Stress is a word that’s bandied around a lot these days, often without much thought. A busy day at work, the kids being a handful, or even watching TV programmes – the BBC’s recent Bodyguard series being a prime example – can all result in exclamations of “I’m stressed!” or “This is so stressful!” But how often do we actually mean it? At what point do these little stresses start becoming a problem? And what can be done to manage it?
Stress isn’t a mental health condition in itself, but if not managed effectively, it can have a significant short- or long-term impact on both mental and physical health, as well as social interactions.
Although there is no medical definition for stress, the general consensus is that it involves pressure – both in terms of situations or events that put pressure on people and people’s individual reactions to being placed under this pressure. Specifically, the Mental Health Foundation (MHF) describes stress as: “The degree to which you feel overwhelmed or unable to cope as a result of pressures that are unmanageable.”
What’s confusing is that people tend to use these terms ‘stress’ and ‘pressure’ interchangeably but in actual fact they’re different concepts.
Chris O’Sullivan, head of business development and engagement at the Mental Health Foundation says that stress is the body’s natural response to certain situations. “It’s that fight or flight response from way back when we were facing sabre-toothed tigers. Now it’s exams or tests or coming across dodgy people in an alley, but still, without it we couldn’t survive.”
Whether it’s a single stressful event or a combination of small stressful experiences building up, there’s potential for everyone to reach their breaking point. As Chris points out: “The stress response exists to enable us to deal with extraordinary events and situations. It’s a natural response. But if you call it stress – if you call it out as an indicator – then it’s a different thing and it’s negative. Otherwise, we’re just under pressure and it’s pressure that’s a good thing. If we’re under pressure at work, for example, we grow by being taken out of our comfort zone. Chronic stress with no let up is when it starts to become a problem.”
The confusion or lack of understanding about what stress is was part of the reason why the Mental Health Foundation picked the topic to focus on for Mental Health Awareness Week 2018 and its Stress: Are we coping? report. According to the survey – the largest known study on stress in the UK to date – 74 per cent of people have felt so stressed at some point over the last year that they felt overwhelmed and unable to cope. “There’s lots of conversation around whether stress is a thing and is there such a thing as good stress,” says Chris. “We used the question ‘over the last year have you at some point felt so stressed that you’ve felt overwhelmed or unable to cope?’ as a lead off and we were astonished at the result of 74 per cent saying yes.”
What’s more, according to the Office for National Statistics Labour Force Survey in 2017, 14.3 million working days were lost to stress, depression and anxiety.
It’s worth remembering that there are different thresholds of stress and what can be stressful for one person might not be for another. In the same way, stress can affect people differently and manifest itself in numerous ways – both physically and psychologically.
“Chances are people won’t come into the pharmacy with psychological symptoms – it’ll be things like heart rate increase, lacking in energy, tummy upsets and feeling sweaty,” says Chris. “It’s all about medically unexplained symptoms and people frequently coming into the pharmacy for the same remedies.”
Pharmacy teams should find ways to discuss stress in an appropriate way and make it clear to customers that while people might not want to go to their GP to talk about their stress – thinking it might waste time or it isn’t important enough – pharmacy is a place where private, confidential conversations about all aspects of health can take place. Chris explains: “Saying explicitly that there’s a space where they can talk and then being receptive and compassionate can be a great help.”
The Mental Health Foundation endorses a ‘making every contact count’ approach by moving to a culture of holistic care. “It’s about connecting community pharmacy tasks back to mental health promotion. They all have a mental health component. Someone might come in with a minor health condition that’s making them feel pretty rattled and there’s an opportunity there to encourage treatment for those minor ailments that will have a knock-on psychological impact,“ says Chris. “And that’s dispensing assistants and counter staff even more than the pharmacist, as they tend to see customers more regularly.”
Services are another way of starting those conversations and offering support. “High blood pressure is a good one, so if there’s a community pharmacy blood pressure screening for hypertension, you’ll have the opportunity to ask about lifestyle,” says Chris. “Pharmacy teams also have the ability to ask the question ‘how are you doing?’ and ‘how are you feeling?’, which can open the door. They might not feel they can deal with the potential answers, but it’s all linked to mental health first aid and there is plenty of support that can be signposted if necessary.”
The MHF’s Stress: Are we Coping survey also found the top stressor reported by participants was long-term health conditions, either one’s own or those of close family and friends, with 36 per cent of all adults who reported experiencing stress in the previous year citing this as a factor.
Chris highlights that these customers will frequently visit the pharmacy for prescriptions and this presents another opportunity for pharmacy teams to offer support. “They may be agitated, less able to deal with things, be irrationally angry, seem distressed or reserved, snap quickly or get tearful and upset. These are all things to look out for,” he says.
Offering these customers a listening ear is just as important as helping customers with long-term health problems stay as well as possible and keep on top of their condition.
“Coming in for their weekly prescription of benzodiazepines, for example, might be the only interaction someone gets and that two minutes of friendly interaction might not be a big deal to you, but it’s a massive thing for them,” says Chris. “If you invite them to talk and offer a positive response then it can be a huge help to their wellbeing.”
Stress is an inevitable part of life, but learning ways of managing, mitigating and preventing stress can be important tools for building resilience and improving mental and physical health and wellbeing.
“I don’t want to simplify something so complex too much, but we’re encouraging people to take note of the 10 ways to wellbeing, which include things like diet, exercise, sleeping more, mindfulness – which has a good evidence base – drinking less, relationships and hobbies,” says Chris. “They’re a good fit with pharmacies as they fit in with smoking cessation, health checks and lifestyle reviews. You have the opportunity to ask about lifestyle and what people do to keep mentally fit, as well as having lots of signposting to community resources.”
Diets high in calories, low in fibre and low in the antioxidant nutrients found in fruit and vegetables have been found to have a negative impact on emotional stress and public health nutritionist Dr Emma Derbyshire says that nutrition certainly has a role to play in stress management.
Co-author of a recent report by brain health supplement brand Equazen – How modern life impacts brain health from cradle to grave – Dr Derbyshire highlights that there’s a vicious cycle when it comes to stress and nutrition. “If you’re stressed it affects your eating patterns and you’re more likely to skip meals and eat unhealthily, which affects your nutritional status. Stress also affects your sleep and a lack of sleep affects appetite,” she says. “If you don’t take time out to eat well and give yourself a brain break then you’re more susceptible to illnesses like colds as well.”
According to Dr Derbyshire there are two main nutrients that impact on brain function: omega-3 fatty acids and iron – neither of which tend to be consumed in the required quantities. “By and large we’re not eating enough omega-3 fatty acids. We should be eating at least one portion of oily fish per week but we’re eating a third of that on average,” says Dr Derbyshire. “We should be consuming a ratio of 1:1 for omega-6 and omega-3 fatty acids but in reality it’s around 15:1 because of the amount of vegetable oils in biscuits and crisps. The two compete for the same enzyme pathways so we’re grossly under-consuming omega-3.”
And the same goes for iron. “Iron is important for cognitive function – brain function. But 47 per cent of young females aged 11-18 consume lower than the recommended guidelines and a quarter of women aged 19-64 do,” Dr Derbyshire adds.
With this in mind, she has five key nutritional tips to pass onto customers to help manage the effects of stress:
74 per cent of people have felt so stressed at some point over the last year that they felt overwhelmed and unable to cope