Anxiety vs. stress: The right definition will lead to better mental-health care

“It seems like every new patient includes anxiety in their personal medical history,” says a co-author of this article on patients in his family practice. But when commenting on their symptoms, he notes patients generally make statements of social stress: bullying by their bosses; the difficulty of their home lives; or in one memorable case demanding, “What are you going to do about my loneliness?” Other physicians have noted a similar phenomenon, with patients lamenting that “every hobby has to be a side-hustle,” “nobody just plays anymore,” and “people have fewer friends than ever before.”

These are not symptoms of psychiatric morbidity (anxiety disorders) but rather social stressors and using medications to resolve them is likely poor care.

Defining “stress” is an important part of this conversation. The American Psychological Association defines stress as: “The emotional response typically triggered by external factors,” contrasting it with anxiety, which is defined as “persistent, excessive worries even in the absence of stressors.” In clinic, these types of presenting complaints can lead to medical mislabelling of stress as “anxiety” and result in prescribing medications in the SSRI/SNRI class or habit-forming benzodiazepines.

The literature confirms the prevalence of stress in primary care is high; 60-80 per cent of visits may have a stress-related component. Recent surveys and studies have shown elevated levels of stress and anxiety due to various factors, including the pandemic and social, political and environmental threats. The COVID pandemic alone has contributed to an increase of primary care visits for mental health issues by 10 per cent. Overmedicalizing “stress” is a concern for optimal patient care. Moreover, it is a concern for the sustainability of health care as high stress levels are linked to low social support and increased use of health-care services.

60-80 per cent of primary care visits may have a stress-related component.

Identifying individuals with high stress levels is challenging since there is a lack of consensus or guideline on the best screening method to be used in family practice. Neither the Canadian Task Force on Preventive Health Care nor the U.S. Preventive Services Task Force have published guidelines on screening for stress. However, several measures of stress are available. Perhaps the Perceived Stress Scale (PSS) is the most widely used, and is a good candidate for screening in family practice as it is short and thoroughly validated. This scale, originally developed in 1983, asks about feelings and thoughts during the previous month and has demonstrated rigorous psychometric properties. Family physicians could use it to help understand how different situations affect patients’ feelings and perceived stress.

In keeping with the fundamental principles of public health, generalized screening for stress among patients in family practice is only justified if there are proven interventions to reduce stress symptoms and consequences. Social prescribing can (1) reduce the burden of unmet social needs by shifting non-medical care for conditions such as stress to the social and community sector; (2) reduce the heavy workload experienced by family physicians and nurse practitioners by empowering people’s self-management skills; and (3) support delivery of personalized care in family practice. The underlying “mechanism” of social prescribing is building/cultivating social connectedness – a powerful and well-established protective factor for health.

A recent systematic review of social prescribing specifically for older adults in primary care found positive effects on outcomes such as social participation and well-being. However, since the impact on health-resource use (cost) varied across studies, the authors recommend stakeholders develop higher quality studies, preferably with a control or comparison group, to flesh out the science behind social prescribing.

A second recent review focused on the factors that lead to successful social prescribing programs. Three critical components of social prescribing were: 1) Assessment before prescription; 2) matching participants with relevant activities; and 3) individualized support from a “link worker,” also known as a “social prescriber” or “community connector.” Studies that exhibited these three components were more likely to have had a positive impact on loneliness, health and well-being, highlighting the importance of person-centeredness in the prescribing process. None of the studies reviewed reported negative results such as a lower level of health and well-being.

The impact of link workers was examined in a third recent systematic review of five randomized trials conducted in the U.S. and the U.K. Unlike the review that identified the importance of link workers, this review found mixed success and suggested that the effectiveness of social prescribing programs may depend on the specific context and the target population.

The potential of social prescribing as an integrated care approach for psychosocial problems in primary care is underscored in these recent reviews. However, their mixed conclusions also highlight the need for more rigorous research, particularly through well-designed randomized controlled trials, to rigorously assess effectiveness and long-term impact. As the U.K. National Health Service is expanding its funding of social prescribing programs, it will be one location to generate robust evidence of social prescribing. However, health-system context may limit U.K. studies applicability in Canada.

Two common themes in the systematic reviews were a wide variation in the demographic of patients given social prescriptions, and a wide variation in the types of interventions deemed as “social prescription.” The field of social prescribing may be more appropriately advanced if future studies focus on less heterogeneous patient populations and evaluate more narrowly defined interventions.

Our next step is to pilot the delivery of social prescribing in our colleague’s family medicine practice, targeted at patients experiencing high levels of stress. We intend to survey patients with the PSS inventory to better understand the patterns of stress in our practice. In addition, decisions will be required about effective specific interventions for patients experiencing stress depending on the most affected demographics. The pilot study will explore the logistics of implementation of screening for stress and delivering social prescriptions.

With knowledge gained from the pilot study, we intend to conduct a randomized controlled trial on social prescribing and help rectify the dearth of high-quality evidence about social prescribing for patients in family practice. This research has the potential to inform how family physicians can best respond to the increase in mental health concerns by providing practical examples that can be used when implementing “evidence-based” social prescribing with distressed patients.