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Effective treatment of stress

Jennifer Wild
Consultant Clinical Psychologist
Institute of Psychiatry
King's College London

While many patients present with a range of health problems, it is certain that almost all will be experiencing stress. What is current best practice for assessing and treating this problem?

The stress patients suffer could be a symptom of a health condition or linked to worries about health or to the ups and downs in life. Patients may even be suffering from post-traumatic stress disorder, a severe stress reaction that develops after traumatic events like a major car accident or a physical attack.

Stress has measurable physical health effects and can make some health problems worse, and primary care nurses have a crucial role in helping patients to manage their stress. Frontline staff are best placed to give key advice for stress whether they see patients at the surgery or are visiting families in their homes.

With help and proper advice, patients can learn to manage their stress and reap wide-ranging benefits, such as more effective problem-solving, faster recovery rates, and a greater sense of happiness and wellbeing.

Assessment
The first thing to do when diagnosing stress is to know the signs and symptoms. Some of these may be symptoms of an underly- ing mental health problem, while others are the product of coping with a physical condition, such as cancer, or a difficult life event, such as job loss.

Signs and symptoms
Feeling overly tired, irritable, unable to cope, burnt out, hopeless, or overwhelmed are some symptoms of stress. Others include feeling run-down, tense, jumpy, prone to colds, difficulty making decisions, sleeping poorly, feeling on edge and difficulty relaxing when there is opportunity to relax.

Current best treatment
Current best treatment involves informing patients of appropriate psychological help when stress is a symptom of depression, anxiety, or post-traumatic stress disorder. When stress is linked to lifeevents, worries about health, or unhelpful coping behaviours, then identifying the vicious cycle of stress will help inform which practical tips and resources to offer your patients, many of which are outlined here.

Stress as a sign of depression
When your patient's key symptoms of stress are coupled with low mood, tearfulness and loss of interest in fun activities, then they may be suffering from depression.

Encourage your patient to chat to their GP, especially if they have experienced thoughts of ending their life. When depression is mild or moderate, exercise is crucial and is also recommended by the National Institute for Health and Clinical Excellence (NICE).

When patients are depressed they typically avoid exercise. It is important to encourage them to increase their activity. To do this, they need to be reminded to make decisions about getting active based on how they want to feel rather than how they are feeling. Exercise will raise their energy levels and foster better coping and problem-solving.

Cognitive behavioural therapy (CBT) is an excellent treatment for mild and moderate depression and is recommended by NICE. Patients can receive treatment as part of the Improving Access to Psychological Therapies (IAPT) programme. They may self-refer or their GP can refer them to a local IAPT service.

CBT works by helping patients to change the thoughts that are linked to low mood and to change the unhelpful behaviours that are keeping their depression in place.

Stress as a sign of generalised anxiety disorder
When your patient shows signs of stress and these are coupled with uncontrollable worries about many topics, such as their health, their finances, their children, their job satisfaction and performance and so on, then your patient may be suffering from generalised anxiety disorder (GAD).GAD is a common anxiety problem that also has physical symptoms that overlap with symptoms of stress, such as feeing on edge, keyed up, unable to relax and feeling tense.

If you think that GAD may be your patient's source of stress, then encourage them to chat to their GP. They may refer them to the IAPT where CBT will be offered for this anxiety problem.
stress As A sign of post-trAumAtic stress disorder When people have suffered a trauma, such as a physical assault or car accident, they will experience stress afterwards. This may be in the form of symptoms of post-traumatic stress disorder (PTSD), such as unwanted memories of the event or it may be due to the consequences of the trauma, particularly if litigation is involved.

It is important to determine whether your patient's stress symptoms may be signs of PTSD. The key symptoms of PTSD include unwanted memories of the trauma that pop into their mind, and avoiding reminders of the trauma, such as the area where it occurred, and feeling hyper-aroused. This includes feeling more irritable, alert, and more jumpy, especially in response to loud noises as well as having difficulty concentrating and sleeping.

If your patient has experienced a trauma and they are showing some of these symptoms, they may be suffering from PTSD. In the first month after a trauma, such symptoms are normal. However, if they last longer than a month, then your patient would benefit from a trauma-focused psychological intervention, such as CBT or eye movement desensitisation and reprocessing therapy, which are recommended by the NICE guidelines.

Practical advice
All too often, stress is a part of our daily lives and the best treatment is ensuring it does not escalate. Typically, stress affects four key domains: our body, thoughts, feelings, and behaviours, and a vicious cycle sets in that keeps stress going.
The best way to treat stress is to break the cycle. This can be achieved by targeting it from a cognitive behavioural point of view; that is, to target the factors that are keeping it going.

