Helping patients manage chronic, common stressors

Americans are under stress. A recent survey of U.S. adults done by the American Psychological Association found that the average stress level was five out of 10, somewhere in the middle between no stress and a great deal. Housing costs, mass shootings, the spread of misinformation, and social divisiveness were all significant stressors, the survey found.

But more personal factors like strained personal relationships, toxic work environments, and the loss of a loved one can also add to feelings of stress, anxiety, and depression. Primary care physicians are often the first ones to hear about stress levels that are shifting from uncomfortable to overwhelming.

“I see a lot of patients experiencing chronic or acute stress. It's something that's very common,” said Marion M. McCrary, MD, FACP, an internal medicine physician at Duke Signature Care, a concierge practice that is part of Duke Health Integrated Practice and an assistant professor of medicine at Duke University School of Medicine in Durham, N.C.

The shortage of psychiatrists in many parts of the U.S. means that stress and accompanying anxiety are more in the purview of primary care, said Mariah Stump, MD, FACP, a primary care physician at Brown Medicine who is also certified in lifestyle medicine and is an assistant professor of medicine at the Warren Alpert Medical School at Brown University in Providence, R.I.

“Primary care is definitely the front line of mental health,” Dr. Stump said. Although evidence on what might help is sparse, there are a few things that internal medicine specialists can do, including incorporating stress management into the care of hypertension, diabetes, or obesity.

Opening the conversation

There isn't one way that stress is identified, Dr. McCrary said. It can be found on screening tools, such as the Patient Health Questionnaire-9 (PHQ-9) or the Generalized Anxiety Disorder 7-item (GAD-7) scale; it can come up during conversations about elevated blood pressure or weight changes; or a patient might mention it when talking about what is new in their lives.

Even if a patient is coming in for follow-up on a specific health issue, it's important to ask open-ended questions about how they are doing overall, according to Dr. McCrary. “Just be open to having these conversations,” she said.

There are several organ systems where stress can manifest itself. Patients may feel pressure or heaviness in their chest or report tiredness or poor sleep, headaches, and bowel issues, Dr. Stump said. Stress can cause inflammation so can also worsen existing underlying pain issues, such as arthritis. “Stress makes everything worse, but if stress is at the root of the problem, then patients may manifest that stress in a lot of organ systems,” she said.

Some people have a lot of insight about how stress impacts their bodies, while others don't. If a patient comes in with stomach issues or headaches, it's helpful to ask if there is anything out of the ordinary going on in their lives, since these symptoms might signal a stress-related trigger, Dr. McCrary said.

“I ask them, ‘Are there patterns of when you notice you feel this way? What may be a trigger?’” she said. “That can be very helpful if I'm not sure if something that is happening physically can be related to the stress.”

Dr. Stump said she sees this phenomenon often with blood pressure management. “Patients will come and say, ‘I don't understand why my blood pressure is so high,’ and then you start talking about lifestyle issues and stress is often a major contributor,” she said.

The body is designed to respond to immediate stressors, like getting cut off in traffic or being chased, but when stress is chronic, the body doesn't shut off the stress response, and the hypothalamic pituitary axis is persistently activated, releasing cortisol. “Chronic stress leads to fatigue, weight gain, poor sleep, and raises inflammation, so over time it is harder for the parasympathetic nervous system to put the brake on this system on overdrive,” Dr. Stump said.

Special populations

Some level of stress is normal and even healthy, but Dr. Stump said she is especially alert for signs of stress from her patients with chronic health conditions. Diabetes, hypertension, high cholesterol, and obesity have a united mechanism of inflammation that is exacerbated by the body's stress response.

Chronic stress may also be at the root of why certain patients have poor control of their underlying conditions, she said. “It is housing insecurity or it's having to work three jobs or it's working the night shift for 30 years and having their sleep disrupted,” Dr. Stump said. “Often we see that chronic stress has a manifestation of making chronic disease worse and setting patients up for chronic diseases.”

