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Canadian Journal of Public Health = Revue Canadienne de Santé Publique logoLink to Canadian Journal of Public Health = Revue Canadienne de Santé Publique
. 2021 Jun 2;112(5):919–926. doi: 10.17269/s41997-021-00526-3

Associations of antidepressant use with alcohol use and problem drinking: Ontario population data from 1999 to 2017

Jesus Chavarria 1,✉, Samantha Wells 1,2,3,4,5, Tara Elton-Marshall 1,2,4, Jürgen Rehm 1,2,3,6,7
PMCID: PMC8523598  PMID: 34076877

Abstract

Objective

This study investigated the rates of and change in past-year antidepressant use from 1999 to 2017 among a representative sample of Ontario adults and past-year alcohol users and problem drinkers. It examined whether alcohol use and problem drinking are associated with antidepressant use over time, whether gender moderated the effect of problem drinking on antidepressant use, and the potential correlates of past-year antidepressant use.

Method

This study utilized data from the Centre for Addiction and Mental Health Monitor study, a repeat cross-sectional telephone survey of the Ontario general adult population. Data are from 15 annual cycles of the survey 1999–2017 (where relevant variables were included), resulting in a sample size of N = 35,210. Variables of interest included demographic variables, past-year antidepressant use, past-year alcohol use, and past-year problem drinking (e.g., 8+ on the Alcohol Use Disorders Identification Test).

Results

Past-year antidepressant use increased from 1999 to 2017 similarly among the full sample, past-year alcohol users, and past-year problem drinkers. Approximately 9% of Ontarians reported past-year antidepressant use in 2017. Overall, past-year problem drinkers were 1.5 times more likely to use antidepressants than non-problem drinkers. Past-year alcohol use was not associated with antidepressant use. Gender moderated the association between past-year problem drinking and antidepressant use.

Conclusion

This study determined that past-year antidepressant use increased from 1999 to 2017, that past-year problem drinkers are more likely to use antidepressants than non-problem drinkers, and that past-year problem drinking is associated with past-year antidepressant use among women but not among men.

Keywords: Ontario, Antidepressant use, Alcohol use, Problem drinking

Introduction

Antidepressant medications are used to treat a number of mental health problems, including major depressive disorder, bulimia nervosa, generalized anxiety disorder, substance use disorders, and schizoaffective disorder (Patten et al., 2007). In Canada, the use of these medications steadily increased between the years 1981 and 2000 (Hemels et al., 2002) and then plateaued at approximately 5% from 2000 to 2012 (Patten et al., 2014). Studies show that women, relative to men, and people who are middle aged (e.g., 26–64 years), relative to those younger (e.g., 15–25 years), are more likely to use antidepressants (Beck et al., 2005; Raymond et al., 2007), whereas research is mixed with regard to the effects of marital status and educational achievement on the use of antidepressants (Bauer et al., 2008; Hansen et al., 2004; Health Canada, 2017; Sinokki et al., 2009; Von Soest et al., 2012). Alcohol use is another important factor as research highlights that this potential maladaptive behaviour is commonly comorbid with psychological disorders treated with antidepressants (Grant et al., 2004; Hasin et al., 2007; Smith & Book, 2010).

Alcohol use is ubiquitous in Canada with approximately 80% of the population reporting some past-year alcohol use (Health Canada, 2017). More concerning, an estimated 18.1% and 3.2% of people report a lifetime and past-year alcohol use disorder (AUD), respectively (Pearson et al., 2013), with research showing that psychological disorders with comorbid AUD result in more severe consequences relative to those without an AUD comorbidity (Alegría et al., 2010; Blanco et al., 2012; Burns & Teesson, 2002; Keel et al., 1999). Given these statistics, and as research indicates that the combined use of alcohol and antidepressants can lead to potentially dangerous effects (NIAAA, 2014), it is important to understand how many people are potentially using these substances concurrently.

