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Stress Management Counseling in the Primary Care Setting Is Rare

Highlights need to restructure primary care delivery

BOSTON - While stress may be a factor in 60 to 80 percent of all visits to primary care physicians, only three percent of patients actually receive stress management counseling, say researchers at Beth Israel Deaconess Medical Center.

The study appears online Nov. 19 in the Archives of Internal Medicine.

"Almost half of Americans report an increase in psychological stress over the past five years. Stress is the elephant in the room. Everyone knows it's there, but physicians rarely talk to patients about it," says lead author, Aditi Nerurkar, MD, MPH, a primary care physician and the Assistant Medical Director of BIDMC's Cheng & Tsui Center for Integrative Care. "In fact, stress management counseling is the least common type of physician counseling, falling behind counseling for nutrition, exercise, weight loss and smoking."

Nerurkar and colleagues examined data from the 2006 to 2009 National Ambulatory Medical Care Survey involving more than 34,000 office visits and 1,263 physicians. They were looking for evidence of doctors who provided stress management help, which included counseling at the visit, providing "information intended to help patients reduces stress through exercise, biofeedback, yoga, etc.," or referrals "to other health professionals for the purpose of coping with stress."

What they found is that stress management counseling by physicians rarely happens in the primary care setting. Just three percent of physicians offer stress counseling, mostly for their more complex patients, particularly those coping with depression.

"Our research suggests that physicians are not providing stress management counseling as prevention, but rather, as a downstream intervention for their sickest patients," says Nerurkar. "Considering what we know about stress and disease, this clearly points to missed opportunities."

The researchers also found that stress management counseling was associated with longer office visits.

"We know that primary care physicians are overburdened. With the volume of patients they see, there simply may not be enough time to provide stress management counseling during the office visit," says senior author, Gloria Yeh, MD, MPH, Director of the Integrative Medicine Fellowship Program at Harvard Medical School and BIDMC. "The fact that we found that so few physicians are counseling their patients about stress supports this, and highlights the need to rethink how primary care is being delivered."

A key step towards incorporating stress management counseling into primary care may be restructuring primary care delivery and payment to support team-based care.

"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," says co-author, Russell S. Phillips, MD, Director of the Harvard Medical School Center for Primary Care.

These changes could help shift counseling to earlier in the disease process.

"Our findings make us wonder whether stress management counseling, if offered earlier to more patients as prevention, could lead to better health outcomes," says Nerurkar, "But more research is needed to establish the role that stress management might play clinically."

In addition to Nerurkar, Yeh and Phillips, co-authors include Asaf Bitton, MD, MPH and Roger B. Davis, ScD of Beth Israel Deaconess Medical Center.

Nerurkar is supported by an Institutional National Research Service Award from the National Institutes of Health. Davis is supported in part by the Harvard Catalyst and the Harvard Clinical and Translational Science Center.

Beth Israel Deaconess Medical Center is a patient care, teaching and research affiliate of Harvard Medical School, and currently ranks third in National Institutes of Health funding among independent hospitals nationwide. BIDMC is clinically affiliated with the Joslin Diabetes Center and is a research partner of Dana-Farber/Harvard Cancer Center. BIDMC is the official hospital of the Boston Red Sox. For more information, visit www.bidmc.org.