questions (ASQ)
- If patient is high risk, refer to psychiatric services and/or send patient to ED immediately
Comorbid mental health conditions (e.g., ADHD, bipolar disorder, psychosis, severe OCD, panic disorder)^{5, 10}
- If mental health co-morbidities suspected, consider referral to psychiatric services for diagnostic clarification
- Comorbid mood disorder significantly increases risk of suicidal behavior
Secondary causes of anxiety / depression (e.g., anemia, thyroid dysfunction, nutrient deficiencies)⁷
- If a physical condition that may affect mental health is detected/ suspected, test for and treat condition while concurrently treating and monitoring mental health symptoms as appropriate
Presence of substance use disorder or addiction issues
- Screen for concerns such as alcohol dependence, drugs, gambling, gaming, and problematic internet use.^{5, 11-13}
- Consider using Substance Use Screening, Brief Intervention, and Referral to Treatment (SBIRT) for screening questions & talking points
- If substance use disorder or addictions issues are present, refer to substance use disorder programs for assessment and treatment

Other considerations

If current abuse is detected, refer to psychiatric services immediately and report to children’s services (mandatory reporting if <16 years)⁷

Consider psychiatric referral for patients:

Considering pregnancy; are pregnant; or, breastfeeding⁹
With post-partum depression⁷
With history of severe abuse/trauma

Create comprehensive mangagement plan

Create comprehensive treatment plan

Based on your initial assessment, select a treatment plan that you and your patient are comfortable with.

Counsel patient on healthy living (e.g., regular sleep, physical activity, diet)
Use psychological therapy as first-line
- Cognitive Behavioural Therapy (CBT) is first-line therapy alone for mild anxiety
Consider pharmacological therapy for select cases
- Severe impairment⁴/struggling (e.g., truancy from school, substance use)
- Unlikely to respond to psychological therapy (due to cognitive or other issues)⁴
- Counselling not readily available (e.g., long wait lists)⁴

Counsel patient on healthy living (e.g., regular sleep, physical activity, diet)
Use psychological therapy as first-line
- Cognitive Behavioural Therapy (CBT) and Interpersonal Therapy (IPT) are both considered first-line therapy alone for mild depression
Consider pharmacological therapy for select cases
- Moderate-to-severe depression
- If psychological therapy is refused, not available or ineffective^{9, 16}
- Family or personal history of depression¹⁰

Establish confidentiality and the limits of confidentiality

Determine if youth is a mature minor (understands treatment benefits/risks and consequences of not treating, can consent to specific treatments) using teach-back techniques (“Can you tell me in your own words what we discussed?”). For more information on consent see Resources
State, “everything we discuss will be kept confidential. I will not discuss it with anyone, including your family, without your permission. The only time this does not apply is in sharing information with other health professionals involved in your care, situations where you or others are at risk of harm, or if there is a court order.”

