Introducing a practical tool to reduce fear and anxiety during COVID-19

The World Health Organization (WHO) declared coronavirus disease 2019 (COVID-19) a public health emergency of international concern on January 30, 2020,¹ and a pandemic on March 11, 2020.² Following these announcements, nations around the world, including Canada, have implemented extreme physical distancing measures to try to reduce the spread of infection across populations.³ These measures have included school closures; event cancellations; restaurant, bar, gym, library, community centre and places of worship closures; travel restrictions; and “stay-at-home” orders for citizens.

While the focus has been on reducing infection transmission rates, acute psychological stress, including anxiety and fear, has emerged as a separate population harm that requires our immediate attention. Anxiety and fear were highly prevalent in individuals affected by severe acute respiratory syndrome (SARS) in 2003.⁴ Recognizing the potential for significant adverse psychological sequelae with the COVID-19 pandemic and the need for the public to have access to evidence-based tools to promote mental health, we created a freely accessible and practical tool to address this important issue.

For the purposes of conceptual clarity, we define fear as a proximal alarm reaction to an immediate real or perceived threat and anxiety as a negative emotive state characterized by anticipation of future threat.⁵ Both fear and anxiety exist on spectrums from low to high and are often normal and adaptive responses. For example, some anxiety about an upcoming presentation or job interview is normative, as is fear if one were confronted with a threatening situation, such as seeing a bear in the woods. However, fear and anxiety may escalate, be out of proportion with the danger posed and develop into more serious psychological disorders affecting eating, sleeping and participation in enjoyable activities.⁶

A 2013 systematic review demonstrated that anxiety disorders are a common problem, with a global prevalence of 7%.⁷ The World Health Assembly created the “Comprehensive Mental Health Action Plan for 2013-2020,” aimed at promoting mental health well-being.⁸ The COVID-19 pandemic and the extreme public health countermeasures undertaken to halt its spread, such as physical/social distancing, have ballooned perceived and actual threats to a massive scale, increasing the risk for anxiety disorders. These threats span all aspects of an individual’s well-being, including the threat related to contracting the disease itself as well as threats related to personal circumstances created by societal disruptions and restrictions (e.g., other health concerns, interruptions in education and employment, social isolation) and general uncertainty about the future. Compounding these already significant challenges is that the very coping strategies many individuals used are now also disrupted through the loss of or challenges accessing in-person social networks, outdoor environment/green spaces, shared or structured physical exercise, community events and organized spiritual worship. Importantly, individuals of all ages, including children, are susceptible to stressors, fear and anxiety. As social creatures, we often look to each other to understand how to respond to a novel situation; this is often called “social referencing” or “social appraisal.”⁹ Unsurprisingly, worries can be “contagious” or spread from one person to another.¹⁰

We created a self-care tool to help the general public prevent and/or cope more effectively with low to moderate levels of acute fear and anxiety during COVID-19. The tool, called the CARD (C-Comfort, A-Ask, R-Relax, D-Distract) System, was originally developed for coping during vaccination, a common anxiety- and fear-inducing medical procedure.¹¹ Each letter of the word CARD includes related interventions that individuals can use to promote coping. The original tool has been adapted to focus on interventions to manage acute fear and anxiety more generally, consistent with a cognitive-behavioural approach.¹² Two versions have been created: one for parents to help their children (available online at www.cpjournal.ca) and one for individuals for themselves (Figure 1; full example available online). Examples of interventions in the different letter categories include finding comfort in maintaining daily routines, asking questions about worries, engaging in activities that keep one relaxed and limiting the amount of time spent focusing on worries.

Figure 1A.

The CARD System

Figure 1B.

Interventions to help reduce fear and manage anxiety

The CARD System offers a simple framework for people to remember different coping options. The ability to self-select or customize the approach (i.e., play your own CARDS) also empowers individuals and allows them to have some control over their situation. CARD helps both children and adults to learn about and build the necessary skills and confidence needed to cope with fears and anxieties that are associated with COVID-19 and other stressful situations. This may include worries that prevent individuals from accepting vaccines, including a future COVID-19 vaccine that may be offered to protect against the disease.¹³

Evidence-based resources that can be recommended to support individuals with their mental health care needs are in high demand. This includes resources for pharmacists and other pharmacy staff. As frontline workers, pharmacists and pharmacy staff bear additional risks for contracting COVID-19 and interact with patients expressing worries about COVID-19. These situational factors may fuel increases in their own stress levels. Pharmacists can use tools such as CARD and recommend it to others to promote mental health. This is particularly relevant now, when access to mental health care providers is limited by physical distancing measures and economic barriers but access to pharmacists continues. It is important to note, however, that individuals who present with more severe symptoms, such as sleep or eating disturbances, are advised to seek help from a health care professional trained in managing anxiety disorders.

In summary, CARD promotes mental health well-being by teaching people about different strategies that they can use to self-manage acute, low to moderate symptoms of anxiety and fear. In addition to being included in this article (and online at www.cpjournal.ca), the CARD tool is currently freely accessible on websites hosted by various national organizations (including Immunize Canada, Anxiety Canada, Canadian Paediatric Society), as well as on The Hospital for Sick Children’s online health information website for the public (https://www.aboutkidshealth.ca/covid-19). This resource can be posted and freely distributed to pharmacy staff and clients. The originally developed CARD tool¹¹ can be similarly posted and distributed to address fear and pain associated with vaccination injections, well-documented and preventable barriers to vaccination,¹⁴ and to increase acceptance of a new COVID-19 vaccine. The original CARD tools can be found at https://www.aboutkidshealth.ca/card.