Stress: assessment and management

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Stress is a natural response to challenging situations and can, to some degree, help people stay alert and respond to demands. However, excessive or prolonged stress can affect physical and mental health, relationships and day-to-day functioning.

Pharmacy patients may ask directly about stress or present with associated symptoms, such as poor sleep, headaches, palpitations, gastrointestinal disturbances, fatigue or difficulty concentrating. Pharmacists should consider stress while remaining alert to anxiety, depression and possible physical causes, including thyroid disease and anaemia.

What is stress?

The World Health Organization defines stress as a state of worry or mental tension caused by a difficult situation. It describes stress as a natural human response that helps people respond to challenges and threats in their lives.

When a person perceives a threat or challenge, activation of the sympathetic nervous system and hypothalamic-pituitary-adrenal axis results in the release of hormones, including adrenaline and cortisol. This forms part of the normal ‘fight or flight’ response and may temporarily increase alertness, heart rate and energy availability.

In the short term, a degree of stress can be helpful, increasing alertness and helping people focus on situations that require attention. Problems arise when stress is excessive, prolonged or difficult to manage, particularly when the demands placed on a person begin to outweigh their ability to cope.

Stress is not in itself a psychiatric diagnosis. Many of the symptoms attributed to stress may instead represent, or coexist with, mental health conditions such as generalised anxiety disorder (GAD), depression, panic disorder and post-traumatic stress disorder.

Similar symptoms may also arise from underlying physical health conditions, such as anaemia, thyroid disease, hypoglycaemia or poorly controlled diabetes, cardiac arrhythmias and sleep disorders.

Causes

The causes of stress vary considerably between individuals. What one person finds manageable may feel overwhelming to another.

Common triggers include work or financial pressures, relationship and family difficulties, caring responsibilities, bereavement, health concerns, education or examination pressures, and loneliness or lack of social support.

Several stressors may occur at the same time, and their cumulative effect may be more difficult to manage than any single problem in isolation. Understanding the patient’s circumstances can therefore help identify where practical support or intervention may be most useful.

Recognising stress

Stress can present in many ways and patients may not initially associate their symptoms with psychological pressure. Emotional and cognitive signs can include feeling overwhelmed, excessive worrying, irritability, tearfulness, difficulty concentrating, forgetfulness, racing thoughts, difficulty making decisions and reduced motivation.

Physical symptoms may include headache, muscle tension or pain, palpitations, dizziness, gastrointestinal disturbances, nausea, fatigue, sleep disturbance, changes in appetite and sexual difficulties.

Behavioural changes may also be apparent. Patients may withdraw from social activities, avoid people or situations, alter their eating or sleeping habits, exercise less, or increase their use of alcohol, tobacco or recreational drugs.

Recognising these changes can help establish the impact of stress on day-to-day functioning and identify potential risks.

Pharmacy assessment

Assessment should take place in a private consultation area and should establish why the patient is seeking help, what has changed and how significantly symptoms are affecting their day-to-day life.

Explore the presenting problem

Ask the patient to describe what they have been experiencing rather than immediately labelling the symptoms as stress. Useful questions might include:

• What symptoms have you been experiencing, and how severe are they?
• When did the symptoms start?
• Was there a particular trigger or recent event that may have contributed?
• Are symptoms improving, worsening or unchanged?
• What have you tried so far?
• What are you most concerned about?

Where a clear stressor is identified, explore whether it is temporary or ongoing and whether anything can realistically be changed.

Functional impact

Establish how much symptoms are affecting the patient’s usual functioning, including their ability to work or study, maintain relationships, manage responsibilities and carry out daily activities.

A marked decline in functioning may suggest that stress is becoming difficult to manage or that an underlying mental health condition should be considered.

Explore what support is available, including family, friends, colleagues or existing professional networks. Limited support or social isolation may make stress more difficult to manage.

Underlying mental health

Ask about persistent low mood, loss of interest or pleasure, excessive anxiety, uncontrollable worry, panic symptoms and significant changes in sleep or appetite. Consider the duration and persistence of symptoms, and whether they extend beyond a specific stressor or situation.

Validated questionnaires, such as GAD-7 or PHQ-9, may support assessment where appropriate but should supplement rather than replace a clinical history.

Risk

Ask directly about thoughts of self-harm or suicide, whether the person feels that life is not worth living and whether they have any intention or plans to act on these thoughts. Explore any previous self-harm or suicide attempts, significant self-neglect and risk to other people.

Where suicidal thoughts are present, establish the immediacy of the risk, including intent, planning, access to means and whether the person feels able to keep themselves safe. Asking directly about suicidal thoughts does not increase risk and should form part of any risk assessment.

Physical causes

Consider whether symptoms may be due to an underlying condition, such as thyroid disease or anaemia. Also consider physiological changes such as menopause or premenstrual syndrome.

Ask about caffeine, alcohol and recreational drug use. Review current medication for adverse effects that could contribute to the presentation.

New, severe, persistent or unexplained symptoms, particularly where accompanied by abnormal clinical findings, should prompt further medical assessment.