Several studies investigating the association between alcohol and antidepressant use have found mixed results. For instance, among an educated sample in the United States taken from a single employer, there was no significant association between problem drinking and antidepressant use (Koopman et al., 2003). A second US study found that, between 1999 and 2010, the prevalence of antidepressant medication use among alcohol drinkers age 20 and over was approximately 9%, but alcohol drinkers were less likely to use antidepressants relative to non-drinkers (Breslow et al., 2015). To our knowledge, only one Canadian study has investigated the use of antidepressants among alcohol drinkers. Specifically, Graham and Massak (2007) determined that antidepressant use was associated with less drinking in depressed men, but had no effect on drinking levels among women. Although these studies begin to shed light on the association between antidepressant and alcohol use, no studies have investigated their co-use in the general Canadian population.

As such, the current study aimed to investigate the rate of and change in past-year antidepressant use from 1999 to 2017 among a full sample of Ontario residents, past-year alcohol users, and past-year problem drinkers. We then tested whether there were any significant differences in the rates of antidepressant use between these groups over time. Finally, we explored an interaction between problem drinking and gender.

Methods

The data used in this study were from the Centre for Addiction and Mental Health (CAMH) Monitor survey. The CAMH Monitor is a random-digit dialed, repeat cross-sectional telephone survey of the general population of Ontario adults aged 18 years and older. The aim of the survey is to provide epidemiological surveillance of indicators related to physical and mental health, including alcohol, tobacco, and illicit drug use. The survey has been continuously fielded since 1996, is conducted by CAMH, and is administered by the Institute for Social Research (ISR) at York University.

Between 1997 and 2010, each annual cycle of the survey included monthly assessments with 170–215 completions per month; between 2011 and 2017, each annual cycle consisted of quarterly assessments with approximately 750 completions per quarter. Each regional stratum employed a two-stage probability selection procedure in which the first stage were households of selected telephone numbers and the second stage were English-speaking respondents aged at least 18 years selected using the last birthday method. All quarterly or monthly samples were combined each calendar year to yield a single annual dataset. The data were weighted to adjust for regional probabilities and varying selection probabilities. The most recently available census figures were used to conduct a post-stratification adjustment to restore the age by gender distribution, with the final sample considered representative of the non-institutionalized Ontario adult population (48% male, Mage [SD] = 47.7 [17.1], 84% urban). The CAMH Monitor survey annual response rate ranged from 41% to 58% (Ialomiteanu et al., 2018), which is consistent with similar survey types (Fan & Yan, 2010; Wright, 2015).

The research ethics boards at CAMH (#305-2009) and York University (#2019-017) have approved the CAMH Monitor survey annually and verbal informed consent was provided by all participants. In order to examine the pattern of antidepressant use since 1999, the current study utilized data from 15 annual cycles of the survey from 1999 to 2017, resulting in a sample size of 37,669 respondents. Data from years 1996, 1997, 1998, 2000, 2005, and 2007 were excluded, as the questionnaires did not assess for problem alcohol use and/or antidepressant use during those waves.

Definitions

Current antidepressant use was measured by a dichotomous (0 = no, 1 = yes) item assessing any antidepressant use in the past 12 months. Current alcohol use was measured using a dichotomous variable (0 = non-drinker, 1 = drinker) to assess the use of any alcohol in the past 12 months. Problematic alcohol use was assessed using a dichotomous hazardous drinking item (0 = non-problematic alcohol use, 1 = problematic alcohol use) based on the Alcohol Use Disorders Identification Test (AUDIT) cutoff score of 8 (range 0–40) and above (Saunders et al., 1993). The AUDIT is a 10-item, 5-point Likert-type scale developed to identify problematic drinking (Saunders et al., 1993). The number of drinks consumed in the past year was calculated as the product of drinking frequency in the past 12 months and the number of drinks typically consumed per occasion. Gender was assessed using a dichotomous item (0 = female, 1 = male), age was assessed using a 3-category item (1 = 18–34, 2 = 35–45, 3 = 55+), marital status was assessed using a 4-category item (1 = married/partnered, 2 = widowed, 3 = divorced/separated, 4 = never married), and education was assessed using a 4-category item (1 = less than high school diploma, 2 = completed high school, 3 = some post-secondary education, 4 = university degree). Interview year was treated as ordinal to investigate the change at each year from baseline (baseline = 1999).

