Stress & insomnia

Nearly half of Britons say they are experiencing increased levels of anxiety in the aftermath of the EU referendum...


Learning objectives

After reading this feature you should be able to:

• Understand the effect anxiety disorders can have on sufferers
• Help sufferers identify and avoid possible anxiety triggers
• Discuss management options including lifestyle changes and medication.


Brexit has led to increased levels of anxiety, with general uncertainty about the UK’s future and the economic impact being the main drivers, according to a survey by anxiety specialists Dr Michael Sinclair and Dr Stephen Cox of bcalm.

Over 50 per cent of anxiety sufferers say they are currently experiencing a spike in their symptoms triggered by Brexit, with 31 per cent saying their symptoms have worsened ‘moderately’ and 22 per cent saying their symptoms have worsened ‘significantly’.

Anxiety is an under-recognised modern pandemic. In June, Cambridge University published a global review of 48 studies, which found more than 60m people in the EU are affected by anxiety disorders, with women and young people affected the most.

According to the national charity Anxiety UK, almost one in five people feel anxious a lot or all of the time, while nearly half feel more anxious than they used to. Work-related anxiety costs the UK economy an estimated £70bn-£100bn annually and 70m sick days each year.

Anxiety types

Acute anxiety – feelings of apprehension, uncertainty and worry – can be triggered, say, by an exam or having a medical test. While this is a normal emotional reaction to a stressful event, according to the Mental Health Foundation almost one in five people feel anxious a lot or all of the time.

When chronic anxiety appears for the first time, it may be confused with stress. Dr Antonis Kousoulis, assistant director at the Mental Health Foundation, says it is important to understand the difference between the two.

“With stress, any situation can leave people feeling frustrated and nervous, whereas anxiety is an inappropriate fear of a specific situation, like a phobia,” he says. “Mild anxiety never gets truly overwhelming but it is always in the background. People living with mild to moderate anxiety often avoid common everyday situations, such as a flight or going to a work meeting. They create their own ‘balance’ to help them deal with anxiety. This is a difficult-to-reach group, as they are not seeking help.”

According to the Balance Your Life report for Kalms Lavender, sub-threshold anxiety is under-reported and under-treated, yet it is twice as common as generalised anxiety disorder (GAD) – the commonest form of anxiety diagnosed by doctors.

Other types of anxiety disorders include panic disorder and obsessive-compulsive disorder (OCD).

GAD affects up to 5 per cent of the UK population. Most people with GAD experience anxiety to a wide range of triggers and situations. “With GAD, someone has a background level of anxiety,” says Nicky Lidbetter, chief executive of Anxiety UK.

“They are constantly on the edge. They often cannot pinpoint a specific cause, moving from one worry to the next. Here at Anxiety UK, we are also seeing a rise in social anxiety disorder, or social phobia, possibly because there is more awareness in the media. The nature of the condition means it is unlikely someone will venture into a public place such as a pharmacy.”

Physical symptoms

Pharmacy customers should referred to their GP if their anxiety affects their daily life or is causing them any distress. According to NICE, recognition of anxiety disorders is poor, particularly in primary care – which means only a minority of people experiencing anxiety disorders ever receive treatment.

The physical symptoms of anxiety are often identified first. Many people recognise the ‘butterflies in the stomach’ feeling, but anxiety can also trigger an increased heart rate, muscle tension, tingling in the hands and feet, shortness of breath, dizziness, headaches and palpitations. It is often only later that the emotional symptoms become more apparent.

According to Nicky Lidbetter, the pharmacy team should be aware of these physical symptoms and that they are very real. “If customers can’t find a physical cause for their symptoms, they should bear in mind that there could be an underlying emotional issue,” she says.

“It is important that the pharmacy team is confident enough to ask questions. However, if the symptoms are impacting on their day-to-day life, customers must go to their GP to rule out any physical cause. For example, thyroid problems and the menopause need to be ruled out, as these can manifest as anxiety-like symptoms.”

Sometimes anxiety is due to a build-up of stress, gradually over a period of time, and there is not one particular major trigger

Possible triggers

Some people know exactly what has triggered their anxiety, often because it started at a particular time in their life. Anxiety may follow a traumatic incident or a significant life event, such as moving house, getting divorced or having surgery. Other people may not be able to think of an identifiable cause. Sometimes anxiety is due to a build-up of stress, gradually over a period of time, and there isn’t one particular major trigger. It could be a tiny event, such as a bad commute to work, that tips the person over the edge.