Psychological therapy options

Scroll (left-right) for details

Cognitive Behaviour Therapy (CBT)
Description
A brief, directive psychotherapy to promote realistic and adaptive thinking patterns, combat negative thinking, build coping skills, improve communication skills and peer relationships, face fears through controlled exposure, and regulate emotions.^1-3
Anxiety (Level of evidence •••)
- Is first-line therapy for anxiety
  - Alone for mild anxiety
  - Plus pharmacotherapy for more severe anxiety
- Evidence is strongest for group, individual, and computer-based formats.³
- Benefits are sustained for 2-5 years after completing CBT.³
- Approaches that include family involvement may have additional benefit.³
Depression (Level of evidence •••)
- Is first-line therapy for adolescents and young adults with depression
  - Alone for mild depression
  - Plus pharmacotherapy for moderate to severe depression^{2, 4}
- Usual duration is 10-16 sessions.⁵
Interpersonal Therapy (IPT)
Description
A highly structured psychotherapy that follows a time limited approach which usually lasts 12-16 weeks.¹It is focused on adapting to changes in relationships, transitioning personal roles, and forming interpersonal relationships.²
Anxiety (Level of evidence •••)
- There is some evidence for IPT in anxiety, but much less than CBT.^{1, 3}
- Most evidence is in social anxiety disorder.³
Depression (Level of evidence •••)
- IPT is first-line therapy for adolescents and young adults with depression⁵
- Alone for mild depression
- Plus pharmacotherapy for moderate to severe depression^{2, 4}
- IPT is at least as effective as CBT for depression.²
- Usual duration is 10-16 sessions.⁵
Family Therapy
Description
A form of psychotherapy that includes family members in the sessions to manage issues relating to family dynamics and their role in mental health, and provide education on strategies for the family to support the youth.⁶
Anxiety (Level of evidence •••)
- Family-based CBT has shown efficacy in treating anxiety. It is not as well-studied as CBT or IPT.³
Depression (Level of evidence •••)
- Not as well-studied as CBT or IPT. There are a few studies of family therapy for youth depression and they show some efficacy although less than CBT.
- Usual duration is 12-16 sessions of 90 minutes.⁶
Psychodynamic Therapy
Description
Also called insight-oriented therapy, this form of psychotherapy focuses on understanding how unconscious processes affect a patient’s behaviour. It involves building self-awareness of how unresolved conflicts from the past can affect present behaviour.
Anxiety (Level of evidence •••)
- Evidence is limited, particularly in youth. One study in adults suggest that it works as well as CBT for reducing anxiety scores, but CBT was superior in measures of worry and depression. Psychodynamic therapy is not as well-studied as CBT or IPT.³
Depression (Level of evidence •••)
- Evidence is limited, but suggests high rates of remission in moderate-to-severe therapy (similar to family therapy; family therapy may produce a quicker remission but results of psychodynamic therapy may last longer)⁶

*”Remission” is defined as loss of diagnostic status and no functional impairment
••• Highest level of evidence (meta-analyses; systematic reviews of RCTs; RCTs with var ying levels of bias)
•• Mid-level evidence (systematic reviews of case studies; high quality case control or cohort studies; experimental studies w/o randomization; case reports or studies)
• Low-level evidence (expert opinion and/or clinical experiences of respected authorities/guideline development group

Pharmacological management

Selective Serotonin Reuptake Inhibitors (SSRIs) are first-line pharmacological therapy

