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Stress counseling rare in primary care setting


While stress may be a factor in 60% to 80% of all visits to primary care physicians, only 3% of patients actually receive stress management counseling, according to a study.

“Almost half of Americans report an increase in psychological stress over the past five years,” Aditi Nerukar, MD, MPH, the study’s lead author and assistant medical director of Beth Israel Deaconess Medical Center’s Cheng & Tsui Center for Integrative Care in Boston, said in a news release. “Everyone knows it’s there, but physicians rarely talk to patients about it.

“In fact, stress management counseling is the least common type of physician counseling, falling behind counseling for nutrition, exercise, weight loss and smoking.”

Nerurkar and colleagues examined data from the 2006 to 2009 National Ambulatory Medical Care Survey involving more than 34,000 office visits and 1,263 physicians. They looked for evidence of doctors who provided stress management help, which included counseling at the visit, offering “information intended to help patients reduce stress through exercise, biofeedback, yoga, etc.,” or referrals “to other health professionals for the purpose of coping with stress.”

They found stress management counseling by physicians rarely happens in the primary care setting. Only 3% of physicians offer stress counseling, mostly for their more complex patients, particularly those coping with depression.

“Our research suggests that physicians are not providing stress management counseling as prevention, but rather as a downstream intervention for their sickest patients,” Nerukar said. “Considering what we know about stress and disease, this clearly points to missed opportunities.”

The researchers also found that stress management counseling was associated with longer office visits.

“We know that primary care physicians are overburdened,” said Gloria Yeh, MD, MPH, the study’s senior author and director of the Integrative Medicine Fellowship Program at Harvard Medical School and BIDMC. “With the volume of patients they see, there simply may not be enough time to provide stress management counseling during the office visit.

“The fact that we found that so few physicians are counseling their patients about stress supports this, and highlights the need to rethink how primary care is being delivered.”

A key step toward incorporating stress management counseling into primary care may be restructuring primary care delivery and payment to support team-based care.

“New payment models designed to promote wellness will enable team-based primary care practices to add counseling and coaching staff to address stress, mental illness and behavioral changes more effectively,” said coauthor Russell S. Phillips, MD, director of the Harvard Medical School Center for Primary Care.”

These changes could help shift counseling to earlier in the disease process, the researchers said.

The study appeared Nov. 19 on the website of the Archives of Internal Medicine and is available via subscription or purchase at


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