Analytic plan

Stata version 15 (StataCorp, 2017) was used for all analyses. All estimates and statistical tests were corrected for the sampling design by using a weighted sample size. Binary logistic regression analyses for survey data (svy: logit) (Lee & Forthofer, 2005) were used to test the associations among gender, past-year alcohol use, past-year problem drinking, the number of drinks consumed in the past year, age, marital status, education, and interview year on current antidepressant use. Next, two additional models were conducted to investigate whether past-year alcohol use and past-year problem drinking significantly altered the rates of antidepressant use per year. Last, a model tested an interaction to determine whether the association between problem drinking and antidepressant use differed by gender. These models controlled for the number of drinks consumed in the past year, age, marital status, and education status. The interactions were tested using a Wald test and probed using a Bonferroni correction using the ‘contrast’ command in Stata. Finally, logistic regression analyses were conducted within each subpopulation using the ‘subpop’ command in Stata (e.g., past-year alcohol users and problem drinkers) to examine the effects of each variable on antidepressant use within each subpopulation.

Results

Descriptive statistics of the weighted full sample and the past-year alcohol use and problem drinking subpopulation samples are provided in Table 1. Approximately 80% of the overall sample (combined across years) identified as past-year alcohol users, 13% identified as past-year problem drinkers, and approximately 7% used an antidepressant in the past year. Among past-year alcohol users, approximately 52% identified as female, 17% were past-year problem drinkers, and 6% used antidepressants in the past year. Among past-year problem drinkers, 28% were female and 8% used antidepressants in the past year.

Table 1.

Descriptive statistics of study variables

Full samplea Past-year alcohol using subpopulationa Past-year problem drinking subpopulationa
Female 51.9% 49.6% 27.7%
Age
 18–34 28.9% 30.0% 47.4%
 35–54 39.8% 40.9% 35.7%
 55+ 31.3% 29.0% 16.9%
Marital status
 Never married 22.8% 23.3% 40.1%
 Married/partner 65.2% 65.8% 51.4%
 Widowed 4.9% 3.8% 1.3%
 Divorced/separated 7.2% 7.1% 7.3%
Education
 Did not complete high school 11.4% 9.5% 9.8%
 Completed high school 23.5% 22.8% 25.9%
 Some post-secondary education 34.1% 35.4% 38.4%
 University degree 31.0% 32.4% 25.9%
Mean drinks consumed in past year (SD) 167.96 (367.37) 212.03 (399.53) 676.08 (669.67)
Drinkers 79.6% - -
Problem alcohol users 13.4% 17.0% -
Using antidepressants 6.6% 6.4% 8.2%
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aWeighted sample. SD standard deviation

Among the entire sample, the rates of past-year antidepressant use, as compared with 1999, were significantly higher in every year with the exception of 2001 (see Table 2). The rate of past-year antidepressant use was approximately 9% in 2017 (see Fig. 1 and Table 3), with the highest probability of using antidepressants occurring in 2015 (OR = 2.9, 95% confidence interval (CI) [2.21, 3.79]). There was an average yearly change of +0.33% in antidepressant use prevalence among the full weighted sample and Table 3 shows the prevalence rates by year. Correlates associated with an increased risk of past-year antidepressant use included identifying as a female (OR = 2.12, 95% CI [1.87, 2.40]), endorsing past-year problem drinking (OR =1.46, 95% CI [1.21, 1.78]), being middle aged (35–55) relative to younger (18–34) (OR = 1.56, 95% CI [1.30, 1.87]), being divorced/separated (OR = 1.78, 95% CI [1.45, 2.19]) relative to single, and having less than a post-secondary education degree (ORs 1.38–1.67; see Table 2). Interaction analyses indicated that neither past-year alcohol use (Wald test F [df] = 0.98 [15], p = 0.468) nor past-year problem drinking (Wald test F [df] = 1.40 [15], p = 0.138) significantly interacted with interview year, signifying that past-year antidepressant use increased relatively equally across the overall sample and past-year drinking and problem drinking subpopulations. However, the problem drinking-by-gender interaction was significant (Wald test F [df] = 11.55 [1], p < 0.001), indicating that problem drinking significantly increased the probability of using antidepressants among women (OR = 1.87, p < 0.001) but had no effect among men (OR = 1.09, p = 0.956).

Table 2.