It's also important to remember that patients with preexisting depression or generalized anxiety disorder are likely to have a heightened response to stress, Dr. Stump said. These patients should be monitored more closely when they are experiencing acute stressors, she said.

Acute stressors are not a health concern for most people, but both acute and chronic stress can create higher risk of bad health outcomes for patients who already have underlying coronary heart disease, said Arshed A. Quyyumi, MD, professor of medicine in the division of cardiology at Emory University School of Medicine and director of the Emory Clinical Cardiovascular Research Institute in Atlanta.

Dr. Quyyumi has been studying the impact of stressors on patients with cardiovascular disease for several years. In a 2023 study in JACC: Advances, he and colleagues found that patients with stable coronary heart disease who scored highest on a scale of psychological distress that included depression, anxiety, anger, general stress, and post-traumatic stress disorder had a twofold higher risk for cardiovascular events than those with the lowest scores.

“The message for the physician is that stress matters, and it matters more in some people than others,” Dr. Quyyumi said.

While evidence points to a heightened risk for certain populations, it is less clear what specific strategies can buffer the impact of stress on chronic illness. A July 2024 study in the American Journal of Preventive Medicine evaluated the impact of social support and physical activity in mitigating the effects of chronic stress on cardiovascular disease events and found no significant impact on risk.

Tiwaloluwa Ajibewa, PhD, an assistant professor of preventive medicine at Northwestern University in Chicago and the lead investigator on the study, said that even though they did not find an impact from physical activity or social support in this cohort, other research has shown benefits. “Maybe it's the measures that we used or the sample that we looked at, but there needs to be a continuation of looking at these positive factors within the environment that could be used to buffer stress,” he said.

Medication vs. meditation

Until more data are available, there is no harm to physicians encouraging movement and social connection, Dr. Ajibewa said. Dr. McCrary said that when her patients' stress becomes chronic or overwhelming, she starts by talking about the basics of sleep and nutrition. She also asks patients to consider what is a priority for them and what other tasks or stressors can be pushed aside.

“I talk with patients a lot about how to ask for what they need and setting boundaries,” she said.

Mindfulness practices that can also be helpful for patients range from grounding techniques to deep breathing to yoga. These don't have to be complicated or expensive. Patients can download free meditation or mindfulness apps on their phones to get started, Dr. McCrary said.

Dr. Stump recommends that patients get into a regular exercise routine that allows their body to experience good endorphins. Then, they should try to connect with someone who supports them and reinforces their healthy behavior choices.

The trigger for considering medication is how much the stress is impacting the patient's day-to-day life or relationships. If a patient can't sleep or if they start to meet criteria for a mood disorder, medication should be discussed, Dr. McCrary said. “Meds are an option, but they would probably not be my first option,” she said.

Dr. Stump said while she also starts with lifestyle interventions, combining medication, like selective serotonin reuptake inhibitors (SSRIs), with behavior modification and counseling is often the most effective option. “The synergy of putting patients under chronic stress on low-dose SSRIs often really helps with the motivation of helping them achieve the lifestyle goals. That's really when they blossom and create sustainable change,” she said.

When patients have experiences with past trauma or are displaying mindset concerns, it's appropriate to refer them for therapy, Dr. McCrary said. She recommends maintaining an up-to-date list of psychologists or social workers who are accepting new patients to avoid delays in patients receiving care.

It's important to refer patients for urgent psychiatric support when there are concerns about safety or self-harm, Dr. Stump said. In those cases, even seeing patients every three months may not be enough to address their needs, and an immediate referral to a mental health colleague is necessary.

Dr. Stump advised clinicians to think about partnering with patients to address stress as part of the management of their chronic health issues. “We're often quick as internists to see people as their hypertension or their diabetes or their obesity, but just having these chronic conditions alone brings stress,” she said. “We need to approach them with some empathy and say, ‘This must be really hard to see your blood sugar not get better. What are some of the things that we can work together on to make this work?’”