Sheila Hardy explains the causes of stress, distress, and depression; how to recognise these conditions; and the role played by practice nurses in prevention and treatment.
There is no medical definition of stress but there are a number of associated signs and symptoms that patients may report to you. They can be divided into feelings, thoughts, behaviour, and physical aspects.1
- Irritability or short temper
- Agitation, inability to relax
- Feeling overwhelmed
- Sense of loneliness and isolation
- General unhappiness
- Memory problems
- Inability to concentrate
- Poor judgment
- Seeing only the negative
- Anxious or racing thoughts
- Constant worrying
- Eating more or less
- Sleeping too much or too little
- Procrastinating or neglecting responsibilities
- Use of alcohol, cigarettes, or drugs for relaxation
- Nervous habits (e.g. nail biting, pacing)
- Aches and pains
- Diarrhoea or constipation
- Nausea, dizziness
- Chest pain, rapid heartbeat
- Loss of libido
- Frequent colds.
Stress is usually the result of difficulties or perceived problems. A person can also experience stress when they are unable to assert their opinion or view. This can lead to overwork, performing inappropriate tasks, or being in situations which are uncomfortable. These circumstances can be in the home or the workplace. Initially, increased stress produces increased performance. Once the person passes a certain point, any more stress results in decreased performance, so trying harder at this point is unproductive or even counterproductive. We need a certain amount of stress to function well, sometimes called healthy tension or eustress (good stress).
How to recognise it
If you suspect that a patient is suffering from stress, consider asking the following questions:
- are you able to sleep properly without any worries going through your mind?
- do you feel impatient or irritable at minor problems?
- is concentrating difficult due to worrying about things?
- is making a decision difficult?
- are you drinking or smoking more?
- are you not enjoying food as much?
- do you feel unable to relax because you feel that something always needs to be done?
- do you feel tense, nauseated, or sweaty?
- do you have a ‘knot’ in your stomach, a dry mouth, or a thumping heart?
If the patient answers positively to several of these questions you need to enquire gently about the possible cause of the stress. It is also useful to ask how often they feel their situation, and how long they have experienced their symptoms. This will help the patient when making a plan to alleviate it.
Distress can be defined as extreme anxiety, sorrow, or pain. The person has unpleasant feelings or emotions that may cause problems with daily functioning. People with a long-term condition are particularly susceptible to distress.
When there is too much stress, when it lasts too long or when it occurs too often, it becomes harmful and causes distress. One of the first symptoms of distress is fatigue, which is often ignored by the individual.
How to recognise it
The King’s Fund recommends making use of consultation techniques that normalise the discussion of mental and emotional aspects of physical illness.2 Using a tool can help the patient to identify particular areas of difficulty. You can then work together to look at the best way to tackle their problems. The Distress Thermometer is a tool that can be used for screening patients for distress from any source.3 It was originally developed for use in patients with cancer and is recommended by NICE for people with language difficulties or sensory impairment.4 Research has been carried out that shows it can be useful in long-term conditions such as stroke.5 Using this tool is a way of enhancing communication between the patient and their healthcare professional as it allows a range of anxieties to be explored. Click here to download.6
Depression is characterised by loss of hope, not being able to think clearly, lethargy, sleep problems, changes in appetite, and irritability; it is a collection of symptoms, not simply an illness categorised by low mood. For a diagnosis, the symptoms need to have been present for a D uration of 2 weeks or more, be causing D istress, and be D isabling (‘the three Ds’), in addition to there being five of the nine diagnostic criteria detailed below.7
Depression is often a response to biopsychosocial (life) events that typically include relationship or financial problems, physical illness, bereavement, moving to a new house, or redundancy. Some people, however, can become depressed for no obvious reason but their suffering is just as real as it is for people whose illness arises as a reaction to life events.
How to recognise it
Depression is diagnosed when a person has recurrence and/or daily frequency of five or more of the following criteria:7
- little interest or pleasure in doing things
- feeling down, depressed, or hopeless
- trouble falling or staying asleep, or sleeping too much
- feeling tired or having little energy
- poor appetite or overeating
- feeling bad about yourself—or that you are a failure or have let yourself or your family down
- trouble concentrating on things, such as reading the newspaper or watching television
- moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual
- thoughts that you would be better off dead or of hurting yourself in some way.
You can screen for depression by asking the screening questions recommended by NICE:8
- ‘During the last month, have you often been bothered by feeling down, depressed, or hopeless?’ Yes/No
- ‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’ Yes/No
If the patient answers ‘No’ to these questions, you can offer them the opportunity to seek help in case their situation changes. If they answer positively you should carry out further screening using a validated tool such as the Patient Health Questionnaire (PHQ-9)9 Download it here.10
The practice nurse role in stress, distress, and depression
The practice nurse has a role in preventing, recognising, and treating stress, distress, and depression.
- Check the patient’s intake of caffeine. Too much caffeine can cause feelings of anxiety and nervousness, sleep disruption (especially difficulty getting off to sleep), restlessness, irritability, increased diuresis, stomach complaints, tremulousness, palpitations, and arrhythmias.11
- Encourage the patient to eat healthily. Nutrition has an impact on short- and long-term mental health. Eating fresh fruit, vegetables, and salad every day and preparing proper meals is associated with good mental health.12
- Promote regular exercise. In addition to its physical benefits, exercise releases endorphins, making the person feel good, provides structure and purpose to the day, and exercising outdoors provides exposure to sunlight and directly boosts mood.13
- Help the patient to get adequate sleep. Adequate sleep enhances immunity, avoids weight gain, improves mental wellbeing, prevents diabetes and heart disease, and increases libido and fertility.14 You can help your patient by discussing their sleep hygiene.
