Town Hall Webcast Transcript

Susan Dentzer: Good morning. I’m Susan Dentzer, and I’m delighted to be moderating today’s discussion on the all important topic of stress. We’re coming to you from the Knight Studio at the Newseum in Washington D.C., and those of you joining us at home and online are the first to learn the findings from the American Psychological Association’s newest report: Stress in America: Our Health at Risk. Since 2007, the American Psychological Association has commissioned the Stress in America survey. Each year the survey examines the serious physical and emotional implications of stress. It goes without saying that stress is a part of all of our lives, and most of us also know that stress has a big impact on our health. Today we’ll discuss some solutions that could lessen this impact, including policy changes and more community support.

Joining me today is a group of experts on stress on physical and emotional health and, most important, on how our physical and emotional health are connected. Dr. Suzanne Bennett Johnson is the president of American Psychological Association and a distinguished research psychologist at Florida State University College of Medicine. Dr. Norman Anderson is the CEO and executive vice president of APA. He’s well known for his research and writing on the effects of stress on development of hypertension. Dr. Katherine Nordal is the executive director for professional practice at APA. Before APA Dr. Nordal managed a clinical and consulting group practice in Mississippi. Jonathan Lever is the vice president for health strategy and innovation at YMCA of the USA. Mr. Lever has been a chief architect in the wise response to the nation’s lifestyle-related health crisis.

APA invited all of you to attend this event because of your interests in primary care and mental health and disease prevention and management. We’ll be taking questions from all of you this morning and hope that this is just the start of a larger dialogue about health policy solutions to stress that include behavioral and physical health. For those of you watching at home you can submit questions via the American Psychological Association’s Facebook page and on Twitter using #stressAPA.

So let’s begin today’s conversation with some key findings from Stress in America: Our Health at Risk. For that we’re going to turn to Norman Anderson again the CEO and executive vice president the APA. Dr. Anderson, before we get to the findings though let’s establish: What do we mean when we use the word “stress”?

Dr. Norman Anderson: Well, stress occurs when we’re faced with situations and circumstances in our lives that exceed — that go beyond — our ability to successfully cope with them. Now, we all need some challenges in our lives just to prevent boredom, to stay engaged and actually to perform. And research has shown that a certain level of challenge — when it goes up — we actually do better in our lives, particularly in our work. It’s just when stress reaches a level that exceeds our ability to cope with it and it goes on for a long period of time — when it’s chronic — that we can say that people are in stressful situations.

Susan Dentzer: And we know more and more that stress actually translates into changes in our bodies, not all of which are good.

Dr. Norman Anderson: That’s one of the reasons we are very interested in studying stress and communicating how important it is. Stress has been found not just to affect us emotionally in terms of increasing depression and anxiety. It affects our behavior and interesting new research is showing it has profound effects on every system of our body. It affects our cardiovascular system, our immune system, our endocrine system. A recent report came out just this week that shows that stress actually causes a reduction, a shrinkage, in certain parts of the brain. So, stress has profound effects on all aspects of functioning.

Susan Dentzer: And as I understand that these happen to be parts of the brain that actually influence what we are going to be experiencing in terms of hypertension or other symptoms.

Dr. Norman Anderson: Yes and it’s a logical extension of stress affects — negatively affects — all these systems of the body, and stress increases our risk for a whole host of chronic illnesses that you will hear about later today.

Susan Dentzer: Okay, so we know this is really worth taking seriously. Let’s go to the findings then of this year’s survey. What are the top line results?

Dr. Norman Anderson: Well it’s really, what we found this year is really a good news, bad news story. The good news is…you know, we started doing the survey in 2007, and what we found over the years is that there is a very slow gradual decline in the level of stress Americans are reporting. It was uh when you look at that top level of stress, that extreme stress category, and in our survey we have a one to 10 scale, with eight, nine, and 10 being extremely high stress. The percentage of people in that extreme stress category has gone down gradually every year, so that’s the good news. The bad news is that nearly 50 percent of our survey participants are reporting that their own individual stress has gone up in the last 5 years and expressly in the last year.

Susan Dentzer: It’s kind of counter intuitive that stress levels would be going down. The economy has been miserable, there is a lot of joblessness, do we have any idea what’s going on?

Dr. Norman Anderson: Well, we are not positive, but what you have to remember is that when we started doing the survey in 2007, that was really the beginning of the massive recession we had, so people were already feeling and experiencing the effects of that recession. So, the decline that you see is really from that extreme high back in 2007. But, still nearly 25 percent of the American public is saying that they experience extreme stress, and because of the large effects of stress on people this is not good.

Susan Dentzer:Now, this year’s survey also asks some particular questions about the effect of stress on caregivers and on people with obesity. What do those results show?

Dr. Norman Anderson: Well, what we found this year, we really wanted to look carefully at a couple of subgroups. One of those subgroups are people we call caregivers. These are people who care for family members who are suffering from a variety of chronic illnesses such as a heart disease, a cancer or Alzheimer's’ disease. Our research this year corroborates; other research has been done that shows that this group is one of the highest stressed demographic groups in this country. It’s really quite remarkable that to see the level of stress that they are under. The other group that’s under a high level of stress are people with chronic diseases including heart disease, but also people with things such as obesity and depression are reporting an extremely high stress levels as well.

