More doctors prescribing stress management

Many medical issues are affected by stress, leading doctors to increasingly help their patients find peace

Dr. Aditi Nerurkar, who developed a stress management practice at Beth Israel Deaconess Medical Center, heads off to practice yoga.Lane Turner/Globe Staff

W hen Vlad Lucien developed high blood pressure earlier this year, the 33-year-old’s doctor referred him to a “stress management” physician to help him handle the daily demands of his job as an office manager. Harlow Robinson decided to seek the same doctor’s help a few months ago, and now uses breathing techniques to help him handle the pressures that come from chairing the history department at Northeastern University. “I can do the breathing exercises at work,” said Robinson (who is also a Globe classical music correspondent). “I shut the door for five minutes to find a little serenity.”

Last June, Dr. Aditi Nerurkar began her innovative stress management practice at Beth Israel Deaconess Medical Center after determining that stress counseling was largely absent from primary care practices. That’s despite research that shows that 60 to 80 percent of medical complaints are exacerbated or triggered by stress.

A handful of other primary care practices in the Boston area have also begun to offer stress management services in the office as insurance companies increase reimbursements for acupuncture, massage therapy, and meditation classes administered under a physician’s supervision. Doctors have also been motivated by recent studies suggesting that patients who learn better coping skills often have better control over chronic conditions like arthritis, heart disease, and diabetes and can reduce their reliance on powerful medications.

“A lot of chronic conditions that we see in primary care have a link to stress, like migraines, stomach complaints, depression, and insomnia,” Nerurkar said. “And stress is a known risk factor for heart disease and diabetes."

Yet the majority of doctors could do more to help their stressed patients: In a study published last January in JAMA Internal Medicine, Nerurkar and her colleagues evaluated recent government surveys involving 5,100 family physicians and found that only 3 percent of those doctors discussed stress management with their patients during office visits. Among those same doctors, 17 percent provided nutrition counseling and 12 percent dispensed exercise advice.

Pressed for time during routine 15-minute office visits, doctors may find it easier and more practical to write prescriptions for painkillers or antidepressants than to delve into the life troubles that may be aggravating physical or psychological symptoms. “Many physicians don’t feel prepared to teach stress management techniques, and it raises the question as to whether it’s something that a doctor does or perhaps that a health coach should do,” said Dr. Russell Phillips, director of Harvard Medical School’s Center for Primary Care.

Phillips is working on an initiative in 19 large primary care practices in Massachusetts teaching hospitals to develop more team-based approaches to care to provide mental health counseling and other services while supporting general practitioners who don’t have the time or expertise.

While yoga, tai chi, and meditation classes are being offered by more of the practices taking part in Phillips’s initiative, getting insurance to pay for the classes can be challenging, Phillips added, especially if a doctor isn’t the one teaching them.

In the 40 minute-long stress management assessment that Nerurkar performs, she first measures a patient’s stress level over the past month via a 10-question “perceived stress scale” test.

After discussing a patient’s stress triggers and teaching meditation and breathing techniques a patient can use to deal with them, Nerurkar writes a stress management prescription tailored to a patient’s lifestyle that includes exercise, relaxation strategies, sleep hygiene tips, and dietary advice. The stress counseling is covered by insurance.

Nerurkar repeats the stress assessment on follow-up visits to help gauge whether patients are better coping with their stress after trying her prescribed techniques.

Lucien, Nerurkar’s patient, said his stress score dropped from 25 to 13 over the past three months after he started playing tennis twice a week, meditating for five-minute sessions, and eating more fruits and vegetables.

“My colleagues at work told me I seemed more relaxed,” he said.

Other primary care practices in Boston have woven stress reduction techniques into patient care by adding mental health counselors. At Bowdoin Street Health Center, doctors can send patients to social workers on site if patients report feeling overwhelmed.

“Our patients tend to be lower income with situational stress that’s financial or due to gang-related issues or grief from losing a loved one,” said Dr. Giovanna Leddy, an internist at Bowdoin. “A year ago, they used to wait at least a month to see a mental health counselor, but now they can see someone that same day.”

The counselor teaches coping mechanisms and can refer patients to psychiatrists or community resource specialists — Bowdoin has two on staff — who can help them find programs for housing, financial, or violence-related issues.

While Leddy has no problem billing for her office visits, insurance coverage for the social workers and community resource specialists, she said, is “still a struggle” and the center relies on private grants to pay that staff.

Boston Medical Center has been able to obtain insurance coverage for its patients seeking stress management by putting physicians in charge of two-hour weekly classes that teach skills such as deep breathing, yoga, tai chi, and healthy cooking.

“We’re really interested in teaching these techniques to help patients reduce pain from chronic conditions like arthritis to reduce their reliance on prescription painkillers like narcotics,” said Paula Gardiner, an internist at Boston Medical Center who performs initial stress evaluations and leads some of the classes.

In a study of 51 patients who completed the eight-week group classes, Gardiner found that their baseline pain score decreased from 7.2 to 6.4 — with 10 being the greatest amount of pain and 1 being the least. She also found significant improvements in depression and sleep difficulties, according to the results, which are scheduled to be presented this week at the American Public Health Association meeting in Boston.

Johnnie Fuller said the classes he attended last spring helped him manage his knee arthritis and tension headaches without acetaminophen or ibuprofen and, more importantly, helped him cope with depression likely triggered by caring for his ill wife who passed away in June.

Besides befriending fellow patients who were also caregivers, the 71-year-old from Cambridge learned to take 15 to 20 minutes of daily “me time” whenever he felt overwhelmed by his daily responsibilities. “I went into a room by myself and practiced slow, deep breathing,” he said. “In the beginning, I didn’t think it would help, but the more I did it, the more the tension lifted.”

His only complaint? The classes didn’t last long enough. He’s now planning to join a free yoga class offered at Boston Medical Center.

Primary care physicians at Southern Jamaica Plain Health Center also offer stress management classes to patients who score high on a depression screening test administered during yearly physical exams.

“It was clear in our experience that overwhelming stress and anxiety were common problems that patients were bringing up during their exams,” said Dr. Juan Jaime de Zengotita, the center’s medical director. “We wanted to increase access to stress-reduction techniques that doctors can’t provide on their own.”