Guideline:
Stress-related conditions
Bibliographic Source(s)
- Stress-related conditions. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2004. 27 p. [129 references]
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: Harris J ed. Occupational Medicine Practice Guidelines: American College of Occupational and Environmental Medicine. Beverly Farms MA: OEM Press; 1997.
Guideline Category
Diagnosis
Evaluation
Management
Treatment
Intended Users
Advanced Practice Nurses
Physician Assistants
Physicians
Utilization Management
Guideline Objective(s)
- To provide information and guidance on generally accepted elements of quality care in occupational and environmental medicine
- To improve the efficiency with which the diagnostic process is conducted the specificity of each diagnostic test performed and the effectiveness of each treatment in relieving symptoms and achieving cure
- To help occupational physicians and primary care practitioners manage employed patients with acute stress-related conditions of relatively short duration
- To help clinicians identify patients who need urgent referral for psychiatric care and provide a framework for treating the majority of patients who do not
Target Population
Adults with potentially work-related stress-related conditions seen in primary care settings
Interventions and Practices Considered
Evaluation
- Medical history including symptoms stressors coping mechanisms and other resources
- Physical examination including a mental status examination
Diagnosis
- Evaluating for potentially life-threatening or other serious diseases that the history and physical examination may suggest
- Coding the visit appropriately
Treatment/Management
- Patient education
- Specialty referral
- Management of medical conditions
- Modification of maladaptive coping mechanisms
- Aerobic exercise
- Stress management techniques
- Relaxation techniques
- Behavioral techniques
- Cognitive techniques and therapy
- Stress inoculation therapy
- External resources and referrals
- Employee assistance programs
- Pharmacotherapy (limited use or in conjunction with specialty referral)
- Anxiolytics
- Antidepressants
- Antipsychotics
- Modified work and accommodations
- Organizational interventions
- Determining disability duration
- Follow-up as appropriate
Major Outcomes Considered
Missed work days
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Note from the National Guideline Clearinghouse (NGC): The American College of Occupational and Environmental Medicine contracted the Work Loss Data Institute to provide medical library research services.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Review
Review of Published Meta-Analyses
Description of the Methods Used to Analyze the Evidence
Contributors reviewed at least one chapter each and reviewed the relevant medical literature that had been published since the creation of the original Guidelines in 1997.
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation
Following the chapter and literature review participants provided written or verbal comments to the American College of Occupational and Environmental Medicine's Practice Guidelines Committee.
Verbal comments were in the form of participation in multi-specialty conference calls during which the issues raised in each chapter were extensively discussed. Draft chapters were prepared and distributed by the American College of Occupational and Environmental Medicine to all chapter reviewers. Follow-up multi-specialty teleconferences were then held as appropriate during which time the draft was again reviewed.
Major Recommendations
General Approach and Basic Principles (refer to the original guideline document for more detailed information)
Stressors may be any life event or circumstance that exerts a physical emotional or cognitive demand on the individual. The lifetime prevalence of major stressful life events is 100% so associated stress-related symptoms may be considered a normal condition of human existence.
- Stress is not a diagnosis disease or syndrome. It is a nonspecific set of emotions or physical symptoms that may or may not be associated with a disease or syndrome. Whether or not stress contributes to a disease or syndrome depends on the vulnerability of the individual; the intensity duration and meaning of the stress; and the nature and availability of modifying resources.
- The initial assessment of patients with acute stress-related conditions focuses on detecting potentially serious psychopathology or red flag conditions requiring urgent specialty referral. The majority of patients with stress-related conditions will not have red flags and can be safely and effectively managed by occupational or primary care physicians.
- Relief of stress depends on its precipitants which are often multifactorial. Psychosocial workplace or socioeconomic issues can be explored with the patient to facilitate early identification of precipitating factors and appropriate interventions that may prevent delayed recovery or relapse. An open honest discussion of the underlying factors often results in an increase in the patient's insight and coping skills which itself helps alleviate many stress-related symptoms.
- Worksite interventions may be helpful in mitigating or eliminating inciting stressors depending on the source of the complaints.
- Medications generally have a limited role. Limit use of anti-anxiety agents to short periods of time (i.e. periods when overwhelming anxiety limits the patient's ability to work or effectively perform the activities of daily living). Antidepressant or antipsychotic medication may be prescribed for major depression or psychosis; however this is best done in conjunction with specialty referral.
- Patients are encouraged to enhance their individual coping skills and to decrease or discontinue maladaptive coping mechanisms such as excessive use of alcohol tobacco or other drugs or excessive food intake. Patients are counseled to redirect their energy to regular aerobic exercise relaxation techniques and cognitive coping mechanisms.
- For uncomplicated cases absence from work should not exceed one work week. Referral for mental health professional assessment may be considered for patients whose anticipated absence from work will exceed one week.
- If symptoms become disabling despite primary care interventions or persist beyond three months referral to a mental health professional is indicated.
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
The type of supporting evidence is not specifically stated for each recommendation.
Potential Benefits
- Improved efficiency of the diagnostic process
- Effective treatment resulting in symptom alleviation and cure
Potential Harms
- Anxiolytics can lead to dependence and do not alter stressors or the individual's coping mechanisms.
- Antidepressants have many side effects and can result in decreased work performance or mania in some people.
- Antipsychotics can decrease motivation and effectiveness at work.
Qualifying Statements
The American College of Occupational and Environmental Medicine provides this segment of guidelines for practitioners and notes that decisions to adopt particular courses of actions must be made by trained practitioners on the basis of the available resources and the particular circumstances presented by the individual patient. Accordingly the American College of Occupational and Environmental Medicine disclaims responsibility for any injury or damage resulting from actions taken by practitioners after considering these guidelines.
Description of Implementation Strategy
An implementation strategy was not provided.
IOM Care Need
Getting Better
IOM Domain
Effectiveness
Patient-centeredness
Bibliographic Source(s)
- Stress-related conditions. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2004. 27 p. [129 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
American College of Occupational and Environmental Medicine
Guideline Committee
American College of Occupational and Environmental Medicine Practice Guidelines Committee
Composition of Group that Authored the Guideline
Chapter Lead: Lee S. Glass MD
Committee Members: Jennifer H. Christian MD MPH FACPM; Philip I. Harber MD MPH FACOEM FCCP; John P. Holland MD MPH FACOEM; Kathryn L. Mueller MD MPH FACEP FACOEM; Douglas J. Patron MD MSPH; Bernyce M. Peplowski DO MS; and Jack Richman MD CCFP DOHS FACOEM
Timothy J. Key MD MPH FACOEM as Responsible Officer and ACOEM President Elect and Edward A. Emmett MD MS FACOEM Chair of the ACOEM Council on Occupational and Environmental Medical Practice contributed to the development of the guidelines as well.
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: Harris J ed. Occupational Medicine Practice Guidelines: American College of Occupational and Environmental Medicine. Beverly Farms MA: OEM Press; 1997.
Guideline Availability
Print copies are available from ACOEM 25 Northwest Point Boulevard Suite 700 Elk Grove Village IL 60007; Phone: 847-818-1800 x399. To order a subscription to the online version call 800-441-9674 or visit http://www.acoempracguides.org/.
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI on May 31 2006. The information was verified by the guideline developer on November 3 2006. This summary was updated by ECRI Institute on November 9 2007 following the U.S. Food and Drug Administration advisory on Antidepressant drugs.
COPYRIGHT STATEMENT
The American College of Occupational and Environmental Medicine the signator of this license represent and warrant that they are the publisher of the guidelines and/or possess all rights necessary to grant the license rights to AHRQ and its agents.
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