If patients aren’t sure what is causing their anxiety, they should be encouraged to keep a daily diary of their symptoms and possible triggers. “They should write down how they feel at particular times of the day or when they are doing specific activities or are exposed to certain situations,” says Dr Kousoulis. “This is one of the first steps in anxiety management, as it can help them to change their lifestyle.”

Anxiety management

Chronic anxiety should not be ignored. Left unmanaged, it can lead to further mental health disorders, high blood pressure, heart problems, gastrointestinal disorders and chronic respiratory disorders. Pharmacy customers showing signs of anxiety should be referred to their GP. Keeping their feelings to themselves will only make their symptoms worse.

GPs often prescribe antidepressants with anxiolytic properties, but Nicky Lidbetter says there are plenty of other options people can try before going down the medication route.

“Medication works well for many people, but managing anxiety isn’t just about popping pills,” she says. “At Anxiety UK, we advocate evidence-based interventions, such as cognitive behavioural therapy (CBT) and counselling, but also clinical hypnotherapy and acupuncture, which seem to work for some people. Anxiety management is also about making lifestyle changes. Pharmacists are ideally placed to discuss the effects
of high caffeine and alcohol intakes and food choices, and can promote the benefits of exercise, relaxation and mindfulness.”

Talking about anxiety is the first step to finding a solution, which is why anxiety management often involves using psychological talking therapies, such as CBT, to challenge thinking patterns. “Patients need to understand their habits and routines and what is causing their anxiety,” says Dr Kousoulis. “That is why CBT and similar therapies can be effective. Patients may also benefit from going to a peer support group, where people have had similar experiences, especially if they are embarrassed to talk about their feelings to a healthcare professional.”

Mindfulness is often used in the management of mental health problems, such as anxiety and depression, because there is some evidence that it affects how the brain works, causing changes in brain wave activity. The Mental Health Foundation has a website dedicated to mindfulness practice (bemindful.co.uk), with an online mindfulness course and a ‘Find a local teacher’ page.

“Mindfulness uses meditation, breathing and yoga,” says Dr Kousoulis. “It can help people relax and sleep better, as well as come to terms with what is making them anxious. Many GPs will often refer patients to this self-help approach for one to two months after their diagnosis to see if it works for them.”

Dr Kousoulis says that exercise is another key management approach. “Anxiety is known to increase adrenaline levels,” he says. “Exercise uses up this adrenaline and releases endorphins. If someone is having a particularly stressful day, 20 minutes of exercise may help to reduce their anxiety. They should do something they enjoy and that they can fit easily into their daily schedule.

“Eating plenty of fruit and vegetables rather than sweet foods is important too, as an increase in blood sugar levels can make anxiety worse.”

Dr Siegfried Kasper, professor of psychiatry and chairman of the Department of Psychiatry and Psychotherapy at the Medical University of Vienna, Austria, suggests customers try herbal remedies. “I have recently been involved in numerous clinical studies that looked into a specially prepared, pharmaceutical quality lavender oil taken orally as a one-a-day capsule,” he says.

“Investigations suggest that it may work by modulating excessive neurotransmitter activity between nerve cells in the brain. Results of the studies suggest that the daily lavender oil capsule can reduce significantly both physical and psychological symptoms of anxiety, with benefits notable after just two weeks.”

If customers do decide to use herbal remedies, it is important that pharmacists check for interactions. “Many people think herbal remedies are inert substances but they can react with prescribed medicines, especially in the case of St John’s wort,” says Nicky Lidbetter. St John’s wort is available over the counter for mild and moderate depression, mild anxiety and sleep problems.

Medicines management

Pharmacists are ideally placed to advise patients about anxiety treatments at all stages of their management programme. “GPs are often pushed for time so they don’t always explain how medicines can impact on someone’s life,” says Nicky Lidbetter.

“The first two weeks on antidepressants, for example, can be critical as side-effects often outweigh the benefits at this stage. Pharmacists should explain to patients what they may experience, including heightened anxiety. [The positive effects of the medication] will usually kick in after the initial two weeks.”