Logistic regression of past-year antidepressant use correlates

Full sample1 Past-year alcohol drinking1 Past-year problem drinking1
OR (SE) 95% CI OR (SE) 95% CI OR (SE) 95% CI
Female gendera 2.12 (0.13) 1.87, 2.40 2.52 (0.18) 2.18, 2.90 3.54 (0.52) 2.65, 4.73
Alcohol drinkerb 0.88 (0.06) 0.77, 1.00 - - - -
Problem alcohol usec 1.46 (0.14) 1.21, 1.78 1.50 (0.15) 1.23, 1.82 - -
Aged
 35–54 1.56 (0.15) 1.30, 1.87 1.32 (0.14) 1.08, 1.61 1.27 (0.30) 0.81, 2.01
 55+ 1.20 (0.12) 0.98, 1.47 0.99 (0.11) 0.79, 1.23 1.02 (0.27) 0.60, 1.73
Marital statuse
 Married/partnered 0.75 (0.07) 0.63, 0.89 0.87 (0.09) 0.71, 1.06 1.20 (.28) 0.76, 1.89
 Widowed 0.96 (0.13) 0.74, 1.24 1.17 (0.19) 0.85, 1.61 1.64 (0.61) 0.79, 3.40
 Divorced/separated 1.78 (0.19) 1.45, 2.19 1.94 (0.23) 1.53, 2.46 2.39 (0.69) 1.36, 4.20
Educationf
 Did not complete high school 1.67 (0.07) 1.38, 2.01 1.69 (0.20) 1.34, 2.13 1.88 (0.50) 1.12, 3.17
 Completed high school 1.38 (0.10) 1.19, 1.59 1.34 (0.11) 1.14, 1.58 1.20 (0.23) 0.82, 1.76
 Some post-secondary education 1.40 (0.09) 1.23, 1.59 1.32 (0.10) 1.15, 1.53 1.01 (0.17) 0.72, 1.41
Drinks consumed in past year 1.01 (0.01) 0.99, 1.02 1.01 (0.01) 1.00, 1.02 1.01 (0.01) 1.00, 1.02
Interview yearg
 2001 0.99 (0.16) 0.72, 1.36 1.21 (0.23) 0.83, 1.76 3.08 (1.71) 1.04, 9.12
 2002 2.29 (0.35) 1.70, 3.10 2.72 (0.49) 1.92, 3.86 8.29 (4.35) 2.98, 23.21
 2003 2.17 (0.32) 1.62, 2.91 2.60 (0.46) 1.84, 3.67 7.25 (3.81) 2.59, 20.33
 2004 1.53 (0.24) 1.13, 2.07 1.72 (0.31) 1.21, 2.46 2.80 (1.54) 0.95, 8.20
 2006 2.02 (0.31) 1.50, 2.71 2.39 (0.43) 1.68, 3.39 5.45 (2.91) 1.92, 15.50
 2008 1.83 (0.29) 1.34, 2.50 2.41 (0.44) 1.69, 3.44 5.33 (2.89) 1.84, 15.44
 2009 1.89 (0.30) 1.39, 2.57 2.19 (0.40) 1.53, 3.12 6.36 (3.44) 2.20, 18.38
 2010 2.10 (0.32) 1.56, 2.82 2.68 (0.47) 1.90, 3.80 4.76 (2.54) 1.67, 13.56
 2011 2.24 (0.35) 1.66, 3.04 2.80 (0.51) 1.96, 3.98 8.71 (4.76) 2.98, 25.41
 2012 2.04 (0.31) 1.52, 2.74 2.41 (0.43) 1.71, 3.41 4.88 (2.70) 1.65, 14.43
 2013 2.33 (0.38) 1.69, 3.21 2.82 (0.54) 1.93, 4.11 8.25 (4.58) 2.78, 24.51
 2014 2.89 (0.45) 2.13, 3.91 3.57 (0.65) 2.49, 5.10 13.89 (7.70) 4.69, 41.18
 2015 2.90 (0.40) 2.21, 3.79 3.42 (0.55) 2.50, 4.69 8.06 (4.09) 2.98, 21.81
 2016 2.48 (0.40) 1.82, 3.40 2.84 (0.53) 1.96, 4.12 7.74 (4.40) 2.54, 23.57
 2017 2.88 (0.48) 2.07, 4.00 3.46 (0.68) 2.36, 5.08 6.18 (3.73) 1.89, 20.19
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CI confidence interval, SE standard error. 1Weighted sample. aMale as reference group. bNon-drinker as reference group. cNon-problem drinker as reference group. d18–34 as reference group. eNever married as reference group. fUniversity degree as reference group. gYear 1999 as reference group. Bold = significant at p < 0.05

Fig. 1.