Susan Dentzer: And we know we have plenty of reasons now to be concerned about obesity with two-thirds of American adults either overweight or obese. It really is a crisis for our country. And Dr. Johnson, what does this mean then for individuals who are obese, as we’ve discussed, or have chronic illnesses?

Dr. Suzanne Bennett Johnson: Well, I think what the survey shows is that being obese or having a chronic illness at all actually increases your stress level. It turns out that over half of the people that responded to the survey said that either their own health problem or health problem in their family was a major source of stress for them. So, if you think about that, and then you add on top of it just all the stressful things that happen in someone’s life, then you realize that having a chronic illness is going to be very difficult to manage. Added stress of the illness and then added stress in your life is going to make it very difficult for you to successfully manage your disease.

Susan Dentzer: So a kind of vicious cycle essentially takes off?

Dr. Suzanne Bennett Johnson: Yes, it is a vicious cycle, and it’s actually the cycle is even bigger than that because it turns out that behaviors that are linked to stress have a lot to do with whether you get these diseases to begin with. It turns out that about 80 percent of heart disease, 80 percent of stroke, 80 percent of diabetes is actually caused by poor lifestyle behaviors. If Americans would quit smoking, eat better, exercise more, we could actually reduce the number of people with chronic illness in this country.

Susan Dentzer: Well, it sounds like all of that is obviously going to be desirable but it’s not going to happen without some policy changes or some, certainly some different ways of delivering health care to these individuals. Correct?

Dr. Suzanne Bennett Johnson: Yes. We are very concerned about the way health care has been delivered in this country. I like to sort of think about it as the disease model of health care. If you have a disease we are going to treat with either drugs or surgeries, but we haven’t successfully addressed the behavioral aspects of either having the disease or either getting the disease, so I think our health care system needs to focus more on people and less on disease.

Susan Dentzer: So Dr. Nordal sounds like there’s role here increasingly to marry psychological interventions with what we would think of as strictly health care of related physical interventions.

Dr. Katherine Nordal: Absolutely. As Dr. Johnson said, chronic illness is a huge problem in this country. We spend about 75 percent of all our health care dollars on chronic illness, and then we have four major behaviors — alcohol and drug use, tobacco use, lack of exercise or sedentary lifestyle and poor nutritional habits — that lead to and exacerbate these chronic illnesses. We have a huge public health concern. It would be easy if we could all, just as the old saying goes, “Just do it” and change our behavior, but it just not that simple. It’s hard for people to change engrained habits of behavior. So when we get stressed out we need to take stock of what it is that’s causing the stress — are we managing it appropriately or not? If we are not able to make the changes we need to by ourselves, we need to consult our physician or a psychologist or another health care provider that can help people make the changes that they need to make because if you just can’t do it on your own and you know you’re running the risk of some really bad health outcomes, it’s important that people take some action to get the help they need.

Susan Dentzer: And the survey this year actually speaks to that topic — the importance of support networks and strategies, really — for supporting people particularly among caregivers.

Dr. Katherine Nordal: Absolutely. The caregiver group seems to do much better when they are plugged in to some sort of a support system. They demonstrated less isolation, less loneliness, better coping strategies, less depression, less irritability and just less risk of chronic disease when they are plugged into the those family and friends and other sorts of community based support systems.

Susan Dentzer: So Jonathan Lever the Y has been wading into this problem, exploring a number of strategies in response to everything we’ve been talking about — obesity, chronic illness and so forth. What are the community level interventions now that you all are engaged in?

Jonathan Lever: Yeah, well, and everybody knows of the Y, but what folks may not know about the Y is that over the last several years we’ve really moved from a focus on the sort of “already fit” population. The people who, if you gave them the keys to YMCA, would be happy to go in and run on the treadmill to folks that we call “health seekers” – people who really struggle to adopt and sustain healthy lifestyles. And as local Ys have begun to think about health seekers, the folks who need support and struggle they’ve become more and more involved in chronic disease prevention programs. And so, the Y and many communities across the country now have chronic disease prevention programs — primary, secondary, tertiary kinds of programs focussed on individuals. Like we have a diabetes prevention program now. Excuse me, it’s now running in many places across the country. It’s a group-based program. We have a program with the LIVESTRONG foundation that’s focused on cancer survivors. We work with families on childhood obesity, and we also work at the community level to address sort of those policy systems change issues — more sidewalks helping kids adopt policies that enable kids to walk to school.

