Yvette C. Terrie, BSPharm, RPh
Stress can have serious health implications, increasing the risk of cardiovascular disease and exacerbating medical conditions such as asthma, diabetes, and hypertension. Stress is unavoidable, but learning to manage it effectively is critical.
Stress is a fact of life and can affect individuals in a variety of ways. At some point in life, every individual experiences some degree of stress; some individuals experience stress more often than others and some have difficulty dealing with stress. Stress can be manifested from any situation or thought that causes an individual to experience frustration, anger, and nervousness, whereas anxiety is a feeling of fear and apprehension.1
Although many individuals manage stress relatively well, some individuals experience physical and/or psychological symptoms. There are times when stress, in limited amounts, can be beneficial and encourages an individual to meet a deadline or get a task done. Studies have shown, however, that individuals who experience excessive amounts of stress may exacerbate or increase the risk of developing various medical conditions. Examples of physical symptoms related to stress include fatigue, headache, gastrointestinal (GI) upset, muscle tension, episodes of dizziness, weight loss or gain, back pain, and teeth grinding.2,3
Psychological symptoms related to stress include irritability, anger, depression, nervousness, and anxiety. In addition, many individuals experience problems sleeping.2,3
Forms of Stress
According to the American Psychological Association (APA), stress can be categorized as acute, episodic acute, and chronic.4
Acute stress is the most common form of stress and is short term. It is described as a reaction to an immediate threat, commonly referred to as the fight or flight response.4,5
Common causes of acute stress include noise, danger, crowding, or isolation.5
Episodic Acute Stress
Episodic acute stress is prevalent among those individuals whose lives are constantly chaotic and demanding. 4,5
These individuals are always in a rush and tend to take on too many tasks at one time.4,5
Individuals who worry a lot are also prone to episodic acute stress.4
Chronic stress is defined as a type of stress that occurs over a long period of time from either internal or external stressors.4
Common causes of chronic stress include financial problems, death of a loved one, long-term relationship issues, or having a demanding job or work schedule.5
Effects of Stress
Stress has been linked to or can exacerbate various medical conditions, such as asthma, fatigue, back pain, arrhythmias, difficulty breathing, headaches, hypertension, irritable bowel syndrome, ulcers, suppression of the immune system, and fluctuations in blood glucose levels in diabetic patients.4-9
Both emotional and physical stress can have a significant negative impact on the heart and vascular system.4-9
Chronic stress has been shown to increase an individual’s heart rate and blood pressure, thus making the heart work harder than normal.4-9
Some studies suggest that the inability to manage stress can be associated with the onset of depression or anxiety and that the repeated release of stress hormones can cause hyperactivity in the hypothalamic-pituitary-adrenal system. This can disrupt normal levels of the neurotransmitter serotonin, which is critical for feelings of well-being.5
Various studies also report that stress can also cause hives and atopic dermatitis.5-9
Stress can impact the GI system, causing or exacerbating conditions such as gastroesophageal reflux disease, peptic ulcers, and ulcerative colitis.5-9
Stress also seems to increase the frequency and severity of migraine headaches. There is scientific evidence indicating that individuals experiencing psychological stress are more prone to developing colds and other infections than their less-stressed peers.5-9
Cardiovascular Disease Risk
While more research needs to be conducted, the American Heart Association reports that various studies suggests that there is a link between the risk of cardiovascular disease and environmental and psychosocial factors.10
Examples of these factors include job strain, social isolation, and personality traits. It is not known if stress acts as an “independent” risk factor for cardiovascular disease.10
Both acute and chronic stress may affect other risk factors and behaviors, such as elevated blood pressure and cholesterol levels, smoking, physical inactivity, and overeating.10
Sources of Stress
According to statistics from an APA poll conducted in 2007 entitled “Stress in America,” more than 33% of individuals in the United States report experiencing high levels of stress, and more than 1 in 5 individuals report experiencing high levels of stress 15 days or more each month.2
Furthermore, an estimated 48% of Americans believe that their individual stress levels have increased over the past few years. The poll identified money and work as some of the leading causes of stress, and 51% report that the housing crisis was a major cause of stress.2
In addition to affecting health, stress can affect both personal and work relationships and productivity at work.2
Numerous studies show job stress is considered to be the greatest source of stress among adults in the United States and that levels of stress have increased significantly over the past few decades.11
In a report published in the November 24, 2009, online edition of the Journal of Epidemiology and Community Health, a study concluded that men who consistently failed to deal with work-related stress issues were twice as likely to have a myocardial infarction or die of cardiovascular disease than those who managed stress in a constructive way.12
Occupational Stress in Health Care
According to the Centers for Disease Control and Prevention’s National Institute for Occupational Safety and Health, occupational stress has been a concern of the health care industry for a long time.2
Results from several studies indicate that health care workers may have increased rates of stress compared with other professions as well as increased rates of depression and anxiety that are directly related to job stress.2
Furthermore, in addition to psychological distress, other by-products of job stress for the health care field include burn out, absenteeism, decreased patient satisfaction, and diagnosis and treatment errors.2
Examples of factors contributing to stress that are common in the health care profession include inadequate staffing levels, long work hours, demanding schedule with little or no breaks, and potential exposure to infectious and/or hazardous substances.2
In general, workplace factors that may contribute to or exacerbate levels of stress include2
• Job demands (work overload)
• Financial and economic factors
• Conflict between work and family roles and responsibilities
• Lack of opportunity for growth or promotion
Pharmacists are in a pivotal position to identify those patients at risk for stress and anxiety disorders such as those dealing with a chronic illness such as diabetes, cardiovascular disease, cancer, stroke, Parkinson’s disease, or multiple sclerosis, or caregivers of those with medical conditions such as Alzheimer’s disease or cancer. During counseling, pharmacists should take the opportunity to remind patients about the effects of stress on overall health. For example, according to the American Diabetes Association, stress can affect patients with diabetes in 2 ways13
• Stress hormones may change blood glucose levels directly.