Scroll (left-right) for details

Fluoxetine
Dose
- 10-40 mg/day
Price*
- ≤ $20
Treatment for**
- Obsessive-Compulsive Disorder (OCD)
- Social Anxiety Disorder (SAD)
- Separation Anxiety Disorder
- Generalized Anxiety Disorder (GAD)
- Depression
View SSRI side effects and warnings
Close
SSRI side effects and warnings
Common SSRI side effects
Suicidal ideation
Most common in first 4 weeks 5
Use Ask Suicide – Screening Questions (ASQ) screening tool ⁹
SSRIs increase suicidal ideation, but untreated anxiety disorders increase suicide risk even more (6 to 8-fold increase in risk).³
Adding CBT may help reduce the risk.⁵
Somnolence, Gastrointestinal (GI) effects, Nervousness, Headache, Restlessness²
Transient; usually improves after the first 2 week
Sexual dysfunction⁵, Weight gain³
Not transient
Can be particularly distressing to youth and reduce adherence⁵
Other side effects
Mania/hyomania, activating effects, altered platelet function, fractures and hyponatremia⁴
Other SSRI warnings
Citalopram is not recommended in congenital long QT syndrome, congenital heart disease, or hepatic impairment.⁴
Abrupt discontinuation can lead to a discontinuation syndrome with GI, psychiatric, vasomotor, and other symptoms.⁴
Additive effects with alcohol and other CNS depressants
General Antidepressant Warnings
Prescribing must be done in the context of an ongoing therapeutic relationship and management plan.⁵
Begin treatment at the lowest dose for 4 weeks4 and titrate based on patient response and adverse effects.²
Consider adjusting dose for younger/low body weight individuals.³
Obtain informed consent from the patient (and family if appropriate).
Neural pathways in youth may not be fully developed, and serotonin and norepinephrine systems have different maturation rates. Therefore, extrapolation of adult data on antidepressants to youth may not be accurate.²
Sertraline
Dose
- 25-20 0 mg/day
Price*
- ≤ $20
Treatment for**
- Obsessive-Compulsive Disorder (OCD)
- Social Anxiety Disorder (SAD)
- Generalized Anxiety Disorder (GAD)
- Depression
View SSRI side effects and warnings
Close
SSRI side effects and warnings
Common SSRI side effects
Suicidal ideation
Most common in first 4 weeks 5
Use Ask Suicide – Screening Questions (ASQ) screening tool ⁹
SSRIs increase suicidal ideation, but untreated anxiety disorders increase suicide risk even more (6 to 8-fold increase in risk).³
Adding CBT may help reduce the risk.⁵
Somnolence, Gastrointestinal (GI) effects, Nervousness, Headache, Restlessness²
Transient; usually improves after the first 2 week
Sexual dysfunction⁵, Weight gain³
Not transient
Can be particularly distressing to youth and reduce adherence⁵
Other side effects
Mania/hyomania, activating effects, altered platelet function, fractures and hyponatremia⁴
Other SSRI warnings
Citalopram is not recommended in congenital long QT syndrome, congenital heart disease, or hepatic impairment.⁴
Abrupt discontinuation can lead to a discontinuation syndrome with GI, psychiatric, vasomotor, and other symptoms.⁴
Additive effects with alcohol and other CNS depressants
General Antidepressant Warnings
Prescribing must be done in the context of an ongoing therapeutic relationship and management plan.⁵
Begin treatment at the lowest dose for 4 weeks4 and titrate based on patient response and adverse effects.²
Consider adjusting dose for younger/low body weight individuals.³
Obtain informed consent from the patient (and family if appropriate).
Neural pathways in youth may not be fully developed, and serotonin and norepinephrine systems have different maturation rates. Therefore, extrapolation of adult data on antidepressants to youth may not be accurate.²
Citalopram
Dose
- 10-40 mg/day
Price*
- ≤ $20
Treatment for**
- Obsessive-Compulsive Disorder (OCD)
- Depression
View SSRI side effects and warnings
Close
SSRI side effects and warnings
Common SSRI side effects
Suicidal ideation
Most common in first 4 weeks 5
Use Ask Suicide – Screening Questions (ASQ) screening tool ⁹
SSRIs increase suicidal ideation, but untreated anxiety disorders increase suicide risk even more (6 to 8-fold increase in risk).³
Adding CBT may help reduce the risk.⁵
Somnolence, Gastrointestinal (GI) effects, Nervousness, Headache, Restlessness²
Transient; usually improves after the first 2 week
Sexual dysfunction⁵, Weight gain³
Not transient
Can be particularly distressing to youth and reduce adherence⁵
Other side effects
Mania/hyomania, activating effects, altered platelet function, fractures and hyponatremia⁴
Other SSRI warnings
Citalopram is not recommended in congenital long QT syndrome, congenital heart disease, or hepatic impairment.⁴
Abrupt discontinuation can lead to a discontinuation syndrome with GI, psychiatric, vasomotor, and other symptoms.⁴
Additive effects with alcohol and other CNS depressants
General Antidepressant Warnings
Prescribing must be done in the context of an ongoing therapeutic relationship and management plan.⁵
Begin treatment at the lowest dose for 4 weeks4 and titrate based on patient response and adverse effects.²
Consider adjusting dose for younger/low body weight individuals.³
Obtain informed consent from the patient (and family if appropriate).
Neural pathways in youth may not be fully developed, and serotonin and norepinephrine systems have different maturation rates. Therefore, extrapolation of adult data on antidepressants to youth may not be accurate.²
