On Tuesday, February 9th, 2021, the quality standards team at Ontario Health hosted a webinar for a primary care audience to talk about how to manage and recognize anxiety disorders during the COVID-19 pandemic.
The webinar was moderated by Dr. David Kaplan, who is a family physician and Chief of Clinical Quality at Ontario Health. Our featured speakers included:
- Randi E. McCabe, BSc, MA, PhD, Director of the Anxiety Treatment and Research Clinic, Psychologist-in-Chief, Mental Health and Addictions Program at St. Joseph's Healthcare Hamilton, Professor, McMaster University, and Co-chair of the Anxiety Disorders and OCD Quality Standards Committee
- Peggy Richter, MD, FRCP(C), Head of the Frederick W. Thompson Anxiety Disorders Centre at Sunnybrook Health Sciences Centre, Associate Professor, University of Toronto, and Co-Chair of the Anxiety Disorders and OCD Quality Standards Committee
- Ethan Chilcott, a student with lived experience of anxiety disorders
- Paul Kurdyak, MD, PhD, FRCPSC, Medical Lead for the Mental Health and Addictions Centre of Excellence
With the help of the expertise from our speakers, we are sharing the answers to the questions we received during the webinar. We have compiled the questions and grouped them based on their topic. If you have any additional questions, comment below or you can email qualitystandards@ontariohealth.ca.
WEBINAR FOLLOW-UP
1. Was the webinar recorded so it can be accessed after the event?
Yes, the link to the recording was shared by email to all webinar registrants and can be found at this link here. The access passcode is: 2u!QnFgM (the password is case sensitive).
2. Will there be a copy of the webinar presentation slides available after the webinar?
Yes, a copy of the webinar slides was shared by email to all webinar registrants and has been attached to this post.
3. Will the webinar be eligible for CPD/CME/Mainpro+ certification credits for attendees?
No, unfortunately this webinar is not eligible for accredited continuing medical education credits. We will be looking into making this possible for future webinars.
LIVED EXPERIENCE STORY
4. Could you speak a bit more to how being able to get your care with your family doctor was different in terms of trust or stigma?
Ethan Chilcott (student with lived experience of anxiety disorders): I definitely was more comfortable speaking to my family doctor about the medication and my mental health knowing from past experience that she was supportive regarding such issues and always willing to help. With new treatment providers I'm always a bit more reluctant to divulge too much information about my ongoing struggles with mental illness because I'm not sure how they respond to that kind of discussion. While I'm not too worried about stigma with medical professionals, I definitely prefer to not give too many details about my symptoms, so its appreciated when a provider either knows me (like my GP) or trusts my appraisal of my symptoms enough to not ask overly intrusive questions about symptoms unless strictly necessary.
IDENTIFICATION, ASSESSMENT, AND COMPREHENSIVE ASSESSMENT
5. Is it still called a panic attack if it is provoked by a stressful event?
Yes, stressful events can trigger panic attacks.
6. Is there a difference in sensitivity and specificity of the two sample screening questions presented for anxiety?
The two example screening questions presented during the webinar for generalized anxiety disorder were: 1) during the past 4 weeks, have you been bothered by feeling worried, tense, or anxious most of the time? 2) Are you frequently tense, irritable, and having trouble sleeping?
Both questions are geared to picking up the symptoms of generalized anxiety disorder. The first question is general and will likely be endorsed by those experiencing other presentations of anxiety disorders as well. However, if someone is endorsing the second question that they are feeling worried, anxious or tense most of the time, it is likely they do need some form of intervention.