So, working at the community level as well and one of the things I thought would be interesting to share is some of the learnings that have really come from this work as it relates to stress. And it has really been touched on by Dr. Nordal already, which is why many programs are group-based. There is magic in group-based programs because people feel encouragement and support by others who are in the program with them. In our diabetes prevention program when people are scared to step on the scale it’s the group that encourages them; you know: “Come on get on that scale and let’s see how we did this week.” Another magic of community-based organizations like the Y is for people who are coping with the disease — not going to a hospital or a clinical setting — to get an intervention really has important psychological benefits. So going to a YMCA where there are kids and families, as you’re wrestling with a disease, is really uplifting and is different than going back to the hospital where it feels like “Wow, I’m back in treatment again.”

Susan Dentzer: The Y has a very important new partnership with APA in engendering a lot of this. Let’s talk about that a bit.

Jonathan Lever: Yeah, we’ve been really blessed to be able to work with the APA and their network of psychologists to run workshops, free workshops at local YMCAs, to help families that are struggling with childhood obesity in their family. And we’re working on a new program with APA and psychologists across the country to help people live well with a particular chronic condition. So we are thrilled to be able to be working with APA and others.

Susan Dentzer: Well, I come back to another point in the Stress in America survey of this year about the sources of stress in people’s lives. 75 percent say it is money, 70 percent say its work, the economy, of course, comes up obviously linked to the money question,67 percent; relationships, 58 percent; family responsibilities, 57 percent. Any surprises there to you, Dr. Anderson? Particularly, we were talking earlier about the sort of anomalous results of the stress. Levels seem to be going down even though the economy is still in quite a state. Would this be the results you’d expect at this point?

Dr. Norman Anderson: Well, I’m sorry to say these are expected because previous surveys in the years we have done this have shown pretty much the same thing: that the kinds of things that cause people excessive extreme stress tend to be the same year to year. And they cluster around economic factors — work, the economy are really the things that give people most concern, followed by another what looks like more interpersonal cluster — relationships in the family; caregiver issue comes up. Relationships with family members can be a source of stress for many.

Susan Dentzer: And what...

Dr. Suzanne Bennett Johnson: And I think the other piece is how many people are stressed over health issues. You know, not just the caregivers dealing with people that are sick, but people that have their own health issues. Over half of the people said that was a major stress. So, it’s sort of the economic piece, the relationship piece and the health piece, and I’m not sure that many Americans actually appreciate the health piece. I think the economic and the relationship piece might not surprise them, but the health piece might.

Susan Dentzer: Well, obviously there are going to be a lot of people for whom all of these are overlapping issues, right?

Dr. Suzanne Bennett Johnson: Yes, definitely.

Susan Dentzer: Stressed about the economy and you also happen to have a chronic illness with the rates of chronic illness.

Dr. Katherine Nordal: And they not only…and they are also interactive. So that is, Dr. Johnson mentioned earlier, having a chronic illness is a stress in and of itself. If it impairs your ability to function in your marriage or in other important ... in your parenting, or in other important relationships that adds to the stress. If you can’t work that adds to the economic stress. The stress then of the economics and the impaired relationships adds to your disease burden, so it can be a really vicious snowballing kind of cycle where all of these things can play off of each other. Our relationships are what we turn to for support. So, if our relationships begin to erode because of arguments about finances in the house, or you can’t do this for your kid ... because of ... your physical disorder, [you might not] be able to meet important roles. It is very addictive and really does set people up for some really bad health outcomes.

Susan Dentzer: Now all of these has to be adding up to a lot of cost, and we know that chronic illnesses are about 75 percent of total U.S health spending. If what I’m hearing basically suggests that there is a major role of stress in all of this, it’s a big significant number I assume, Dr. Johnson.

Dr. Suzanne Bennett Johnson: Well yes, and I guess what I was sort of saying before and I’d love to say again is that to me what’s sad is we actually know how to help people manage stress. We actually know how to help people lead healthier lives but somehow our health care system is not focusing on that, it’s sort of waiting till everybody is sick and then it’s handing out all kinds of bio-medical interventions to help you with your disease. So what are we left with? We are left with more and more people that are getting chronic illnesses in my view unnecessarily and increasing health care costs. So until we actually start focusing on stress and behavior, I don’t see any change in the increasing amount of chronic illness in this country, and I don’t see any change in the increasing cost of health care in this country.

Dr. Norman Anderson: Yes, if you just ... as Dr. Johnson said, 75 percent of health care costs associated with chronic illnesses. What’s driving the chronic illnesses? Stress is a major driver of the chronic illnesses. Unhealthy behaviors are major drivers of the chronic illnesses but we are in our health care systems are obsessed with treating the chronic illnesses rather than backing up a step focusing on prevention, focusing on lifestyle change, focusing on stress management to help prevent people from developing these devastating illnesses.

Susan Dentzer: Alright, so let’s talk a bit about what we might need to do then. Most people are, if they are lucky and have health coverage accessing primary care. What do we need to do to bring more of the behavioral care into primary care at this point, Dr. Anderson?