- Promote relaxation. This can both prevent and relieve the symptoms of stress. Releasing any tension in the body and clearing thoughts helps the person to deal with any issues. If you recommend any forms of relaxation to a patient, you need to explain that these are skills that need to be learned and take practice. Many people give up before feeling the benefits because they cannot do it straight away.
- ‘Time out’ and leisure. To remain well and prevent stress, people need breaks from work and time for themselves. It is a balance that people often get wrong because of outside pressure. If a patient reports fatigue, then you should advise doing something about it before it becomes exhaustion.
- Help patients to change stressful situations. You can help patients by providing a listening ear, offering written information, and signposting them to people who can give practical advice. Being a non-judgemental confidant will provide the patient with support.
- Problem-solving. Providing the opportunity for patients to talk about their problem is not only therapeutic but can help them to see things from a different point of view. This opens up more potential solutions.
- Help patients to change their thinking. Wellbeing is more likely to be maintained when people:
- look at things more positively
- see problems as opportunities
- refute negative thoughts
- keep a sense of humour.
This does not come naturally to everyone but can be learnt.
- Listen actively, i.e. pay close attention to what the patient is saying, ask questions, and paraphrase to ensure full comprehension, use eye contact and body language to acknowledge you are listening
- Use the tools described above
- Find out:
- how their problem is affecting them and note their mood
- what is troubling them the most
- what helps them cope with this and offer brief advice if appropriate
- Offer empathic comment (to encourage hope)
- Ask about suicide intent. If you are concerned, the patient should see the GP immediately.
The treatment of stress and distress is dependent on the cause. Listening effectively will help you to determine this. Someone who is depressed may require medication and specialist help. Your local Improving Access to Psychological Therapies (IAPT) service may offer a psychological service.
The preventative measures described above can also be used as part of the patient’s treatment for stress, distress, and depression.
This article offers a brief overview. It is recommended that you access training in mental health and wellbeing if possible. The Charlie Waller Memorial Trust offers free ‘train the trainer’ training, which includes five face-to-face modules. This can be arranged through your organisation (usually the CCG) and Dr Sheila Hardy. If you are interested, please talk to your CCG.
You can also access seven e-learning modules by registering with Health Education England’s portal and click on registration. Once you have registered, go to Mental Health Awareness Programme, then Practice Nurses.
- NHS Choices. How to deal with stress. www.nhs.uk/Conditions/stress-anxiety-depression/Pages/understanding-stress.aspx (accessed 22 May 2017).
- Naylor C, Parsonage M, McDaid D et al. Long-term conditions and mental health: the cost of co-morbidities. The King’s Fund and Centre for Mental Health, 2012. Available at: www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/long-term-conditions-mental-health-cost-comorbidities-naylor-feb12.pdf
- Roth A, Kornblith A, Batel-Copel L et al. Rapid screening for psychologic distress in men with prostate carcinoma: a pilot study. Cancer 1998;82 (10): 1904–1908.
- NICE. Depression in adults with a chronic physical health problem. NICE Clinical Guideline 91. NICE, 2009. Available at: www.nice.org.uk/CG91
- Gillespie D, Cadden A. The Distress Management System for Stroke (DMSS): an approach for screening and initial intervention for post-stroke psychological distress. J Nurs Educ Pract 2013; 3 (10): 150–158.
- National Comprehensive Cancer Network. NCCN distress thermometer and problem list for patients. Available at: www.nccn.org/patients/resources/life_with_cancer/distress.aspx (accessed 10 May 2017).
- American Psychiatric Association. The diagnostic and statistical manual of mental disorders—fifth edition. Arlington, VA: American Psychiatric Association, 2013.
- NICE. Depression in adults: recognition and management. NICE Clinical Guideline 90. NICE, 2009 (updated 2016). Available at: www.nice.org.uk/CG90
- Spitzer R, Kroenke K, Williams J. The Patient Health Questionnaire Primary Care Study Group. Validation and utility of a self-report version of PRIME-MD. The PHQ primary care study. JAMA 1999; 282 (18): 1737–1744.
- Patient. Patient Health Questionnaire (PHQ-9). patient.info/doctor/patient-health-questionnaire-phq-9 (accessed 22 May 2017).
- Nawrot P, Jordan S, Eastwood J et al. Effects of caffeine on human health. Food Addit Contam 2003; (1): 1–30.
- Mental Health Foundation. Diet and mental health. www.mentalhealth.org.uk/a-to-z/d/diet-and-mental-health (accessed 11 May 2017).
- Taylor A. Physical activity and mental health. Royal College of Psychiatrists, 2012. www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/physicalactivity.aspx (accessed 11 May 2017).
- NHS Choices. Why lack of sleep is bad for your health. www.nhs.uk/Livewell/tiredness-and-fatigue/Pages/lack-of-sleep-health-risks.aspx (accessed 22 May 2017).