7. Is there specific information regarding the differences between children and adults, care, treatments?
The Anxiety Disorders Quality Standard includes information that is relevant for children and adolescents (under age 18 years). The following are clinical practice guidelines with recommendations for children and adolescents:
- Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders from the American Academy of Child & Adolescent Psychiatry, 2020 (link)
- Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder, 2018 (link)
- Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorder, from Martin A. Katzman et al. on behalf of the Anxiety Disorders Association of Canada and McGill University, 2014 (link)
- NICE Clinical Guideline - Social Anxiety Disorder: recognition, assessment, and treatment, 2013 (link)
TREATMENT: SELF-HELP
8. What are ways to encourage patients to try self-help resources?
Dr. Randi McCabe:
- Don't recommend too many resources at once. Recommend a couple and then follow back up to see what they thought about them
- Consider further follow up brief sessions to check in on their symptoms as they progress through working through a particular resource/workbook geared to their primary concern
9. Do you have any suggestions for workbooks and where we can find them?
Dr. Peggy Richter: There are a number of good websites which curate their list of workbooks. For example, Anxiety and Depression Association of America and Anxiety Canada.
10. What are your thoughts on breathing techniques and meditation as treatments for anxiety disorders?
Dr. Peggy Richter: Relaxation and breathing are not considered a standalone or required component of treatment but can nonetheless be very helpful. Mindfulness is increasingly being looked at in anxiety disorders and there are wonderful videos on YouTube as well as many very good apps which have some resources for free.
TREATMENT: COGNITIVE BEHAVIOUR THERAPY (CBT)
11. How are CBT therapies available for patients in Ontario? What is the list of sites where Ontario Structured Psychotherapy program is currently available?
Some of the free available resources for patients include:
- Internet-Based Cognitive Behavioural Therapy (iCBT)
- MindBeacon Therapist Guided Program: free mental health support (based on CBT) for Ontario adults aged 16+ who are dealing with stress, anxiety, depression and more
- AbilitiCBT by Morneau Shepell: an iCBT program you can access from any device, at any time. Move through 10 structured modules, at your own pace, while your therapist monitors your progress
- Ontario Structured Psychotherapy (OSP) Program for depression and anxiety: offered through four pilot regions and will be expanded to other parts of the province over the next year. The pilot network leads are included below:
For additional self-help/lower intensity treatment resources for patients that were shared during the webinar, please see the presentation slide deck attached to this post.
12. How can our clinic/our region get involved with the Ontario Structured Psychotherapy program moving forward?
This information is being finalized and will be shared broadly as soon as it becomes available.
13. Are there any CBT training course resources you would recommend/suggest?
Dr. Randi McCabe: CBT should be provided by a health care professional with training in delivery of CBT specific to anxiety disorders (CACBT certification preferred). CBT training resources include:
14. Are there other resources for mental health conditions that are refractory to CBT?
Dr. Randi McCabe: CBT is an action-oriented treatment and requires a patient to be ready to engage in a change strategy. Therapy requires patient effort and openness to learning new information and practicing different strategies to manage anxiety.
If it appears a patient is refractory to CBT, it may be that it was not the right time for them to engage in treatment (e.g., not ready in terms of time required or psychological readiness). In addition, if there has not been full engagement, the patient may not have received an adequate “dose”. This does not mean that it would not work at a different time in the future.
Alternate approaches to consider include pharmacotherapy and other psychotherapeutic approaches (e.g., mindfulness and acceptance-based approaches). It should also be determined whether the CBT was focused on the principal concern. Anxiety disorders are often comorbid with other conditions including other anxiety disorders. If the CBT is focused on a problem that is not of principal concern, then it may not be successful in leading to symptom reduction.
TREATMENT: MEDICATION
15. What is the preferred choice of pharmacotherapy for adolescents with anxiety?
The following are clinical practice guideline include recommendations for children and adolescents:
- Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders from the American Academy of Child & Adolescent Psychiatry, 2020 (link)
- Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorder, from Martin A. Katzman et al. on behalf of the Anxiety Disorders Association of Canada and McGill University, 2014 (link)
16. How do you determine when a patient is in remission?
In the quality standard, remission is defined as when the patient has few or no substantial symptoms [following treatment]. Using a validated assessment measure to monitor symptom severity will help assist in determining remission when combined with patient self-report.
AVAILABLE RESOURCES
17. Where can I find the quality standards?
All of the completed quality standards can be found online here.
18. Where can I find the Anxiety Disorders placemat and/or patient guide?
Find the Anxiety Disorders placement here and the associated patient guide here.
