'Our health at risk'

First the good news: The percentage of Americans who report feeling extreme stress dropped 10 percentage points since 2007 when APA conducted its first Stress in America survey, from 32 percent to 22 percent. On a scale of 1 to 10, the mean rating for stress in 2011 fell to 5.2, the lowest level in five years (it was 5.4 in 2009 and 2010; 5.9 in 2008; and 6.2 in 2007). Extreme stress was likely highest in 2007 because that was the start of the economic downturn, the researchers suggest.

But the bad news from APA's latest data is noteworthy: A significant number of respondents reported that stress has only a slight or no impact on their physical health (31 percent) or on their mental health (36 percent). That's true even though stress is a proven precursor of many chronic conditions, such as depression and cardiovascular disease, and often makes existing illnesses worse, said APA CEO Norman B. Anderson, PhD, during a Jan. 11 panel discussion on the survey, "Stress in America: Our Health at Risk."

"Seventy-five percent of health-care costs are associated with chronic illnesses," said Anderson. "What's a key driver of chronic illnesses? Stress."

It's a vicious cycle since those with the highest stress are often those with chronic conditions, said APA President Suzanne Bennett Johnson, PhD, who also served on the panel, broadcast live on the Web from the Newseum in Washington, D.C.

According to the survey results, while Americans without a chronic health problem had a 5.2 stress rating, people who were depressed had an average stress rating of 6.3 and people who were obese had a 6.0 rating.

"Somehow our health-care system is not focusing on [stress]," Johnson said. "It's waiting until everybody is sick and then handing out biomedical interventions to help you with your disease, so we're left with more people getting chronic illnesses unnecessarily and increasing health-care costs."

What's the solution? Ensuring Americans have access to psychologists through a team-based, patient-care approach that can help people make lifestyle changes before chronic diseases set in, the panelists said. Psychologists have a wealth of evidence-based ways to help people reduce their stress, such as helping them think in new ways and teaching them relaxation techniques and time-management skills.

The Patient Protection and Affordable Care Act offers an opportunity to bring more of these interventions to Americans by encouraging health-care providers to better coordinate patient care. APA supports in particular the idea of team-based care, in which patients would be seen by a variety of health-care providers, including physicians, nurse practitioners and psychologists.

"We need to be sure that the payment models are in place and that incentives (for patients and providers) are in place so we can make that a reality," said Anderson.

The act will also enable more Americans to get the care they need earlier. Under the law, as of 2014, 32 million more Americans will have health insurance. Currently, people don't seek care soon enough because they lack insurance coverage, said panelist Katherine Nordal, PhD, executive director of APA's Practice Directorate. Soon, she said, more people will be screened for their risk of depression, obesity and other ailments, hopefully well before they develop chronic conditions.

"Treating the illness after it has developed is not the way to drive down health costs in this country," Nordal said.

Caregivers and others at risk

The APA survey also found that caregivers are under a significant amount of stress. According to the National Alliance for Caregiving, 65.7 million Americans served as caregivers for an ill or disabled relative in 2009. On a scale of 1 to 10, caregivers' mean level of stress was 6.5 compared with 5.2 among the general public. In fact, 55 percent of caregivers said they felt overwhelmed by the amount of care they must provide.

And the number of caregivers is expected to climb dramatically in the coming years. In 2011, the first Baby Boomers—those born from 1946 to 1964—turned 65, joining the ranks of the nation's older citizens. By 2030, the number of Americans age 65 or older is expected to double, to 72 million, according to the U.S. Department of Health and Human Services' Administration on Aging.

"The caregiver stress situation is only going to get worse," said Johnson, again pointing to the need for more team-based care. "The focus is always on the person with the illness, and of course that is important, but no one bothers to ask the caregiver anything. That's what we are advocating for here, a health-care system that looks at the whole person, that really looks at the whole family."

The health system has to take into account all of the demonstrated risk factors for illness, said Anderson. "We have to ask people about the stress in their lives, about nutrition, whether they are exercising and about family relationships," he said.

Other key survey findings include:

• Younger Americans are more stressed than older adults. When asked to rank their stress on a scale of 1 to 10, Millennials (age 18–32) had an average rating of 5.4 and Gen Xers (age 33–46) 5.6, compared with 4.9 for Boomers (age 47–65) and 4.5 for Matures (age 66 and older). The most significant stressors for Millennials, Gen Xers and Boomers are money (80 percent, 77 percent and 77 percent), work (72 percent, 77 percent and 64 percent) and housing costs (49 percent, 51 percent and 54 percent). Matures (63 percent) were most likely to cite their families' health problems as a source of stress.

• Easterners are more stressed. East Coast dwellers are slightly less able to manage their stress than other Americans, and appear to not be coping with stress as well as they did a year ago, the survey found. For example, Easterners appear to be exercising less: In 2010, 20 percent of Easterners reported that they vigorously exercised, while in 2011, that number dropped to 12 percent.
  
  Overall, the survey found that Westerners report being among the healthiest Americans and do a better job managing their stress. For example, 24 percent report exercising every day and 7 percent report "always" eating healthfully, versus 5 percent in the East and South and 3 percent for the Midwest. When it comes to managing stress, emotions play a slightly more significant role in the South compared with other regions of the country: 28 percent of Southerners reported that they lack the willpower to change because their emotions interfere, compared with 17 percent of Midwesterners, 20 percent of Easterners and 21 percent of Westerners. Easterners are also more likely to say that they are too busy and stressed to make positive lifestyle changes.

• Men perceive and cope with stress differently. While many men recognize the impact stress can have on their lives, they are less likely than women to do something about it, the survey found. Women are more likely to see psychologists as helpful during times of stress. Men are also less likely to make lifestyle or behavioral changes to reduce their stress, even though men are more likely to be diagnosed with health conditions linked to high stress and unhealthy lifestyles.

To help men better understand the connection between health and stress, Anderson said it's time for more aggressive public education campaigns targeted at men. While 20 years ago most people didn't recognize the link between stress and health, he said, "through research, through public education campaigns, through community-based organizations like the YMCA, most people now acknowledge there's a link. But for certain subgroups, we still have a long way to go."

The online survey of 1,226 Americans was conducted for APA by Harris Interactive in August and September of last year. Read a copy of the full report online.