Escitalopram
Dose
- 10-20 mg/day (may start at 5 mg if concerned about initial sensitivity to side effects) ^{31, 32}
Price*
- ≤ $20
Treatment for**
- Social Anxiety Disorder (SAD)
- Depression
View SSRI side effects and warnings
Close
SSRI side effects and warnings
Common SSRI side effects
Suicidal ideation
Most common in first 4 weeks 5
Use Ask Suicide – Screening Questions (ASQ) screening tool ⁹
SSRIs increase suicidal ideation, but untreated anxiety disorders increase suicide risk even more (6 to 8-fold increase in risk).³
Adding CBT may help reduce the risk.⁵
Somnolence, Gastrointestinal (GI) effects, Nervousness, Headache, Restlessness²
Transient; usually improves after the first 2 week
Sexual dysfunction⁵, Weight gain³
Not transient
Can be particularly distressing to youth and reduce adherence⁵
Other side effects
Mania/hyomania, activating effects, altered platelet function, fractures and hyponatremia⁴
Other SSRI warnings
Citalopram is not recommended in congenital long QT syndrome, congenital heart disease, or hepatic impairment.⁴
Abrupt discontinuation can lead to a discontinuation syndrome with GI, psychiatric, vasomotor, and other symptoms.⁴
Additive effects with alcohol and other CNS depressants
General Antidepressant Warnings
Prescribing must be done in the context of an ongoing therapeutic relationship and management plan.⁵
Begin treatment at the lowest dose for 4 weeks4 and titrate based on patient response and adverse effects.²
Consider adjusting dose for younger/low body weight individuals.³
Obtain informed consent from the patient (and family if appropriate).
Neural pathways in youth may not be fully developed, and serotonin and norepinephrine systems have different maturation rates. Therefore, extrapolation of adult data on antidepressants to youth may not be accurate.²
Fluvoxamine
Dose
- 25-300 mg/day
Price*
- ≤ $20
Treatment for**
- Obsessive-Compulsive Disorder (OCD)
- Social Anxiety Disorder (SAD)
- Separation Anxiety Disorder
- Generalized Anxiety Disorder (GAD)
View SSRI side effects and warnings
Close
SSRI side effects and warnings
Common SSRI side effects
Suicidal ideation
Most common in first 4 weeks 5
Use Ask Suicide – Screening Questions (ASQ) screening tool ⁹
SSRIs increase suicidal ideation, but untreated anxiety disorders increase suicide risk even more (6 to 8-fold increase in risk).³
Adding CBT may help reduce the risk.⁵
Somnolence, Gastrointestinal (GI) effects, Nervousness, Headache, Restlessness²
Transient; usually improves after the first 2 week
Sexual dysfunction⁵, Weight gain³
Not transient
Can be particularly distressing to youth and reduce adherence⁵
Other side effects
Mania/hyomania, activating effects, altered platelet function, fractures and hyponatremia⁴
Other SSRI warnings
Citalopram is not recommended in congenital long QT syndrome, congenital heart disease, or hepatic impairment.⁴
Abrupt discontinuation can lead to a discontinuation syndrome with GI, psychiatric, vasomotor, and other symptoms.⁴
Additive effects with alcohol and other CNS depressants
General Antidepressant Warnings
Prescribing must be done in the context of an ongoing therapeutic relationship and management plan.⁵
Begin treatment at the lowest dose for 4 weeks4 and titrate based on patient response and adverse effects.²
Consider adjusting dose for younger/low body weight individuals.³
Obtain informed consent from the patient (and family if appropriate).
Neural pathways in youth may not be fully developed, and serotonin and norepinephrine systems have different maturation rates. Therefore, extrapolation of adult data on antidepressants to youth may not be accurate.²
Paroxetine
Dose
- 10-50 mg/day
Price*
- $20 – $40
Treatment for**
- Obsessive-Compulsive Disorder (OCD)
- Social Anxiety Disorder (SAD)
View SSRI side effects and warnings
Close
SSRI side effects and warnings
Common SSRI side effects
Suicidal ideation
Most common in first 4 weeks 5
Use Ask Suicide – Screening Questions (ASQ) screening tool ⁹
SSRIs increase suicidal ideation, but untreated anxiety disorders increase suicide risk even more (6 to 8-fold increase in risk).³
Adding CBT may help reduce the risk.⁵
Somnolence, Gastrointestinal (GI) effects, Nervousness, Headache, Restlessness²
Transient; usually improves after the first 2 week
Sexual dysfunction⁵, Weight gain³
Not transient
Can be particularly distressing to youth and reduce adherence⁵
Other side effects
Mania/hyomania, activating effects, altered platelet function, fractures and hyponatremia⁴
Other SSRI warnings
Citalopram is not recommended in congenital long QT syndrome, congenital heart disease, or hepatic impairment.⁴
Abrupt discontinuation can lead to a discontinuation syndrome with GI, psychiatric, vasomotor, and other symptoms.⁴
Additive effects with alcohol and other CNS depressants
General Antidepressant Warnings
Prescribing must be done in the context of an ongoing therapeutic relationship and management plan.⁵
Begin treatment at the lowest dose for 4 weeks4 and titrate based on patient response and adverse effects.²
Consider adjusting dose for younger/low body weight individuals.³
Obtain informed consent from the patient (and family if appropriate).
Neural pathways in youth may not be fully developed, and serotonin and norepinephrine systems have different maturation rates. Therefore, extrapolation of adult data on antidepressants to youth may not be accurate.²