Dr. Norman Anderson: Well, one of the things that we are excited about is really the potential with the health care reform to make some of these changes. It’s going to take a lot of work. But one of the movements that we have been participating in and are very excited about it is this whole team-based care where patients don’t just see a single physician a primary care doctor for example, but when they go to a physician office they are actually seen by a team of health professionals, including psychologists, nurse practitioners, social workers, others that really focus on what we have been talking about earlier — that chronic illness, treatment and prevention really requires a holistic approach, for we are just not focusing on the biological aspects of which are important and given appeal for that. But we are focusing on things like stress and lifestyle management. So this team-based care is really the wave of the future but we have to make sure that the appropriate payment models are in place, the appropriate incentives are in place so we can make that a reality.

Susan Dentzer: We hear a lot of the phrase “patient-centered medical home” for example; it sounds like you are saying, in effect, you got to have people who are comfortable and professional in dealing with behavior health issues right at the table, right there in the patient-centered medical home environment. Correct.

Dr. Suzanne Bennett Johnson:That’s exactly right. As Dr. Anderson said we’re certainly very supportive of that concept of health care. Realizing that you have to treat the whole person and treating the illness after its developed and chronic is not a way to drive down health care costs in this country at all. The good news with the Affordable Care Act is that beginning in 2014 we are going to have 32 million more Americans who are going to be covered with some sort of health insurance program, whether it’s through Medicaid expansion or the health insurance exchanges. And that may be part of the reason we have had so many un-insured persons in this country: that folks don’t go to the doctor until they are absolutely desperate or are so sick that they are way down the road with their illness. So I think with the new focus on the patients at medical home, more focus on prevention, more reimbursement for screening for things like depression and obesity and more team-based approach to care, so that we are treating the whole person and not just treating a disease, has the potential to have a very positive impact in the long-term.

Susan Dentzer: So Jonathan, how do the community support things that you all have been doing, ring themselves around the patient-centered medical home to provide that additional support.

Jonathan Lever: That’s a great question. We are very encouraged by the concept of the patient-centered medical home. I think the challenge is the traditional health care environment doesn’t see community-based organizations as legitimate players necessarily in the health space. And yet we know the Y and other community-based providers can get outstanding results on lots of different metrics. But that we need, we meaning the community-based organizations need to be part and parcel of that team of folks who are helping the individual. I mean a doctor has I think it’s, you know, 8 to 12 minutes to spend with an individual. When a person comes to our diabetes prevention program, for example, we have him for at least 16 weeks, and they are in a group format. So, shortening that community to clinic gap is, I think, is one of the challenges that we are wrestling with right now but see great hope for the future.

Susan Dentzer: Now you spoke earlier about the Y focusing more and more on health-seeking individuals, particularly also focusing on individuals who, as you said, don’t necessarily have access to health clubs — some lower income people. How do people with lower or even minimal incomes access the services you all provide?

Jonathan Lever: Sure. Well, some of all the programs that we offer are no cost or they are being subsidized by others, and all YMCAs engage in local fundraising. That’s one of the benefits of working with community-based organizations: They can bring other resources to the table. And why scholarship individuals who don’t have the ... who don’t have the ability to pay for perhaps a program and they can be part and parcel of the program just like everybody else. And I do think that’s a virtue of community-based organizations that we are dealing with a government program. You either qualify or not. Period. The end. There is no additional support. Community-based organizations can leverage other resources public and private to help those individuals who don’t have the ability to pay.

Susan Dentzer: So if I’m a low-income obese person with diabetes just feeling enormous stress because of my illness. And we know diabetes is an incredible stressful illness to have I…what, how do I get to the Y? How do I access those services?

Jonathan Lever: You go to the YMCA and, say I want to participate in this program, I think it would be wonderful for me and local wise we’ll work and do everything possible to engage you in you in those programs. So yeah, we have an open door policy.

Susan Dentzer: So let’s come back again to this group of people, caregivers who are dealing with many, many elderly relatives in many cases. Also, we know younger people can experience high levels of disability, and there are lots of caregivers taking care of younger people as well. These results showing this decided difference in the stress levels really are troubling when you think about the fact that there really aren’t a lot sources of support for caregivers in this country. There aren’t a lot of respite care programs; there aren’t a lot of avenues for them to relieve their stress. What do we need to do from a policy level about that, Dr. Johnson?

Dr. Suzanne Bennett Johnson: Well, I think that a couple of things to keep in mind is this caregiver stress issue is only going to get worse. With the baby boomer generation, of which I am a member, it getting older we’re going to have more and more older people who have very high rates of chronic illness on needing care. And that generation is also going to be providing care — we call them the sandwich generation — they’re not only going to be facing their own illnesses, but their parents’ illnesses, sometimes their children’s illnesses. So we’re going to see more of this as a problem. In my experience, what happens is when you go into the health care system the focus is always on the person with the illness. Of course that’s important, but it’s as if no one bothers to ask the caregiver anything, and that’s what we are arguing here or trying to advocate for — is a health care system that looks not at the whole person but, really in this case, the whole family. If you don’t take care of their caregiver, health care costs are going to escalate astronomically because you won’t be able to keep that person in the home. They’ll have to go to some sort of facility, which will cost all this kind of money. So it’s just another good example of needing a health care system that focuses on people, rather than diseases.

