The stressed but not ‘mentally ill’: How can we actually help?

Rosie Marshall is a GP based in Wiltshire. 

General practice routinely involves supporting patients presenting with diverse manifestations of stress. This can be a challenging issue for clinicians to manage because by definition there are underlying circumstances (sometimes related to complex and systemic problems, often beyond the scope of the individual) that ultimately need to be changed, and of course we have no magic wand for this. This can feel, to me, like an elephant in the consultation room. Where presentations appear to be an understandable and rational reaction to challenging circumstances, are standard medical approaches to mental illness the best way forward or do we need to expand our skill set?

Caused by material or existential factors, stress is of course inevitable in life. When our coping resources are exceeded by prolonged or high impact exposure, the potential impacts can be profound, including severe mental as well as physical illness. But not every stressed person is suffering from mental illness. It is unsurprising that the issue sparks confusion when the specialists are still in dispute about what mental illness is. Publication of the American Psychiatric Association’s revised DSM-5 in 2013 stirred considerable controversy, with many in the psychiatry and psychology worlds arguing that diagnostic criteria were being lowered to the point of incorporating part of the normal spectrum of human emotional life. All but the severest manifestations of stress will likely be encountered by GPs rather than psychiatrists (if the patient presents to a medical professional at all), and we are unlikely to spend time agonising over categorisation systems. From a practical perspective, we know there is a complicated relationship between wellness/illness and the presence or absence of symptoms.

In the current version of ICD-10, ‘stress’ occurring in the absence of a singular crisis-level event would fall under adjustment disorder. This is defined as a state of emotional disturbance arising from a significant life change or stressful event. The DSM-5 definition of adjustment disorder specifies that the distress present is out of proportion to the severity of the stressor and beyond cultural expectations of a normal response. Similar to the contentious issue of bereavement, it can still be difficult to differentiate between a ‘normal’ response, and mental illness, being subjective even within one cultural context. This can feel more like an art than a science.

Outside the diagnostic remit of adjustment disorder (or PTSD/acute stress reaction), stress seems to be a grey area in terms of management guidelines, although numerous mental health charities are (quite rightly) telling individuals to visit their GP when stressed. The question is, when people come seeking help, what tools do we have to offer meaningful assistance, rather than a ‘band-aid’ approach to managing the symptoms of stress? I am not proposing to offer management guidance but rather consideration of the issue.

Identifying a stressor and fixing it to alleviate symptoms may present a straightforward process. More often, finding a solution is complicated and may feel unachievable. Attempting to directly confront the challenges in an individual’s reality can seem uncomfortable or inappropriate because we know it is not necessarily easy for them to actually make changes. Their agency will often be limited by numerous material and psycho-social factors, some well beyond their own or anybody’s control, and changing habitualised behaviour is difficult. Additionally as we witness daily, life is inherently complex and reality may be elusive in the formulation of internal narratives and perceptions. In the telling of our own life stories, our memories are curiously malleable. What is lacking or dysfunctional may be readily apparent to an observer but insight cannot simply be delivered: it is best gained through a process of self-discovery requiring motivation and time.

Where there is an ongoing stressor with no likely beneficial outcome, ultimately the need for change has to be recognised and then actually acted upon by the patient, if action is possible. Motivational interviewing techniques may help to facilitate this, although these require practice and finesse. Psychological therapy can be incredibly helpful in guiding patients through a process of self-realisation, enabling them to identify key underlying issues and think about how they might be able to alter their circumstances or strengthen their coping mechanisms. It is likely to be most successful when appropriately individualised.

In some situations where a stressful event has been and gone, time will be the ultimate healer and reassurance enough (of course not in cases of PTSD). Exercise, nutrition, green spaces and mindfulness may well help with stress management and are always a good idea for general wellbeing, but may in many circumstances be unlikely to represent a cure for stress unless underlying issues are addressed. This is equally the case for alternative or complementary therapies. If a stressor is worth enduring for the likely resultant benefits, or circumstances are unalterable, then of course all of these approaches might be worth considering to make life more manageable, depending on context and preferences.