*For 30-day supply. Please note that dispensing fees have not been included.
** denotes highest level of evidence (meta-analyses, systematic reviews of RCTs, RCTs with varying levels of bias)

Other medication option

Select medication option for details

Anxiety

Venlafaxine XR (Level of evidence ••• for SAD)³
Although SSRIs are the preferred treatment, there is also good evidence for venlafaxine (37.5 – 225 mg/day) in SAD.^{3, 8}

Depression

Venlafaxine (Level of evidence •••)^2,4,6
Venlafaxine is a second-line medication option for depression in youth. Start with an SSRI and if there is no response, switch to a different SSRI before trying venlafaxine.⁴Antidepressant treatment should continue for at least 6 months after remission.²

••• Highest level of evidence (meta-analyses; systematic reviews of RCTs; RCTs with varying levels of bias)
•• Mid-level evidence (systematic reviews of case studies; high quality case control or cohort studies; experimental studies w/o randomization; case reports or studies)
• Low-level evidence (expert opinion and/or clinical experiences of respected authorities/guideline development group

Anxiety

Clomipramine (Level of evidence ••• for OCD)³
Although SSRIs are the preferred treatment, there is also good evidence for clomipramine (primarily in OCD)^.3

Depression

Not recommended (Level of evidence ••• against use)^2,4,6
TCAs should generally not be used to treat depression in youth.^2,5Studies have shown little or no benefit², and side effects/risks are significant.

Anxiety

Benzodiazepines are generally not recommended except for as short-term therapy in situations where rapid symptom reduction is needed to allow exposure – related psychotherapy (e.g., panic disorder, school refusal behaviour). May increase overdose risk if used with methadone or Suboxone therapy for addictions. Agents with good evidence in this context:
- Alprazolam (Level of evidence • for panic disorder, ••• against use for SAD, GAD, and school-refusal)³
- Clonazepam (Level of evidence • for panic disorder,••• against use for SAD, GAD, and school-refusal)³

Depression

Not recommended due to lack of evidence^2,4,6
Benzodiazepines do not have a role in managing depression in youth. ^2,4,5

Anxiety

Alprazolam (Level of evidence •• for OCD)³
Riluzole (Level of evidence • for OCD)³
Mirtazapine (Level of evidence •• for SAD)³
SSRIs are preferred treatment. Some evidence for aripiprazole or riluzole for treatment-resistant OCD, particularly as adjunctive therapies. Some evidence for mirtazapine in treatment of SAD, though evidence is conflicting.³

Depression

Adjunctive treatments: Currently, there is no research on which to base an evidence-based recommendation for adding a second anti-depressant or augmentation with a mood stabilizer for non-responsive or chronic depression in youth. Specialist consultation is recommended.⁵Repetitive transcranial magnetic stimulation (rTMS) may be considered for treatment-resistant depression.⁴

Overcoming barriers to treatment

Psychological treatments

Private health insurance or Employee Assistance Program (EAP) may cover some of the costs
Visit 211 to help connect patients to available resources in their community
Consider using OHIP-covered CBT provider, MoodGym (free online CBT) or Centre for Mindfulness Studies
Offer free mental health apps such as MindShift (for anxiety), MoodTools (for depression), or MoodKit (CBT app for depression). For a full list of reviewed apps, visit the following website: American Depression and Anxiety Association (ADAA)