19. What multilingual resources are available?
The quality standard resources are also available in French, including the anxiety disorders quality standard, patient guide, and placemat.
Here are some additional resources for patients that are available in French:
- Websites
- Telephone lines and system navigation support
Resources for patients available in additional languages:
- Fact sheets
- Fact sheets available in 25 languages from Centre for Addictions and Mental Health. (Link) Topics including: “About mental health”, “Asking for help when things are not right”, “Coping with stress”
- “What is an anxiety disorder?”, fact sheets are available in 22 languages (Link)
- Telephone lines and system navigation support
- ConnexOntario (1-866-531-2600): Identify your language and participate in a 3-way call with a translator (Link)
- Hope for Wellness Helpline (1-855-242-3310 or live web chat): immediate mental health counseling and crisis intervention for all Indigenous peoples across Canada (available in some Indigenous languages)
- Talk 4 Healing (1-855-554-4325, live web chat): Indigenous women can get help, support and resources 7 days a week, 24 hours a day with services available in 14 languages
20. Are there any system navigation or mental health resources specifically for older adults?
One of the resources shared during the presentation is not specifically for older adults, but is inclusive of older adults:
- ConnexOntario is a free 24/7 information and referral service for people experiencing mental illness, problems with alcohol and drugs, and/or gambling, which includes older adults.
21. Are you able to recommend mobile apps for meditation and anxiety? What is the evidence supporting the mobile apps (e.g., the Wysa chatbot app compared to Woebot chatbot app)?
Many mobile apps focus on mental health and mindfulness. For example:
- MindShift CBT (free)—an app from Anxiety Canada that uses strategies based on CBT to help develop more effective ways of managing anxiety
- Headspace (free trial)— an app that guides users through mindfulness and meditation exercises
- Wysa: Mental Health Support (free)—an app that works as an emotionally intelligent chatbot that uses AI to react to the emotions you express, supporting people with stress, anxiety, and depression
- Anxiety Coach ($4.99)— a self-help app that addresses fears and worries using CBT strategies
Please note that this is a list of example mobile apps, which are not validated by Ontario Health. Please visit ADAA.org (the Anxiety and Depression Association of America) for a list of reviews for apps based on ease of use, effectiveness, personalization, interactive/feedback, and research evidence.
VIRTUAL CARE AND ELECTRONIC MEDICAL RECORD (EMR) DEMONSTRATION
22. Do you have suggestions for a reasonable way to approach and manage anxiety in a virtual setting, keeping in mind the time constraints (e.g., 10 minutes or so)?
Dr. Randi McCabe and Dr. Peggy Richter:
- When working with someone with their anxiety in short time blocks, if a patient is interested in purchasing/using a workbook, then you could meet them for follow up sessions in 15-minute blocks. This is a guided self-help intervention since therapy is hard to do in 10-15 minutes. And then if that does not help then you might need to consider leveling up to more intensive CBT or medication
- If high-intensity CBT is available, it is an option that is working very well in the new virtual era. Many sites are also offering group therapy and individual therapy online
- Working virtually with patients can have its advantages, if it is lower barrier for patients to participate and health care providers can get more insight into how well the person may be coping at home
23. Where can I find the anxiety disorders placemat and patient guide resources for electronic medical records (EMR) that you mentioned during the webinar?
Please find the new Quality Standards Placemats available for download on Quorum to be used in your EMR for the following topics: anxiety disorders, osteoarthritis, and low back pain.
In addition, step-by-step guides to provide further support on how to integrate the placemats into specific EMRs are currently in development and will be released soon.
24. Which EMRs are compatible with the placemat and the patient guide?
The quality standard placemats and patient guides are currently available for the following EMRs: Accuro, PSS, and Oscar.
A step-by-step guide to provide further support on how to integrate the placemats into specific EMRs are currently in development and will be released soon.
25. If I don't have a compatible EMR, how can I access the placemat or patient guide?
You can access the quality standard and all of its resources for free online. Each resource can be viewed in your browser and/or downloaded as a PDF file to be viewed online or printed, including the Anxiety Disorders quality standard, placemat, and patient guide.