It can be difficult to know whether an individual is likely to benefit from medication. For some it will, of course, be entirely appropriate and beneficial. Medication may appear an attractive fix to the ‘worried well’ and persuading them it is not necessarily the answer can prove challenging. My general assumption is that if there are not symptoms of an underlying depression or anxiety disorder, then antidepressants are unlikely to help (short of a placebo effect). If an individual does try an antidepressant and benefits from a placebo effect, they may lose faith in medical help when the effect inevitably dissipates.

Conversely, if the source of stress resolves and they feel better, they may attribute the improvement to the antidepressant and believe it is the answer in future. Many patients try various medications over time, and instead of finding a more satisfying job, or leaving their dismissive partner, they come back asking what they can try next. Receiving treatment may facilitate avoidance of confronting the emotional complexity and messiness of ‘normal life’. As stated by T.S. Eliot, ‘Human kind cannot bear very much reality’. Medication is turned to readily by doctors (even diazepam, which is surely comparable to prescribing alcohol), but this is somewhat understandable in view of the complexities described above, when we have ten (or fifteen) minutes and are likely to be somewhere on the stress spectrum ourselves.

Fit notes may be a helpful way to communicate with a patient’s place of employment, if work is a source of stress. However, surely in many circumstances the patient should first be encouraged to attempt a communication with their work in order to avoid fostering unnecessary dependence. Weighing up the risks and benefits of time off work can be difficult. It may offer a period of genuinely needed respite and reflection and time to action change. However, if nothing changes during the interim and the patient spends their time in an agony of worry about returning to a mountain of catch-up and all the same stresses, then it seems an unproductive strategy. We all know that prolonged periods off work can contribute to a deterioration in mental health: occupation or meaningful pursuit is a human need.

Some patients may live in a seemingly constant state of stress regardless of circumstances or treatment, for example due to personality traits related to complex background factors. This is not to cast judgement, but understanding that this is their norm may facilitate a more productive working relationship.

GPs are no longer paternalistic advisors and we have not trained as life coaches, counsellors or psychotherapists, but we may feel called into these roles by some patients. It leads me to wonder, what is our role here? Importantly of course we need to try to identify those who are ‘mentally ill’, those at risk of harm, or those who would benefit from medication. But beyond this? Sending everybody for psychological therapy seems like the best way to rapidly render the psychological therapy service unserviceable due to infeasible waiting times. Should we have more training in the basics of life coaching or psychological therapy? We are of course unlikely to achieve any level of mastery of these subjects, when they are themselves vast areas of professional expertise and we already have quite enough on our plates to deal with as medical generalists. Nor is a 10 minute GP consultation the right medium for these practices.

The self-help industry is booming, with an astonishing diversity of books, podcasts and apps available. Some of these represent high quality, valuable resources for the motivated. However, quality is hugely variable, many are not evidence-based and some can lead down dubious paths. Highly contradictory advice may be offered, and an individual may not know which area of self-care would be beneficial to explore without starting with a certain degree of insight. Should we be delving into this realm? But again, how can we become acquainted with and critically appraise this immense and constantly evolving bank of work, and condense the best contributions into an efficiently deliverable and individualised format?

Perhaps the elephant in the room is that rather than accessing some store of medical knowledge to support a stressed patient, I am falling back on my own common sense and personal experience and this does not feel legitimate: it can trigger my imposter syndrome and make me feel stressed.

An awareness that our ability to help is extremely limited can cause feelings of inadequacy and frustration, which can contribute to burn-out. Perhaps we should be embracing our limitations and admit that we do not currently have the answer to curing the underlying stressors of modern life. We must carefully avoid the transference of worry onto our own shoulders: we are truly not responsible for our patients’ difficulties or life choices, although we can offer concern. If nothing else in the intractable cases, what we can take pride in offering is a listening ear, compassion and validation, and through this the possibility of human connection.

 

Featured photo by Ayo Ogunseinde on Unsplash