Pharmacotherapy

Private health insurance
•Reach out to drug companies to enquire about their compassionate use programs
Ontario Works and Ontario Disability Support Program provide funding for drug coverage and transportation to medical appointments

Patient care while waiting for referral

Long wait for referral to psychological therapy or specialist care? Here are a few ways to support your patient in the meantime:

Provide interim counselling:
- Informal counselling in your office (tips on using CBT with your patient)
- Online CBT:
Consider starting drug therapy while waiting for referral
Offer lifestyle modifications

These tips are for patients who are stable enough to wait for referral. Patients at high immediate risk of harm to self or others should be sent to the emergency department for further assessment. See Keeping Your Patients Safe for tips on assessing a patient’s risk of harm to self or others.

Follow-up and monitoring

Follow-up

When starting patients on psychological therapy or pharmacological therapy primary care providers should follow up the week after initiating treatment to check to see if patient is tolerating treatment.

Anxiety follow-up

Psychological therapy has a success rate of approximately 70%.⁴ Antidepressants have a success rate of approximately 60-80%.21, 22 Response (defined as 25-50% reduction in symptoms) rates may vary by patient and disorder.

Depression follow-up

Initial therapy (psychological and/or medications) is successful in about 60% of youth with depression.⁹

Usual response times

CBT or IPT: 6-10 sessions for initial response; 10-16 sessions total⁹
Antidepressants:
- For anxiety: 2-8 weeks for initial response; 8-12 weeks for full response⁴
- Fore depression: up to 4 weeks for initial effect 8-12 weeks for full response

Monitoring

Monitoring psychological therapy

When to monitor

For the first 12-20 weeks, the psychotherapist should assess response to treatment in detail. The PCP should assess for barriers, progress and any suicidal thinking or behaviour as often as they feel necessary based on their clinical judgment.

What to monitor

Suicidal behaviour or thinking
Any new mental health issues/symptom
Barriers to therapy (e.g., cost, convenience, transportation, etc.)
Response to treatment

How to monitor

Ideally by PCP with input from patient (via phone or in-person)
Consider using scales such as the Clinical Global Impression (CGI) scale, which works for both anxiety and depression, or the scale originally used for screening/diagnosis (e.g., PHQ-9, GAD-7, SCARED) to determine response to treatment⁴

Practice points⁷

Encourage patient to maintain daily activities (e.g., school, work, social activities)
Encourage healthy thinking with positive appraisals
Work with your patient to develop realistic treatment goals; this may start as achievable daily goals

Monitoring antidepressants

When to monitor

1 week before starting medication: observe symptoms that might subsequently be interpreted as adverse events⁹
Within 1 week after initiating treatment⁹
Every 1 to 2 weeks, up to 8 weeks; at 12 weeks; as clinically indicated post 12 week period.²³
Some patients (e.g., pre-existing suicidal thinking/behaviour, decline psychological therapy, etc.) may require closer monitoring⁹

**Guidelines recommend weekly monitoring for the first 4 weeks.^9,22

What to monitor⁹

Suicidal thinking or behaviour
Unusual changes in behaviour (e.g., agitation, social withdrawal)
Manic or psychotic symptoms
Adverse effects (e.g., sexual dysfunction, tremors, etc.) and weight changes”⁴
Review of mental state
General progress/clinical worsening
Response to treatment

How to monitor

Ideally by PCP with input from patient (via phone or in-person)
Consider using scales such as the Clinical Global Impression (CGI) scale, which works for both anxiety and depression, or the scale originally used for screening/diagnosis (e.g., PHQ-9, GAD-7, SCARED) to determine response to treatment⁴

Practice points⁷

Consider providing your patient or parent/legal guardian the Antidepressant Monitoring Form for them to self-monitor and document symptoms and adverse events while taking antidepressants
In some cases, it may be helpful for the patient or caregiver to monitor daily for worsening symptoms or any unusual changes or behaviours (particularly emergence of suicidality). Discuss an emergency plan as well as a plan for follow-up
Counsel patient and ensure that they have realistic expectations about the medication and the importance of healthy living
Work with your patient to develop realistic treatment goals; this may start as achievable daily goals

