• Work Loss Data Institute. Stress related conditions and other mental disorders. Corpus Christi (TX): Work Loss Data Institute; 2007 Apr 12. 153 p. [204 references]

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

Initial Diagnosis

Stress is the most common mental condition treated by occupational or primary care physicians and will be the focus of this guideline. References to additional mental disorders are found in the procedure summary in the original guideline document, although the more severe of those usually require referral to a specialist. Stress is not its own diagnosis but rather a combination of nonspecific emotional or physical symptoms varying in intensity and duration, which may or may not be related to a specific incident. The stress might also be associated with a particular disease or syndrome, but that is not always the case.

A stressor is defined as anything that exerts a physical, emotional, or mental demand on an individual. Stress often occurs when the individual has anxiety because of a mismatch between perceived demands and resources, whether work-related or personal. The source of stress can be acute (such as an employee relocation) or chronic (such as consistently poor relations with a supervisor).

For some people, stress causes or contributes to a deterioration of physical health, resulting in more headaches or more common colds. While the scientific literature is not clear on this topic, stress may also contribute to the worsening of more serious conditions such as heart disease, irritable bowel disease, or ulcers, depending on the individual's coping methods. On the other hand, the presence of certain physical conditions could be the cause of stress.

Initial Evaluation

Focus on identifying possible red flags or warning signs for potentially serious psychopathology that would require immediate specialty referral. Red flags may include impairment of mental functions, overwhelming symptoms, signs of substance abuse, or debilitating depression. In the absence of red flags, the occupational or primary care physician can handle most common stress-related conditions safely.

In talking to the patient, it is important for the physician to get him or her to try and explain or pinpoint incidents or reasons for the stress, rather than to just generalize (i.e., "I hate my job," "Everything makes me stressed out," etc.). The physician may have to ask more specific questions about work or home life if the patient is initially unwilling or unable to address specific issues.

Occupational stress usually stems from one of three common models:

1. Person-environment fit model: Poor job fit, such as a mismatch between the skills of the individual and the demands of the job, or a disparity between the individual's career-related desires versus actual opportunities presented, is a leading cause of workplace stress.
2. Demand control model: Jobs that place high demands on the worker but give him or her little control or opportunities for decision-making lead to high job strain, a source of stress that is consistently linked as a contributor to physical conditions such as cardiovascular mortality, heart disease, and hypertension. Consideration should be given to the influence of the individual's occupational and personal history, which may have an effect on how this model applies to his or her situation.
3. Effort-reward model: Shows that stress is often the result of high effort without social reward. Like the demand control model, this model points out that a low ratio of effort to reward leads to sustained autonomic arousal and can cause physical effects such as high blood pressure or myocardial infarction.

Exploration of how and if the patient's stress follows the path of one of the above models will be helpful in determining treatment.

More specific sources of stress include bereavement, illness, familial changes or disorder, or other common and/or traumatic life changes. Time off work may be helpful, although the ultimate goal should be to preserve the patient's ability to function both occupationally and socially. Time off should not be so excessive that the employee loses his or her sense of function and appreciation at work and at home.

Initial Therapy

1. Pursuing the patient's thoughts on how his or her stress relates to the above models may help determine the source of stress and cultivate ideas on how to eliminate or cope with the stress. Patient education and understanding about stress is necessary for effective stress management to take place.
2. Other common treatment pathways include the use of one or more of the following:
   1. Relaxation techniques (such as meditation)
   2. Exercise (aerobic exercise has been shown to positively influence mood)
   3. Behavioral training (such as time management, anger management, assertiveness, or conflict resolution training)
   4. Stress inoculation therapy
   5. Cognitive therapy
   6. Modified work
   7. Organizational interventions

3. Pharmaceutical therapy (limited, short-term use of anti-anxiety agents to improve function--anything else should be used in conjunction with a specialty referral)

Follow-up visits are an important part of treatment and should be conducted by a mid-level practitioner in person or via phone every three or four days, depending on the severity of the case, while a path to recognizable treatment is established and followed. Failure to improve or make significant progress after several months may indicate the need for psychiatric assessment or counseling.

None provided

During the comprehensive medical literature review, preference was given to high quality systematic reviews, meta-analyses, and clinical trials over the past ten years, plus existing nationally recognized treatment guidelines from the leading specialty societies.

The heart of each Work Loss Data Institute guideline is the Procedure Summary (see the original guideline document), which provides a concise synopsis of effectiveness, if any, of each treatment method based on existing medical evidence. Each summary and subsequent recommendation is hyper-linked into the studies on which they are based, in abstract form, which have been ranked, highlighted and indexed.

• Work Loss Data Institute. Stress related conditions and other mental disorders. Corpus Christi (TX): Work Loss Data Institute; 2007 Apr 12. 153 p. [204 references]

Not applicable: The guideline was not adapted from another source.

2004 (revised 2007 Apr 12)

Work Loss Data Institute - Public For Profit Organization

Not stated

Not stated

There are no conflicts of interest among the guideline development members.

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

This NGC summary was completed by ECRI on April 4, 2005. This summary was updated by ECRI on August 15, 2005, following the U.S. Food and Drug Administration advisory on antidepressant medications. This summary was updated by ECRI on October 20, 2005, following the U.S. Food and Drug Administration advisory on Cymbalta (duloxetine hydrochloride). This NGC summary was updated by ECRI on January 30, 2006, November 13, 2006, April 2, 2007, and August 29, 2007. This summary was updated by ECRI Institute on October 31, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.