Fig. 1

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Past-year antidepressant use prevalence among Ontario adults, past-year alcohol users, and past-year problem drinkers. There are no data for years 2000, 2005, and 2007

Table 3.

Yearly antidepressant use prevalence rates

Past-year prevalence rate of antidepressant use
Year Full sample1 Alcohol using1 Problem drinking1
1999 3.59% 2.95% 1.53%
2001 3.64% 3.71% 4.25%
2002 8.26% 8.17% 12.06%
2003 7.33% 7.24% 9.54%
2004 5.39% 4.88% 3.89%
2006 6.56% 6.24% 6.85%
2008 6.02% 6.43% 7.96%
2009 6.21% 6.03% 8.77%
2010 7.51% 7.33% 6.44%
2011 7.08% 7.22% 12.46%
2012 6.68% 6.44% 6.42%
2013 7.46% 7.31% 10.44%
2014 8.89% 8.96% 16.42%
2015 8.72% 8.45% 9.98%
2016 7.73% 7.13% 10.08%
2017 8.85% 8.56% 8.21%
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1Weighted sample. There are no data for years 2000, 2005, and 2007

Examination of potential correlates with past-year antidepressant use among the past-year alcohol using and problem drinking subpopulations indicated that self-identified gender and marital status each had consistent effects on past-year antidepressant use among the different populations (see Table 2). With the exception of not completing high school among past-year problem drinkers (OR = 1.88, 95% CI [1.12–3.17]), level of education completed and age were not associated with past-year antidepressant use among past-year alcohol users and problem drinkers (see Table 2). Similar to the analyses among the entire sample, the rate of antidepressant use was significantly higher in most years after 1999 in both the past-year alcohol using and problem drinking subpopulations (see Table 3 for prevalence rates).

Discussion

This study sought to investigate the rate of and change in past-year antidepressant use from 1999 to 2017, and whether past-year alcohol use and problem drinking were associated with an increase in past-year use of antidepressants over time among a sample of Ontario residents. The results indicate that the odds of using antidepressants in the past year have increased since 1999, with rates of use in 2017 nearing approximately 9% of the Ontario adult population, higher than those reported in previous studies among the entire Canadian population (e.g., 5.5%) (Hemels et al., 2002; Patten et al., 2014). Interestingly, the general increase in past-year antidepressant use from 1999 to 2017 among the entire sample was similar to the increases among past-year alcohol drinkers and past-year problem drinkers, highlighting that past-year alcohol use and abuse is not associated with faster increases in antidepressant use.

Although alcohol use and abuse did not affect the increase in past-year antidepressant use over time, individuals with past-year problem drinking were 1.5 times more likely to endorse past-year antidepressant use relative to those who were not past-year problem drinkers. This is consistent with research showing that problem drinking is comorbid with a number of psychological disorders typically treated with the use of antidepressants (Grant et al., 2004; Hasin et al., 2007; Smith & Book, 2010). Given that mental disorders comorbid with AUD tend to result in more severe consequences than those without AUD (Alegría et al., 2010; Blanco et al., 2012; Burns & Teesson, 2002; Keel et al., 1999), and as there are concerns that antidepressant use may exacerbate alcohol use problems (Chick et al., 2004; Kranzler et al., 1996), continued investigation into both the rates of antidepressant use among problem drinkers and the potential impact of combined alcohol and antidepressant use on drinking and mental health-related outcomes is necessary.

It is also important to note that the association between problem drinking and an increased probability for antidepressant use is inconsistent with two US studies that did not find this effect. However, differences in the study design may explain these discrepancies. First, the Koopman et al. (2003) study, which found no association between problem drinking and antidepressant use, was conducted among a biased sample of educated employees from a single company. As such, these individuals may have been less likely to exhibit problem drinking as it may have interfered with their employment. Second, the Breslow et al. (2015) study found that non-drinkers were more likely to use antidepressants relative to drinkers, but the study did not quantify ‘problem drinking’. Indeed, the current study found that past-year alcohol drinking was not associated with antidepressant use, but problem drinking, as assessed by the AUDIT, was associated with an increased likelihood of using antidepressants in the past year.

