Many exam room opportunities missed to uncover stress

Up to 80% of primary care appointments have a stress-related component, but only 3% involve discussions on the pressures patients are experiencing.

By — Posted Nov. 30, 2012

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Doctors should routinely ask adult patients whether they feel stressed, says the lead author of a recent report on stress management in primary care.

Only 3% of primary care office visits involve stress management counseling, said a report published online Nov. 19 in the Archives of Internal Medicine.

However, another study shows that 60% to 80% of primary care appointments have a stress-related component. Pressures related to family, work and other issues can exacerbate common medical conditions such as cardiovascular disease by increasing blood pressure, cortisol levels, and heart and respiration rates, health professionals say.

Stress management counseling was defined in the Archives report as physicians offering patients information to help them reduce pressures in their lives through activities such as exercise. Stress management also could involve counseling patients on ways to cope with their pressures or referring them to specialists.

“Considering what we know about stress and disease, [the findings] clearly point to missed opportunities,” said Boston internist Aditi Nerurkar, MD, MPH, lead author of the study. She also is assistant medical director of Beth Israel Deaconess Medical Center and Cheng and Tsui Center for Integrative Care in Boston.

Dr. Nerurkar encourages physicians to have patients rate their overall stress levels from 1 to 10. Individuals who rate their pressures high could be referred to health professionals who can discuss ways to manage stress better, she said. Helping patients cope with stress could improve their happiness and lessen their risk of becoming ill, she added.

For the report, researchers examined National Ambulatory Medical Care Survey data on 34,065 adult primary care visits that occurred between 2006 and 2009. The visits involved 1,263 internists and family physicians nationwide.

Researchers found that stress management counseling was most common among patients who were younger, had multiple chronic conditions and lived in the Northeast. Physicians were more likely to counsel patients with depressive disorders than people with other conditions commonly seen in primary care, data show.

As expected, stress management counseling was associated with longer office visits, Dr. Nerurkar said (link).

The report shows that primary care physicians offer other forms of health counseling more frequently than they do for stress. For instance, 16.8% of all visits involved counseling for nutrition, 12.3% for physical activity and 6.3% for weight reduction.

“Our findings suggest that while primary care physicians are aware of the links between stress and depression, the role that stress may play in other nonmental health conditions may be less well-recognized,” the study said.

The ultimate goal is for primary care practices to adopt a team-based model where stress can be addressed by a staff member such as a health coach or health educator who is located on the site, the study said.

“New payment models designed to promote wellness will enable team-based primary care practices to add counseling and coaching staff to address stress, mental illness and behavioral change more effectively,” said co-author Russell S. Phillips, MD, director of the Harvard Medical School Center for Primary Care.

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