Susan Dentzer: So how would we do that? How would we structure that, Dr. Anderson?

Dr. Norman Anderson: Well, one of the things that I think that we’re getting at is the health care system really needs to be structured to take into account all of the potential risk factors, all the demonstrated risk factors for illness. So if we do that, yes, we are focusing on biological assessments, but we also have to ask people about the stress in their lives, we have to ask them about their diet, the nutrition, whether they’re exercising and we need to ask them about family relationships, what’s going on in the family so a person could have an opening to say, “Well, I’ve been taking care of my relative who has this chronic illness, that should be a clue,” a cue, if you will, for physicians to think that this is a risk factor. They know the data, evidence-based medicine; they know what the data are and what the data say and that should be a cue to tie that person to appropriate services. Again if there’s team based care then there’s someone on the team who might be able to asses, the care giver, the psychologist, social worker, nurse practitioner or other.

Susan Dentzer: Well again, as the survey indicates, this high level of stress — decidedly higher level of stress for caregivers — is mirrored by the higher level of stress for those with obesity. And let’s come back to that topic as well. Again, with the amazing rise in obesity in this country, and the degree to which we’re going to have to get serious as a country really fast, we know that one of the most important things we’re going to have to do is lifestyle interventions, but those are hard. It’s hard for people to change behavior. We all know this; we all struggle with this. Well, how can a psychologist and others who focus on the behavioral aspects of care be better utilized in that process? Not just only of addressing the stress that is felt by those with obesity but encouraging them to get, integrate the stress into their lives in such a way that they can make the kind of behavioral changes that are needed? Dr. Nordal?

Dr. Katherine Nordal: I think it’s important — again back to this — health care teams that physicians and nurse practitioners and physicians assistants understand and appreciate that the role that psychology has always played in terms of the research and the evidence-based for how to help people change behavior. Back to the Affordable Care Act, we have middle health parity with that now. There are other ways also that psychologists can be engaged in the health system to help people change health related behaviors — middle health parity that will also be included in the medicate expansion and in the health insurance exchange programs. So, what this means is that individuals can’t have access with much less expense to them maybe their little expense to them to the needed, to that needed kind of care. But, it’s also important to go back to the idea of the family because people cannot change in the vacuum. You can be very, very motivated to change, but if you’re not working with someone that understands the family dynamics — maybe the dynamics in your marriage or the dynamics between you and your children or other things were going on in the family environment and in your community environment — that do or do not support the kinds of changes that you need, it’s just really, really difficult.

Susan Dentzer: I wanted to draw to other points of the survey, one is actually an interesting regional difference in stress levels, and the survey shows that Easterners reports slightly higher levels of stress than Americans in other regions. How do we think that is, Dr. Johnson? I know it’s a terrible time in Washington, it’s going to be that bad every place else?

[CROSS TALK]

Dr. Suzanne Bennett Johnson: Yeah, you know, I think living in New York, Washington, there’s a lot of high-stress jobs, and those cities attract people that are very motivated and excited about moving their careers forward. But those careers can be quite stressful — that’s one possibility. There it’s also expensive to live in those areas of the country and, as we know, the economy has really been in trouble lately. People have been very concerned with money — that was the number one stress, I believe in our survey — and so I think any area of the country where costs of living are high you may see an increase in stress.

Susan Dentzer: Could it possibly be some people need stress in their lives or gravitate toward it? Or, is the Northeast a magnet for people who just love a stressful life, or a lifestyle or a profession?

Dr. Norman Anderson: Well actually, there’s some indication on our survey data that suggest that there might be a little bit of that going on for example when you just look at Washington, the Washington, D.C., data. There was a higher percentage of people who said they were really energized by challenges. They really felt that they need a challenge or want a challenge in their lives, so they gravitated to a place that had plenty of that available to them. The other thing that we found in the survey was the stress levels were lowest out west, and I think Dr. Johnson is right: You really have to say well there’s something about the West that’s great. Well, it could be, but it also attracts people who want to be involved in that kind of environment. So it’s both the nature of the physical environment being on the coast for example, being in the sunny warm climate but which does attract people who want to be with others who have a more relaxed lifestyle. It’s a possibility.

Dr. Suzanne Bennett Johnson: It’s like ... thinking about the East, and particularly, it’s highly urbanized and it may be more difficult when people move into that kind of environment to really get plugged into support systems and networks. It may be more difficult to find whatever that group is that you’re looking for. We’re very mobile; many people don’t have family that live in the same area where they do, and a lot of the highly urbanized areas. So, I think it’s probably a lot of those things. But another interesting finding in the survey — that I’m not sure what the reason — is a lot of the symptoms of stress that report, were reported physical as well as the emotional symptoms. The irritability anger, depression and anxiety were higher in the Midwest than anywhere else, and you sort of think about the Midwest as the hot land of the country, you know, and you dig in the dirt and get all of this good relief from your stress. But I was a little bit surprised by the very high levels unless they maybe were partially affected by some of the cities data with places like Detroit that have just been just devastated economically. But yeah, the Midwest people had the highest reported levels on almost all the emotional symptoms, as well as sleep disturbance and stomach problems and that sort of thing.

