• Stress-related conditions. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2004. 27 p. [129 references]

This is the current release of the guideline.

This guideline updates a previous version: Harris, J, ed. Occupational Medicine Practice Guidelines: American College of Occupational and Environmental Medicine. Beverly Farms, MA: OEM Press; 1997.

Stress-related conditions

Diagnosis
Evaluation
Management
Treatment

Family Practice
Internal Medicine
Physical Medicine and Rehabilitation
Preventive Medicine
Psychiatry

Advanced Practice Nurses
Physician Assistants
Physicians
Utilization Management

• To provide information and guidance on generally accepted elements of quality care in occupational and environmental medicine
• To improve the efficiency with which the diagnostic process is conducted, the specificity of each diagnostic test performed, and the effectiveness of each treatment in relieving symptoms and achieving cure
• To help occupational physicians and primary care practitioners manage employed patients with acute stress-related conditions of relatively short duration
• To help clinicians identify patients who need urgent referral for psychiatric care and provide a framework for treating the majority of patients who do not

Adults with potentially work-related stress-related conditions seen in primary care settings

Evaluation

1. Medical history including symptoms, stressors, coping mechanisms, and other resources
2. Physical examination including a mental status examination

Diagnosis

1. Evaluating for potentially life-threatening or other serious diseases that the history and physical examination may suggest
2. Coding the visit appropriately

Treatment/Management

1. Patient education
2. Specialty referral
3. Management of medical conditions
4. Modification of maladaptive coping mechanisms
5. Aerobic exercise
6. Stress management techniques
   • Relaxation techniques
   • Behavioral techniques
   • Cognitive techniques and therapy
   • Stress inoculation therapy
7. External resources and referrals
   • Employee assistance programs
8. Pharmacotherapy (limited use or in conjunction with specialty referral)
   • Anxiolytics
   • Antidepressants
   • Antipsychotics
9. Modified work and accommodations
10. Organizational interventions
11. Determining disability duration
12. Follow-up, as appropriate

Missed work days

Searches of Electronic Databases

Note from the National Guideline Clearinghouse (NGC): The American College of Occupational and Environmental Medicine contracted the Work Loss Data Institute to provide medical library research services.

Not stated

Expert Consensus

Not applicable

Review
Review of Published Meta-Analyses

Contributors reviewed at least one chapter each and reviewed the relevant medical literature that had been published since the creation of the original Guidelines in 1997.

Expert Consensus

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Following the chapter and literature review, participants provided written or verbal comments to the American College of Occupational and Environmental Medicine's Practice Guidelines Committee.

Verbal comments were in the form of participation in multi-specialty conference calls, during which the issues raised in each chapter were extensively discussed. Draft chapters were prepared and distributed by the American College of Occupational and Environmental Medicine to all chapter reviewers. Follow-up multi-specialty teleconferences were then held as appropriate, during which time the draft was again reviewed.

General Approach and Basic Principles (refer to the original guideline document for more detailed information)

Stressors may be any life event or circumstance that exerts a physical, emotional, or cognitive demand on the individual. The lifetime prevalence of major stressful life events is 100%, so associated stress-related symptoms may be considered a normal condition of human existence.

• Stress is not a diagnosis, disease, or syndrome. It is a nonspecific set of emotions or physical symptoms that may or may not be associated with a disease or syndrome. Whether or not stress contributes to a disease or syndrome depends on the vulnerability of the individual; the intensity, duration, and meaning of the stress; and the nature and availability of modifying resources.
• The initial assessment of patients with acute stress-related conditions focuses on detecting potentially serious psychopathology, or red flag conditions, requiring urgent specialty referral. The majority of patients with stress-related conditions will not have red flags and can be safely and effectively managed by occupational or primary care physicians.
• Relief of stress depends on its precipitants, which are often multifactorial. Psychosocial, workplace, or socioeconomic issues can be explored with the patient to facilitate early identification of precipitating factors and appropriate interventions that may prevent delayed recovery or relapse. An open, honest discussion of the underlying factors often results in an increase in the patient's insight and coping skills, which itself helps alleviate many stress-related symptoms.
• Worksite interventions may be helpful in mitigating or eliminating inciting stressors, depending on the source of the complaints.
• Medications generally have a limited role. Limit use of anti-anxiety agents to short periods of time (i.e., periods when overwhelming anxiety limits the patient's ability to work or effectively perform the activities of daily living). Antidepressant or antipsychotic medication may be prescribed for major depression or psychosis; however, this is best done in conjunction with specialty referral.
• Patients are encouraged to enhance their individual coping skills and to decrease or discontinue maladaptive coping mechanisms such as excessive use of alcohol, tobacco, or other drugs, or excessive food intake. Patients are counseled to redirect their energy to regular aerobic exercise, relaxation techniques, and cognitive coping mechanisms.
• For uncomplicated cases, absence from work should not exceed one work week. Referral for mental health professional assessment may be considered for patients whose anticipated absence from work will exceed one week.
• If symptoms become disabling despite primary care interventions or persist beyond three months, referral to a mental health professional is indicated.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

• Improved efficiency of the diagnostic process
• Effective treatment resulting in symptom alleviation and cure

• Anxiolytics can lead to dependence and do not alter stressors or the individual's coping mechanisms.
• Antidepressants have many side effects and can result in decreased work performance or mania in some people.
• Antipsychotics can decrease motivation and effectiveness at work.

The American College of Occupational and Environmental Medicine provides this segment of guidelines for practitioners and notes that decisions to adopt particular courses of actions must be made by trained practitioners on the basis of the available resources and the particular circumstances presented by the individual patient. Accordingly, the American College of Occupational and Environmental Medicine disclaims responsibility for any injury or damage resulting from actions taken by practitioners after considering these guidelines.

An implementation strategy was not provided.

Getting Better

Effectiveness
Patient-centeredness

• Stress-related conditions. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2004. 27 p. [129 references]

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

1997 (revised 2004)

American College of Occupational and Environmental Medicine - Medical Specialty Society

American College of Occupational and Environmental Medicine

American College of Occupational and Environmental Medicine Practice Guidelines Committee

Chapter Lead: Lee S. Glass, MD

Committee Members: Jennifer H. Christian, MD, MPH, FACPM; Philip I. Harber, MD, MPH, FACOEM, FCCP; John P. Holland, MD, MPH, FACOEM; Kathryn L. Mueller, MD, MPH, FACEP, FACOEM; Douglas J. Patron, MD, MSPH; Bernyce M. Peplowski, DO, MS; and Jack Richman, MD, CCFP, DOHS, FACOEM

Timothy J. Key, MD, MPH, FACOEM, as Responsible Officer and ACOEM President Elect, and Edward A. Emmett, MD, MS, FACOEM, Chair of the ACOEM Council on Occupational and Environmental Medical Practice, contributed to the development of the guidelines as well.

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Harris, J, ed. Occupational Medicine Practice Guidelines: American College of Occupational and Environmental Medicine. Beverly Farms, MA: OEM Press; 1997.

None available

None available

This NGC summary was completed by ECRI on May 31, 2006. The information was verified by the guideline developer on November 3, 2006. This summary was updated by ECRI Institute on November 9, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs.

The American College of Occupational and Environmental Medicine, the signator of this license, represent and warrant that they are the publisher of the guidelines and/or possess all rights necessary to grant the license rights to AHRQ and its agents.