It is usually more practical and effective to first address theunhelpful behaviours that perpetuate stress. These may include staying up late, avoiding work or dealing with a key problem, drinking, taking recreational drugs, and eating junk food.

Sleep
Helping your patients to establish a healthy sleep routine is highly beneficial. Good sleep improves mood, and research shows that happier moods are linked to more effective problem-solving. Patients should be encouraged to go to sleep at the same time every night and to get up at the same time in the morning. If patients are unable to sleep within 20 minutes of going to bed, they should get up and read a book or listen to sounds of nature or gentle music before going back to bed.

Worrying can keep people awake. Useful guidance is to encourage your patient to write out their worry and then follow the worry decision tree. If they can do something about it, such as send an email or gain information from the internet, then they should do so. If there are no steps that they can immediately take to solve the problem and linked worry, then they should be encouraged to write out a list of steps that would be helpful to start the next day. Then they should go back to bed.

Procrastination
Avoiding tasks and deadlines only serves to increase stress and lead to more unhelpful behaviours. Patients should be encour- aged to make a list of the tasks they are facing and break them down into small achievable steps.

Drinking and drugs
The government guidelines recommend a maximum of 21 units of alcohol per week for men and 14 units per week for women. If your patients are drinking more than this or their drinking has recently increased, they would benefit from monitoring. If they find that they are showing signs of intolerance or are unable to reduce their drinking, then they may be on the road to depend- ence and would benefit from visiting an alcohol service. The same is true for recreational drugs.

Eating junk food
Sugary food and drink give the body an initial buzz and then blood sugar levels plummet, leading to feelings of fatigue and poor concentration. If your patient's diet is unhealthy clear guidance on healthy eating will be helpful. Suggest eating three meals a day, which includes vegetables, and choosing snacks that release energy slowly, such as cheese and crackers rather than chocolate bars. Make sure your patients are drinking enough water.

Exercise
Recommended by NICE for treating mild and moderate depres- sion, exercise is always a helpful behaviour for improving mood and reducing stress. It clears the mind and also improves sleep patterns. Encourage your patients to go for a brisk walk or engage in another cardio activity of 20 minutes five times per week as recommended by the Department of Health.

Learning to relax
The cycle of stress can become ingrained and breaking out of it involves changing unhelpful behaviours as well as learning new ones. People who have been stressed for a long time may need to learn how to relax. A few minutes of mindful breathing ormeditation every day will help to restore a sense of calm and promote relaxed feelings. Meditation is recommended by BUPA and has been linked to enormous health benefits.

Conclusion
Most patients will be suffering from stress, which may be linked to their physical or mental health, or to events in their lives.

Primary care nurses need to rule out the key psychological problems in which stress is a symptom, such as depression, generalised anxiety disorder, and post-traumatic stress. If patients are suffering from these conditions, then an evidence-based treatment, such as CBT, will help.

If stress is related to financial concerns, such as debt, or the exhaustion of caring for others, then external resources will help. The Citizen's Advice Bureau offers free financial and legal advice. NHS Choices provides information on respite for carers (see Resources).

There are numerous support groups for people with a range of health problems, such as cancer, diabetes or leukemia, and patients may benefit from being guided to these.

To break the cycle of stress, patients will need to identify the behaviours that are keeping their stress going and replace them with more helpful behaviours. As their behav- iours change, they will experience more effective problem- solving, positive feelings and adaptive thoughts.

It is important to recognise that it takes time to change unhelpful habits, and one of the best approaches to treating stress is to take one day at a time, break every problem into manageable steps, and seek the support of friends and family.
As the nation's healthcare moves toward promoting personal responsibility for health, recognising and managing triggers for poor health is crucial. Since stress exacerbates ill health, recognising and managing stress has the potential to prevent some health problems and improve management of existing health conditions, one of the key goals of the NHS. Here, nurses have a major role. Helping patients to manage their stress today will ultimately reduce costs of care in the long-term.

Resources
NICE Guidelines: Depression http://guidance.nice.org.uk/CG90 NICE Guidelines: PTSD www.nice.org.uk/CG26
NHS Choices: Alcohol and Drugs www.nhs.uk/Livewell/alcohol/Pages/Alcoholhome.aspx
Improving Access to Psychological Therapies (IAPT) Programme www.iapt.nhs.uk
Department of Health Advice: Exercise
www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publication PolicyAndGuidance/DH_4080994
BBC: Sleep www.bbc.co.uk/science/humanbody/sleep/
BUPA: Meditation www.bupa.co.uk/individuals/health-information/directory/m/hi-meditation
NHS Choices: support groups for parents, carers and specific health conditions www.nhs.uk/Pages/HomePage.aspx