Susan Dentzer: Another interesting difference in the survey was the difference between men and women — the gender difference — and the survey does appear to suggest that men maybe are just not getting some of the connections between their stress levels and personal health. They say they are more likely than women to say that they do do enough to manage their stress, but if you look at their levels of their stress-related illness, that doesn’t necessarily compute, does it Dr. Johnson?

Dr. Suzanne Bennett Johnson: Yeah, well, turns out that women in many, many studies report higher levels of stress than men. So they could certainly be more stressed. They could also be more willing to acknowledge their stress. We found a survey that women also report that they think stress is directly linked to health more often than men; they also report that they try to do something about their stress often unsuccessfully. They also report that they think seeing a psychologist would help them. They do this all more than men. Men don’t think they’re that stressed, they don’t think stress is linked to health that much, they don’t really report trying to do too much about it, and in the survey, they actually had more chronic illness. They had high blood pressure, they had more heart disease and they had more diabetes. So I kind of agree with you. I feel like the men aren’t really getting the link and the women are.

Susan Dentzer: So let’s go to our token men on the panel and ask them for some perspective. Dr. Anderson, what do we do about this?

Dr. Norman Anderson: Well I think it shows that we have to continue a fairly aggressive education campaign. I mean 10, 20years ago, or even further back, it would be hard to get anyone in the general population, certainly not the majority, to say there is a link between stress and health and certainly not in the medical establishment. But through research, through public education campaigns, though the work of community-based organizations like the Y, more people, most people, now acknowledge there is a link, but for certain subgroups we still have a long way to go. Men as you suggest are less likely to admit that link, particularly for themselves. So I think we need to have some targeted education programs for men, and one example is the National Institute of Mental Health. A few years ago they started a program called Real Men‒Real Depression because men do get depressed, but men are less likely to seek treatment and less likely to acknowledge it. So I think through targeted public education campaigns we can start to close that gender gap a little bit.

Susan Dentzer: Alright. We’re going to go now to some questions from our audience near and far.

Female speaker: Near and far, our first question is from Twitter @justbeachy asks, “I don’t understand the link between health issues and stress. What is that link?”

Susan Dentzer: OK. Well we talked a bit about that but let’s make it a little bit more concrete, Dr. Anderson. We know as we were saying earlier that actually when you experience stress and what is stress, I mean, you know — cavemen who saw a saber tooth tiger felt stressed — chemicals flow in the body that activate responses. So we know now that those responses actually have health implications, as you said, on every organ system.

Dr. Norman Anderson: Yes, and the difference between what was happening to the cave people versus us today is that their stress peaked when they were running from an animal, but then when that was over, it went back down. Ours tends to be much more chronic, unrelenting, constant. The link between that kind of stress and health has to do with the effects on the body, so if you have stress here you have illness here and the thing in the middle, biology — and by biology I mean stress — reduces the immune system’s ability to protect us from illnesses. It increases activity within the cardiovascular system that increases the likelihood of high blood pressure and heart disease.

It’s actually been shown that people under high stress actually have arteries that are more clogged than others, and when people are sick already and they experience stress, it makes the sickness worse. The research has shown that people with HIV/AIDs, for example, those under the highest level of stress have a more rapid progression of the illness than those that are on the low levels of stress. People who have heart disease who have high levels of stress are more likely to have a second heart attack than those who have lower stress. So there is a specific link between stress and physiology that leads to disease.

Susan Dentzer: And we...

Dr. Suzanne Bennett Johnson: Could I just add to that?

Susan Dentzer: Of course.

Dr. Suzanne Bennett Johnson: There is some very interesting research that even with a common cold that people that are stressed. If you take a whole group of people, and some people are stressed and some people aren’t, they do studies where they actually expose people to the common cold, the germs and the people — not everyone gets it. Turns out, when we get exposed to the common cold germs, most people actually don’t get the common cold, only some of us do. And it turns out when you do these studies that if you’re stressed, you’re far more likely to get even a common cold.

Susan Dentzer: Again the immune system responds properly.

Dr. Suzanne Bennett Johnson: It’s the immune system effect, yes.

Susan Dentzer: Probably playing into that great. Let’s take a question here.

Female speaker 2: Good morning. My name is Leocadia. I’m with the American Academy of Physician Assistants and Dr. Johnson, you said we know how to treat people with stress. Can you expand on that? And what I mean is, what methods or treatments are you referring to and who is the “we?” Because I would say that as primary care providers who are often in the front line, we don’t, excuse me, we don’t have the expertise to treat stress. We don’t have the adequate time in a patient visit, so can you give an example of what we should be doing and who should be doing it?