Management

Management depends on symptom severity, impact on daily life and whether an underlying mental health condition is present. For uncomplicated stress, the focus is usually on addressing the stressor alongside self-care and psychological support.

Where an underlying condition is identified, management should be guided by relevant clinical guidance and may include pharmacological treatment where appropriate.

Address the underlying stressor

Where possible, effective management should address the source of the stress rather than any symptoms alone.

For work-related stress, consider whether changes to workload, flexible working, temporary adjustments, occupational health support or an employee assistance programme may be appropriate. Financial difficulties may warrant signposting to debt or welfare support, while patients with caring responsibilities may benefit from local carers’ services.

Where a specific stressor can be identified, explore whether practical changes could reduce its impact or make the situation more manageable.

Lifestyle and self-care

Advise patients to maintain regular physical activity, a consistent sleep routine, and regular, balanced meals. Advise them to limit caffeine and energy drinks, particularly where anxiety, palpitations or insomnia are present, and to avoid using alcohol, smoking or recreational drugs as a way of coping with stress.

Encourage patients to maintain contact with supportive friends and family, break large or overwhelming tasks into smaller achievable steps, and make time for enjoyable or relaxing activities. Breathing exercises, meditation and yoga may also help manage feelings of tension or anxiety.

Psychological support

Psychological support can be helpful when stress persists or begins to affect daily functioning. Options may include cognitive behavioural therapy (CBT), counselling, mindfulness-based interventions or structured stress management programmes, depending on the patient’s needs and what local services are available.

Access routes vary across the UK. In England, for example, adults can usually self-refer to NHS Talking Therapies for anxiety and depression without first seeing their GP. In Scotland, access to psychological therapies is generally through a GP or another healthcare professional, although self-referral to digital talking therapies may be available in some areas.

Independent prescribing

There is no medicine specifically indicated for everyday stress and medication should not be used anyway as a substitute for addressing an identifiable stressor.

Where assessment identifies an underlying mental or physical health condition, a pharmacist independent prescriber may be able to initiate treatment where this falls within their individual scope of competence, provided that:

• The diagnosis has been adequately established
• Treatment is indicated by current guidance
• The pharmacist is competent to assess and manage the condition
• Relevant physical and mental health risks have been assessed
• Informed consent has been obtained
• Appropriate follow-up and monitoring can be provided
• Suitable clinical governance and communication arrangements are in place.

Treatment should be guided by the diagnosed condition, its severity, patient preference and current national guidance. For GAD, NICE recommends psychological interventions and drug treatment at defined stages of management.

Where medication is indicated, a selective serotonin reuptake inhibitor (SSRI) should be offered, with sertraline generally favoured first-line on cost-effectiveness grounds, although this remains an off-label indication in the UK. If ineffective or poorly tolerated, an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI) may be considered.

For depression, NICE recommends treatment according to severity. For more severe depression, defined as a PHQ-9 score of 16 or more, options include individual CBT, antidepressant treatment or a combination of the two. Such presentations may be more appropriately managed with GP or specialist mental health input, depending on the complexity and risk.

For less severe depression, defined as a PHQ-9 score below 16, antidepressants should not routinely be offered first-line unless this is the person’s preference. Non-pharmacological management and referral for psychological support are generally the appropriate first step.

Where a physical health condition is identified, treatment should follow clinical guidance and remain within a pharmacist prescriber’s competence, with referral where further investigation or specialist input is required.

Local commissioning arrangements will determine whether treatment can be provided within an NHS service or requires an appropriately governed private pathway.

Referral

Arrange urgent or emergency assessment, as appropriate, if the patient has red flag features such as:

• Active suicidal thoughts with intent or a plan
• Immediate risk of serious self-harm or harm to another person
• Severe agitation, behavioural disturbance or psychotic symptoms
• Acute confusion
• Severe self-neglect or inability to care for themselves safely
• Chest pain, syncope, severe breathlessness or other symptoms suggesting an acute physical emergency.

Refer the patient to their GP or an appropriate specialist service, with urgency determined by the clinical presentation and level of risk, if:

• Symptoms are persistent or worsening
• Stress is significantly affecting work, relationships or normal functioning
• Diagnosis is uncertain
• An underlying condition requires further investigation or specialist management, or falls outside a pharmacist’s scope of competence.

Safety netting

Every consultation should end with clear advice on what to do if symptoms change.

Advise patients to seek further help if their symptoms persist, worsen or begin to interfere substantially with everyday life. They should seek urgent help if they develop thoughts of harming themselves or others, feel unable to keep themselves safe, or experience severe or concerning physical symptoms.

Remind patients that stress can change over time and that reassessment may be needed if symptoms become more persistent, severe, or suggestive of anxiety or depression.

Conclusion

Stress can present with a wide range of emotional, cognitive, behavioural and physical symptoms. Effective management requires careful assessment of the symptoms, circumstances and level of risk.

Community pharmacists and their teams should provide self-care advice, help patients address or manage identifiable stressors, and signpost to psychological or other support. They should also remain alert to symptoms that may indicate an underlying mental or physical health condition.