SSRIs are the first-line pharmacological therapy. If response to SSRIs is inadequate:

1. Evaluate

Whether diagnosis is correct⁹
Previously undetected comorbid conditions (e.g., bipolar disorder)¹⁶
External factors (quality of therapeutic relationship; whether treatment goals are shared; youth’s motivation to change; ongoing adverse circumstances)
Substance abuse
Adherence⁹

2. Consider referral or other treatments

For youth < 18 years:
- Consider referral to a specialist or a collaborative care relationship (where you work together with a specialist on the patient’s care)
For youth ≥ 18 years:
- Consider a trial of one of the medications listed in the “Other medication options” found in Management
  AND/OR
- Consider referral to a specialist or a collaborative care relationship (where you work together with a specialist on the patient’s care)^{9, 23}

Transition to adult mental health care

Between the ages of 18 and 21, youth transition into the adult mental health system, which can affect current stabilized conditions.30

Tips for a smooth transition

Start planning ahead of time – look into local services well in advance of patient’s transition.
Give your patient and their family (if involved) advanced notice that they will need to transition and what this process will involve.
Help support your patient during the transition by referring them to local adult mental health providers and services.
Check in with the patient after the transition to ensure that they have received access to care and to ask if they are satisfied with the services.²⁸

Resources

Patient resources for youth and families

Safety planning and resources

Emergency safety plan – include:

Ensure that your patient has a crisis plan and resources that they can access when needed
Kids Help Phone: 1-800-668-6868 (up to age 20)
Good2Talk: 1-866-925-5454 (university/college students)
Crisis Line: 1-866-996-0991 (all ages)
Ontario Distress Centres

Sample plans

Support

Case management^{24, 25}

Offer case management to patients who need help with day-to-day activities, such as shopping, banking, arranging medical appointments, and budgeting

Case management resources

ConnexOntario: Directory of local services; search resources with keyword “case management”
The Access Point (for Greater Toronto Area)
eMental Health service coordination and case management

Parent/legal guardian handouts/parenting supports

How to talk with your teen
CAMH: Information for Parents (handouts on parenting and mental health issues)

Safe school environment

Ask “Do you feel safe at school?”
If needed, help build a Bullying Safety Plan and offer bullying resources like Stopabully.ca

Other resources

Community resources

ConnexOntario: Directory of local services
- Mental health: 1-800-531-2600
- Addictions: 1-800-565-8603
Canadian Mental Health Association: Ontario Services & Support: List of programs delivered by community agencies, hospitals or health clinics
Ontario Peer Development Initiative: Directory of patient support organizations in each LHIN

Addiction

Screening/support

Perform screening and brief intervention – see SBIRT
Connect patients to local services:
- 211Ontario: Mental Health/Addictions: local programs and resources
- Healthline: LHIN programs and resources
- Mental Health Helpline / ConnexOntario: 1-866-531-2600

Patient/family handouts

CAMH: Information for youth (handouts on alcohol, drugs, and gambling)
CAMH: Information for parents (handouts and videos on addictions)

Poverty

Screening/Intervention

Identify patients who live in poverty and intervene – see Poverty Tool: A Clinical Tool For Primary Care Providers

Additional resources

Provider resources

References

[1]
Canadian Mental Health Association – British Columbia Division. Mental illnesses in children and youth. [Accessed 15 May 2017].
[2]
U.S. Preventive Services Task Force. Final recommendation statement – depression in children and adolescents: screening. [Accessed 15 May 2017].
[3]
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Acknowledgments and legal

This Tool was developed as part of the Knowledge Translation in Primary Care Initiative, led by Centre for Effective Practice with collaboration from the Ontario College of Family Physicians and the Nurse Practitioners’ Association of Ontario. Clinical leadership for the development of the tool was provided by Dr. Muna Chowdhury MD, CCFP FCFP The tool was subject to external review by health care providers and other relevant stakeholders. This tool was funded by the Government of Ontario as part of the Knowledge Translation in Primary Care Initiative.