A significant problem drinking-by-gender interaction indicated that problem drinking led to a greater probability of antidepressant use among women but had no effect among men. This is partially consistent with research that found antidepressant use to be associated with less alcohol consumption among depressed men relative to depressed women (Graham & Massak, 2007). However, as these results of the current study are correlational, several other factors may contribute to this finding. Women are not only more likely to be diagnosed with disorders that are typically treated with antidepressants (e.g., anxiety, depression) (Jalnapurkar et al., 2018; Weissman et al., 1993), but they are more likely to initially present for treatment (Coffino et al., 2019; Kessler et al., 1981; Liddon et al., 2018) and are more likely to be overprescribed antidepressant medications relative to men (Mojitabai & Olfson, 2011; Sundbom et al., 2017). As such, these factors may also account for the strong effects between antidepressant use and problem drinking among women.

The current study had several strengths, including the use of a large combined sample of residents from Ontario, Canada, spanning across 18 years and the use of a well-validated alcohol problems inventory. Several limitations must also be noted. First, the current study did not assess for mental health diagnoses; therefore, we could not identify the disorder for which the antidepressants were prescribed. Next, no causal inferences between problem drinking and antidepressant use can be made as the data are cross-sectional. Longitudinal research following the same participants for multiple assessments to understand the causal influences on using antidepressants is needed. Third, although attempts were made to reduce bias by including cellular phone numbers, research indicates that telephone surveys can lead to biased results due to technological advancements such as call screening and number portability (Kempf & Remington, 2007). Last, as only data from the Ontario province were used, these data may not generalize to the Canadian population outside of Ontario. Future studies should include Canadians from all provinces.

Conclusion

The results of this study indicate that past-year antidepressant use increased from 1999 to 2017 and that this increase was similar among a representative sample of Ontarians, past-year alcohol users, and past-year problem drinkers. Overall, past-year problem drinkers were approximately 1.5 times more likely to endorse using antidepressants in the past year, highlighting the need for continued investigation into the co-use of alcohol and antidepressants.

Contributions to knowledge

What does this study add to existing knowledge?

  • This was the first study to assess the rates of antidepressant use among alcohol drinkers and problem drinkers in a general population sample of Ontarians.

  • Since 1999, the rate of antidepressant use has increased to approximately 9%, which is higher than rates reported in comparable studies.

  • Although problem drinkers were significantly more likely to endorse using antidepressant medications, alcohol drinking and problem drinking did not contribute to the rate in which antidepressant use increased.

What are the key implications for public health interventions, practice or policy?

  • Past-year alcohol problem drinkers are 1.5 times more likely to endorse using antidepressants than non-problem drinkers.

  • Given that the co-use of alcohol and antidepressants may lead to potentially dangerous effects, efforts should be made to monitor problem drinkers who are also using antidepressants.

Author contributions

All authors contributed to the study conception and design. Jesus Chavarria conducted the analyses and developed the full draft of the manuscript. Dr. Jürgen Rehm conducted the analyses and provided edits on all drafts. Drs. Tara Elton-Marshall and Samantha Wells provided feedback on all drafts.

Funding

Dr. Jürgen Rehm and Dr. Tara Elton-Marshall acknowledge funding from Canadian Institutes of Health Research (CIHR) for the Ontario CRISM Node Team (grant # SMN-139150).

Data and code availability

It is our policy that external researchers require a user agreement and approval to use our data. Contact Yeshambel Nigatu (Yeshambel.Nigatu@camh.ca) to inquire about obtaining the data. Contact Jesus Chavarria (jesus.chavarria@camh.ca) to inquire about obtaining the analysis code.

Declarations

Ethics approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee at both CAMH (#305-2009) and York University (#2019-017) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Consent to participate

Verbal informed consent was provided by all participants in the current study.

Consent for publication

Not applicable.

Conflict of interest

The authors declare no competing interests.

Disclaimer

The funder had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

It is our policy that external researchers require a user agreement and approval to use our data. Contact Yeshambel Nigatu (Yeshambel.Nigatu@camh.ca) to inquire about obtaining the data. Contact Jesus Chavarria (jesus.chavarria@camh.ca) to inquire about obtaining the analysis code.

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