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

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.
Talking points
View talking points
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
Talking points
View talking points

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

Talking points
View talking points
  • Risk of suicide or harm to self/others9
  • 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

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

Stack of papers. Create comprehensive treatment plan

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

Anxiety
  • 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

 

Depression
  • 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 ineffective9, 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 depression2, 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.1 It 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 depression2, 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

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  • 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
  • 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
  • Citalopram

    Dose

    • 10-40 mg/day

    Price*

    • ≤ $20

    Treatment for**

    • Obsessive-Compulsive Disorder (OCD)
    • Depression
    View SSRI side effects and warnings
  • 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
  • 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
  • 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

*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.4 Antidepressant 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. 2,5 Studies have shown little or no benefit2, and side effects/risks are significant.

 

••• 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

  • 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 evidence2,4,6
  • Benzodiazepines do not have a role in managing depression in youth. 2,4,5

 

••• 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

  • 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.5 Repetitive transcranial magnetic stimulation (rTMS) may be considered for treatment-resistant depression.4

 

••• 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

Overcoming barriers to treatment

Psychological treatments
Pharmacotherapy

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:

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
Support
Case management24, 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

Addiction
Poverty

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]

    Siu AL, U.S. Preventive Services Task Force. Screening for depression in adults: U.S. Preventive Services Task Force recommendation Statement. JAMA. 2016;315(4):380-387.

  • [4]

    Katzman MA, Bleau P, Blier P, Chokka P, Kjernisted K, Van Ameringen M, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14(Suppl 1):S1.

  • [5]

    Connolly SD, Bernstein GA, Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. Am. Acad. Child Adolesc. Psychiatry. 2007;46(2):267-283.

  • [6]

    Richardson LP, McCauley E, Grossman DC, McCarty CA, Richards J, Russo JE, et al. Evaluation of the Patient Health Questionnaire-9 Item for detecting major depression among adolescents. Pediatrics. 2010;126(6):1117-1123.

  • [7]

    British Columbia Guidelines and Protocols Advisory Committee. Anxiety and depression in children and youth – diagnosis and treatment. [Accessed 15 May 2017].

  • [8]

    Institute for Clinical Systems Improvement. Depression, adult in primary care. [Accessed 15 May 2017].

  • [9]

    McDermott B, Baigent M, Chanen A, Fraser L, Graetz B, Hayman N, et al. Clinical practice guidelines: Depression in adolescents and young adults. [Accessed 15 May 2017].

  • [10]

    Clark MS, Jansen KL, Cloy JA. Treatment of childhood and adolescent depression. Am Fam Physician. 2012;86(5):442-448.

  • [11]

    Brezing C, Derevensky JL, Potenza MN. Non-substance-addictive behaviors in youth: Pathological gambling and problematic internet use. Child Adolesc Psychiatr Clin N Am. 2010;19(3):625-641

  • [12]

    Canadian Paediatric Society. Gambling in children and adolescents. [Accessed 15 May 2017].

  • [13]

    Kiraly O, Griffths MD, Urban R, Farkas J, Kokonyei G, elekes Z, et al. Problematic internet use and problematic online gaming are not the same: Findings from a large nationally representative adolescent sample. Cyberpsychol Behav Soc Netw. 2014;17(12):749-54.

  • [14]

    American Academy of Pediatrics Committee of Substance Abuse. Policy statement: Substance use screening, brief intervention, and referral to treatment for pediatricians. Pediatrics. 2011;128(5):e1330-e1340.

  • [15]

    Lamb J, Pepler DJ, Craig W. Approach to bullying and victimization. Can Fam Phys. 2009;55(4):356-60.

  • [16]

    MacQueen GM, Frey BN, Ismail Z, Jaworska N, Steiner M, Lieshout RJ, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: Section 6: Special populations: youth, women, and the elderly. Can J Psychiatry. 2016;61(9):588-603.

  • [17]

    Centre for Effective Practice. Management of chronic insomnia. [Accessed 15 May 2017].

  • [18]

    Dietitians of Canada. Promoting mental health through healthy eating and nutritional care. [Accessed 15 May 2017].

  • [19]

    EatRight Ontario. What is a registered dietitian? [Accessed 15 May 2017].

  • [20]

    Centre for Addiction and Mental Health. Antidepressant medication. [Accessed 15 May 2017].

  • [21]

    Ipser JC, Stein DJ, Hawkridge S, Hoppe L. Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev. 2009;8;(3):CD005170

  • [22]

    Kodish I, Rockhill C, Varley C. Pharmacotherapy for anxiety disorders in children and adolescents. Dialogues Clin Neurosci. 2011;13(4):439-452.

  • [23]

    Overbeck G, Davidsen AS, Kousgaard MB. Enablers and barriers to implementing collaborative care for anxiety and depression: A systematic qualitative review. Implement Sci.
    2016;11:165.

  • [24]

    Canadian Mental Health Association. Case management services. [Accessed 15 May 2017].

  • [25]

    Government of Ontario. Home and community care. [Accessed 15 May 2017].

  • [26]

    Empowering Parents. How to discipline kids: The key to being a consistent parent. [Accessed 15 May 2017].

  • [27]

    Canadian Paediatric Society. Supporting the mental health of children and youth of separating parents. [Accessed 15 May 2017].

  • [28]

    HealthyDebate. Lost in transition: The gap between child and adult mental health services. [Accessed 15 May 2017].

  • [29]

    Canadian Medical Protective Association. Can a child provide consent? [Accessed 15 May 2017].

  • [30]

    Parents’ Lifelines of Eastern Ontario. Coping when your child has mental health challenges. [Accessed 15 May 2017].

  • [31]

    Escitalopram [product monograph]. Montreal, QC: Lundbeck Canada Inc., [updated June 9, 2016, cited 30 May 2017].

  • [32]

    Buck ML. Escitalopram for treatment of depression in adolescents. Pediatr Pharm. 2009;15:9.

  • [33]

    Centers for Disease Control and Prevention. Sleep and sleep disorders. [accessed 15 May 2017].

  • [34]

    Centre for Addiction and Mental Health. Asking the right questions 2: Talking with clients about sexual orientation and gender identity in mental health, counselling, and addiction settings. [accessed 15 May 2017].