This tool was developed for licensed health care professionals in Ontario as a guide only and does not constitute medical or other professional advice. Health care professionals are required to exercise their own clinical judgment in using this tool. Neither the Centre for Effective Practice (“CEP”), Ontario College of Family Physicians, Nurse Practitioners’ Association of Ontario, Government of Ontario, nor any of their respective agents, appointees, directors, officers, employees, contractors, members or volunteers: (i) are providing medical, diagnostic or treatment services through this tool; (ii) to the extent permitted by applicable law, accept any responsibility for the use or misuse of this tool by any individual including, but not limited to, primary care providers or entity, including for any loss, damage or injury (including death) arising from or in connection with the use of this tool, in whole or in part; or (iii) give or make any representation, warranty or endorsement of any external sources referenced in this Tool (whether specifically named or not) that are owned or operated by third parties, including any information or advice contained therein

Youth Mental Health: Anxiety and Depression is a product of the Centre for Effective Practice. Permission to use, copy, and distribute this material for all non-commercial and research purposes is granted, provided the above disclaimer, this paragraph and the following paragraphs, and appropriate citations appear in all copies, modifications, and distributions. Use of the Youth Mental Health: Anxiety and Depression for commercial purposes or any modifications of the resource are subject to change and use must be negotiated with the Centre for Effective Practice (Email: info@cep.health).

For statistical and bibliographic purposes, please notify the Centre for Effective Practice (info@cep.health) of any use or reprinting of the tool. Please use the below citation when referencing the tool: Reprinted with Permission from Centre for Effective Practice. (June 2017). Youth Mental Health: Anxiety and Depression. Ontario. Toronto: Centre for Effective Practice

Developed by

In collaboration with

Youth Mental Health Anxiety and Depression

Screening / Assessment

Red flags2,7

Red flags 2,7

Modified Patient Health Questionnaire (PHQ-4)

Anxiety

Depression

Further assessment

Consent and confidentiality: when to involve parents/legal guardians?

Is the youth a mentally competent adult or a ”mature minor”?29

Yes, youth is a mentally competent adult or a “mature minor”

Talking points

Yes, youth is mentally competent adult or a “mature minor” talking points

No, youth is not a mentally competent adult or a “mature minor”

Talking points

No, youth is not a mentally competent adult or a “mature minor” talking points

Conduct diagnostic assessment 8,9

Additional assessment

Talking points

Talking points

Communication tips

Talking points

Other considerations

Create comprehensive mangagement plan

Create comprehensive treatment plan

Establish confidentiality and the limits of confidentiality

Healthy living

Healthy living

Regular sleep:

Physical activity

Healthy eating18

Talking points

Talking points

Psychological therapy options

Scroll (left-right) for details

Cognitive Behaviour Therapy (CBT)

Interpersonal Therapy (IPT)

Family Therapy

Psychodynamic Therapy

Pharmacological management

Scroll (left-right) for details

Fluoxetine

SSRI side effects and warnings

Common SSRI side effects

Other side effects

Other SSRI warnings

General Antidepressant Warnings

Sertraline

SSRI side effects and warnings

Common SSRI side effects

Other side effects

Other SSRI warnings

General Antidepressant Warnings

Citalopram

SSRI side effects and warnings

Common SSRI side effects

Other side effects

Other SSRI warnings

General Antidepressant Warnings

Escitalopram

SSRI side effects and warnings

Common SSRI side effects

Other side effects

Other SSRI warnings

General Antidepressant Warnings

Fluvoxamine

SSRI side effects and warnings

Common SSRI side effects

Other side effects

Other SSRI warnings

General Antidepressant Warnings

Paroxetine

SSRI side effects and warnings

Common SSRI side effects

Other side effects

Other SSRI warnings

General Antidepressant Warnings

Other medication option

Select medication option for details

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Red flags^2,7

Red flags ^2,7

Is the youth a mentally competent adult or a ”mature minor”?²⁹

Conduct diagnostic assessment ^8,9

Healthy eating¹⁸

Practice points⁷

What to monitor⁹

Practice points⁷

Case management^{24, 25}