Dr. Suzanne Bennett Johnson: Sure. So for me, I think the ideal model is what we call the integrated care model — what Dr. Anderson was talking about — a team-based model where a patient would come in to you and you would have access to somebody like me who you would call up and say, “Dr. Johnson, I need you to see this person. They’re reporting a lot of stress.” But before you even did that you would already have asked the person about their stress level. So we would be, we would develop this partnership and then I would chat with this patient and we would come up with some ideas, some plans of how they’re going to manage their stress. There’re a lot of ways to manage stress, you know. Some of them have been suggested, certainly things like social connections, family, relaxation training, time management. There is a whole host we can use that are all evidence-based that show that you can help people manage their stress more successfully.

Susan Dentzer: It’s also possible to recommend that people go and access the services of the Y right? We know that, as you were saying earlier, Jonathan, that whole notion of social support and peer support can be so important in your health and we know that the contrast is true also. Social isolation is really bad for your health so…

Jonathan Lever: Yeah, and in fact I brought this with me, this is something called the big picture deck that we use at the YMCA. It’s a visual tool for exploring well-being, and what we do is we invite people to come to the Y, we show them pictures and we ask them, “What’s going well in your life and what do you wish you could do better?” And we have conversations about people’s well-being and we figure out how we can plug them into social support systems at the Y. There are not many places where you can go to talk about well-being and we hope the Y and other community-based organizations will be such a place.

Susan Dentzer: Good.

Dr. Katherine Nordal: Can I add something to that? I was going to say one of the things that we haven’t talked about a whole lot here today that has a lot to do, I think, with our health, is how we see the world as an individual. How we think about the world and about our situation and that would be another strategy that psychologists could help people with, because sometime when you can’t make the changes that you need to make, it’s because you’ve got some thinking patterns that are blocking you and keeping you from being able to make those changes. And psychologists are pretty expert at helping people to analyze their thinking patterns and learn new ways of thinking and perceiving the world that are healthier, maybe, than the habits that they bring to the situation.

Susan Dentzer: So if I’m a person who started to believe that everything results in catastrophe, you can sort of walk me through that and say, well that’s really not the case; you need to maybe look at it from a different perspective.

Dr. Katherine Nordal: Correct.

Susan Dentzer: OK. Good, another question.

Female speaker 1: We have another question from Twitter. This is from @ETurnerPhD. What efforts are APA making to impact policy related to behavioral health?

[CROSS TALK]

Dr. Katherine Nordal: I will be glad to start. We have a very active health care reform team at the American Psychological Association that involves a lot of senior staff, including Dr. Anderson, where we coordinate across all parts of APA around a variety of issues related to health care, from integrated care to reducing health disparities to concerns about particular populations of high-risk patients like patients with HIV and AIDS, persons with lesbian, gay, bisexual kinds of concerns. So we have a very integrated kind of approach. I think with a really strong team we do a lot of government relations work with a lot of different departments, not only on the health, but also with some agencies. We have a strong science government relations department that advocates for research and appropriate funding for the kinds of behavioral health, kinds of research that need to be done to help improve the system.

Dr. Norman Anderson: Let me just add something to that. We’ve been involved and recently, we’ve talked about the importance of team-based care. Well, one of the things that APA has done, we’ve joined the executive committee on something called the Patient Centered Primary Care Collaborative. This is an organization where all the key players in health care come together to help shape the new health care system. And it was very important for APA not just to participate in that effort but to be on the executive committee and help actually to shape that conversation to make sure the things we’ve been talking about today are included.

Susan Dentzer: And has there been receptivity to having APA at the table?

Dr. Norman Anderson: I’ve been very happy and very pleased that there has been that receptivity. There was the annual conference of the collaborative, it was just last fall and we…it was a day-long event with maybe five or six panels. There were at least two or three of those panels that talked about behavioral factors, so we were very pleased with that.

Susan Dentzer: Right.

Dr. Katherine Nordal: And there is a subgroup of that collaborative as well that focuses on behavioral health issues, including mental health and substance abuse issues, and it’s a growing and pretty strong part of that group as well.

Susan Dentzer: And we know it would have to be substance abuse in particular, so highly correlated with many of these other chronic conditions than it would be…

Dr. Suzanne Bennett Johnson: Yes [Indiscernible] [0:52:06] Family stress.

Susan Dentzer: And having stress indeed. Let’s take another question.

Rosemary: Hi, my name is Rosemary and I just got a new job so I have a new insurance plan and I need to find a medical home. I’d like to find something that has a more integrative approach and just sort of team-based that was mentioned here, approach to medicine, preventive medicine as well as wellness. What are ways or questions I could ask when looking for a primary care provider that could lead me to find one that utilizes this approach?

Susan Dentzer: Well it’s a good question because unfortunately I think the fact is that there just aren’t quite enough patient-centered medical homes at his point, but what would be one way to start, Doctor Anderson?

Dr. Norman Anderson: Well this is a, as you mentioned, this is a new movement, but there has been integrated care in this country prior to the development of the medical home malware. I think that one thing consumers can do is ask their primary care physicians about services for behavior change, for stress management. I think a lot of the change will come when consumers begin to demand these kinds of elements to their health care plans and demand that their primary care physicians offer these kinds of services.