• When under stress, individuals may drink more alcohol or exercise less, and may forget or not have time to monitor glucose levels or adhere to diet plans.
The management of stress should be individualized and based on the severity, type, and frequency of stress. Cognitive behavioral therapy is considered to be one of the most effective means of reducing stress.5,14
The Table highlights techniques to prevent and manage stress. Patients experiencing chronic stress or displaying symptoms related to anxiety disorders, such as posttraumatic stress disorder, should always be referred to their primary health care provider for further assessment and treatment.
Since stress can cause sleep disturbances, some patients may elect to use the various OTC sleep aids on the market or may want to discuss the use of the various prescription sleep aids. Some patients may elect to use OTC analgesics for stress-related headaches. Patients should be advised to use these products as directed and to contact their primary health care provider if symptoms persist or worsen. In addition, some patients may elect to use alternative or homeopathic products marketed for mild episodes of stress and tension relief. Patients with medical conditions and those taking any other medications should be advised to consult their primary health care provider before using any of these products to avoid possible drug interactions or contraindications.
While stress is almost inevitable, how an individual reacts to and manages stress is important to one’s overall wellbeing and health. While sometimes it is easier said than done, it is important for individuals to learn how to effectively manage stress in healthy ways. Individuals with chronic stress should be encouraged to seek help, which may include counseling, finding ways to relax, and discuss the possibility of medications with their physician.1
In addition, since the health care field can be demanding, health care professionals should find constructive means to manage stress and take care of themselves, so that they can provide quality care to their patients. As health care professionals, it is our inherent duty to be concerned about the health of our patients and provide them with the necessary information to take active roles in their health. Pharmacists can reassure patients that they are not alone in dealing with stress and provide them with valuable resources on effectively controlling stress, instead of letting stress take control. ■
Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.
1. Stress and anxiety. Medline Plus website. http://www.nlm.nih.gov/medlineplus/ency/article/003211.htm. Accessed February 4, 2010.
2. Stress a major health problem in the U.S., the APA warns. American Psychological Association website. http://www.apa.org/news/press/releases/2007/10/stress.aspx. Accessed February 3,2010.
3. Stress: how to cope with life’s challenges. American Academy of Family Physicians website. http://familydoctor.org/online/famdocen/home/common/mentalhealth/stress/167.printerview.html. Accessed February 4, 2010.
4. Stress: The different kinds of stress. American Psychological Association website. http://www.apa.org/helpcenter/stress-kinds.aspx. Accessed February 11, 2010.
5. Stress Patient Education. MD Consult website. http://www.mdconsult.com/das/patient/body/183591010-3/953060367/10041/9440.html. Accessed February 5, 2010.
6. Exposure to stress: occupational hazards in the hospitals. Center for Disease Control National Institute for Occupational Safety and Health website. http://www.cdc.gov/niosh/docs/2008-136/default.html. Accessed February 4, 2010.
7. Stress management: Understand your sources of stress. Mayo Clinic website. http://www.mayoclinic.com/health/stress-management/SR00031. Accessed February 4, 2010.
8. Chronic stress and the heart. The Journal of the American Medical Association Patient Page http://jama.ama-assn.org/cgi/content/full/298/14/1722. Accessed February 4, 2010.
9. Effects of stress. The American Institute of Stress website. http://www.stress.org/topic-effects.htm. Accessed February 4, 2010.
10. Stress and heart disease. American Heart Association website. http://www.americanheart.org/presenter.jhtml?identifier=4750. Accessed February 3, 2010.
11. Job stress. The American Institute of Stress website. http://www.stress.org/topic-workplace.htm. Accessed February 3, 2010.
12. Stifled anger at work doubles men’s risk for heart attack. Medline Plus website. http://www.nlm.nih.gov/medlineplus/news/fullstory_92208.html. Accessed February 4, 2010.
13. Stress. American Diabetes Association website. http://www.diabetes.org/living-with-diabetes/complications/stress.html?print=t. Accessed February 4, 2010.
14. Psychotherapies. National Institute of Mental Health website. http://www.nimh.nih.gov/health/topics/psychotherapies/index.shtml. Accessed February 3, 2010.
15. Stress tip sheet. American Psychological Association website. http://www.apa.org/helpcenter/stress-tips.aspx. Accessed February 4, 2010.
16. Managing stress for people with heart failure. American Heart Association website. http://www.americanheart.org/presenter.jhtml?identifier=360. Accessed February 5, 2010.