If patients have been on their medicines for some time, pharmacists may wish to discuss whether they need to have them reviewed. “Check everything they are taking, especially if they are being seen by a range of consultants,” says Lidbetter. “Some people are on antidepressants for years. Ask whether their medication is still helping and check if there is anything newer on the market, as prescribers often prescribe what they know.

“Also discuss helping people to step down from a high dose, especially with benzodiazepines or SSRIs. Some medicines are available in liquid forms as well as tablets, which can help with increasing or decreasing doses as required.”

Lidbetter believes pharmacists play an essential role in anxiety management and suggests widening access to pharmacy support. “Since some forms of anxiety stop people leaving the house, pharmacists could offer other ways to obtain pharmacy medicines and expertise, without the customer being there in person,” she says. “This could be through home deliveries and phone calls offering advice and support.

“Pharmacists also need to ensure they have a private space in their pharmacies away from the counter to discuss wellbeing issues if customers appear anxious or distressed. Anxiety needs to be brought more into the pharmacy domain and help should be more accessible. Community pharmacists and their support teams need to be comfortable enough to talk about mental health issues when called upon.”


Key facts

• NICE says recognition of anxiety disorders is poor, particularly in primary care
• Pharmacists are ideally placed to advise customers about anxiety treatments
• If patients aren’t sure what is causing their anxiety, they should be encouraged to keep a daily diary of their symptoms and possible triggers


Short-term sleep problems

Everyone has problems sleeping at times, whether it is trouble getting to sleep, staying asleep all night or waking early. Most sleep problems resolve after a short period of time but sometimes they persist and impact on a person’s day-to-day life. If people continue to sleep badly, this can affect energy levels, mood and concentration, which in turn can increase the risk of accidents. Poor sleep can also affect their relationships and social life.

Common triggers of short-term sleep problems include a poor sleep routine, stress or anxiety, environmental factors such as room temperature, allergies, medication and pain. Many people may ask a pharmacist for advice on self-help measures or suitable over-the-counter sleep aids.

Regular bedtime routine

A regular bedtime routine can help people wind down, but most people don’t go to bed and wake up at the same time each day. According to Jessica Alexander of the Sleep Council, most adults need between six and nine hours of sleep every night. “A bedtime ritual teaches the brain to become familiar with sleep times and wake times,” she says. “It programmes the brain and internal body clock to get used to a set routine.”

Everyone has their own way of relaxing and winding down. This may include having a warm bath, writing ‘to do’ lists to organise their thoughts for the next day, relaxation exercises (e.g. light yoga stretches), relaxation CDs, reading a book or listening to music.


Stress is one of the biggest triggers of poor sleep. According to research commissioned by Potter’s Herbals, 86 per cent of British people admitted to being stressed at some point in their daily lives, with seven in ten describing their stress as moderate or extreme. According to Chireal Shallow, registered practitioner psychologist and accredited CBT psychotherapist, nearly half of those surveyed said they have trouble sleeping as a result of stress.

“It is not just the effect stress has on keeping us awake at night,” she says. “It can actually cause physical concerns. The research echoes this, as 43 per cent of the respondents admitted to getting headaches when stressed, and 35 per cent felt constantly exhausted.”

If stress or worry is causing poor sleep, customers can try relaxation techniques before they go to bed. However, on a more long-term basis, they need to identify the trigger and take practical measures to address the problem. This may involve, for example, getting financial advice or talking to their employer about reducing their workload.


According to Allergy UK, allergies affect over 21m adults in the UK. Allergic rhinitis is well known for causing nasal congestion, a runny nose, itching, post-nasal drip and sneezing – but it can also trigger daytime sleepiness, disrupted night-time sleep, fatigue and headaches. Nearly 60 per cent of indoor allergy sufferers say their symptoms feel worse when they are in the bedroom, especially at night.

The house dust mite is one of the commonest triggers of allergies and asthma. A typically used mattress has anywhere from 100,000 to 10 million mites inside, as moisture (from sweat), dead skin cells and warmth turn mattresses (especially old ones) into the perfect breeding ground. For this reason, it is recommended that mattresses be replaced regularly – ideally around seven years.

New mattresses should be aired each morning, cleaned regularly and covered with allergen protectors to stop house dust mites thriving. It is also important to make sure the bedroom is well-ventilated. To relieve allergy symptoms, pharmacy customers could try a daily antihistamine and a corticosteroid nasal spray.

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