Susan Dentzer: How much of that is going on, Doctor Nordal, at this point?

Dr. Katherine Nordal: Oh that’s hard to estimate. There are…it’s probably several hundred practices or maybe several thousand now around the country. The government is putting a lot of innovation funding into developing these models and evaluating them to see just how effective they are going to be and getting the kinds of results that they want. But there are big systems, for example Geisinger Health in Pennsylvania, has a patient-centered medical home. There’s some other systems, Intermountain, I’m at a loss for names but there’s several systems that have adopted the patient-centered medical homes as part of their health care model, but they tend to be typically the larger health care systems right now.

Susan Dentzer: So the big integrated systems like Kaiser Permanente, et cetera.

Dr. Suzanne Bennett Johnson: I’d like to add something to that. I’m really glad you asked that question because thinking about the name they are using, “patient-centered medical home.” Well if it’s really patient-centered, it’s supposed to be about you, which means that you should be empowered to ask any question you want. And I just want to support Doctor Anderson’s point that I think empowering patients, empowering people, is really what we need to do in this country. To demand the kind of services you deserve, not only in your health care system but to use that same empowerment with your community. We are not going to solve the obesity problem in this country unless we not only change our health care system but we change our communities.

Susan Dentzer: We have another question.

Female speaker 3: Another question from Twitter. @Kstar202 asks, “I am a caretaker of my 85-year-old mother. Are there support groups for caregivers that you can suggest or ways that I can find them?

Susan Dentzer: What would be the way to proceed with that?

Dr. Katherine Nordal: One way to proceed might be, in whatever community the person lives is to contact their local hospital. Sometimes hospitals, particularly if they have long-term care facilities associated with them or skilled nursing facilities associated with them, will have some sort of community support group for caregivers at the hospital, so that may be one way. And there are oftentimes in communities senior centers that may be United Way-funded. Another exact level community-based kind of program that may offer respite care, for example, they may have drop-in centers where you can take your elderly parent to spend the day or several hours during the day and they oftentimes will also have support groups there for caregivers. So those would be two good places too: any place in your community that has senior services with hospital based or community based services.

Susan Dentzer: Like, as for example, Inotera Area Agency and Aging could be helpful with her search and the National Family Caregivers Association probably could provide support.

Dr. Norman Anderson: Actually on our website we have some resources for family caregivers at apa.org; they should be able to find those.

Dr. Katherine Nordal: The toolkit.

Dr. Norman Anderson: Toolkit

Dr. Katherine Nordal: Caregiving toolkit on our website.

Susan Dentzer: Great. Alright we have one last question.

Angel Lloyd Fenric: Hello, my name is Angel Lloyd Fenric. I am wondering if APA is fostering any dialogue with the faith-based community around stress and health.

Susan Dentzer: What’s the status of that?

Dr. Katherine Nordal: I’m not sure, to tell you the truth. We may not have the right person up here to answer that question. I think however that we have…certainly have an appreciation that faith-based communities are very, very important. I came here from Mississippi and faith-based communities were very important there. They were a very important part of the community support system and they oftentimes were the first group are… We had a community pastoral council; they were one of the first groups that we activated when there were disasters in the area, for example, so they are a critical, critical part of reaching people, maybe more so in some parts in the country than others. We can certainly get someone from one of our directorates in touch if you’ll speak with me when we wrap up and I’ll see if we can find out more information for you about that.

Dr. Suzanne Bennett Johnson: Can I add something to that? Although I’d like to add something — the larger psychology community is very interested in faith-based communities for several reasons. The first is that for a very large part of our population, prayer is a coping mechanism for managing stresses, an important one. But secondly, for many of these health care concerns that we have — obesity, diabetes — honestly, the churches are where we do a lot of our best work. It’s a sort of another community-based approach to the chronic illness, obesity epidemic our country is facing.

Susan Dentzer: Well to wrap up, next year APA will carry out the survey yet again. This year we have the good news piece, which was that the levels of stress seem to be going down. Let’s say we wanted, we were hoping to aim for next year the trend line to continue to go down to have a positive effect on people’s ability to deal with stress. What would be the most important thing all of you think needs to happen in order to bring that result about? And if we could keep our answers short in the interest of time it would be great. But Jonathan. I’d love to start with you. What would be the most important thing on a wise agenda to continue to drive down levels of stress in the country?

Jonathan Lever: II think just continuing to help people realize the community-based organizations like the Y are places of aspiration and inspiration, and free places where people can go to get support they need. And we’re not a traditional health care provider, but we are increasingly in the health care space and we are not going to solve any of the problems we talked about if we think we are going to do at the doctor’s office.

Susan Dentzer: Doctor Nordal?

Dr. Katherine Nordal: I think continuing to educate the public is recently trying to do through our public education campaign activities to get people to get it and understand, and you have to have recognition that stress is killing you, in many cases, before people are really willing to step out of the plate and do what they need to do. It’s a public education for sure.

Susan Dentzer: Doctor Anderson?

Dr. Norman Anderson: And with that educated public they need a health care system that is supportive of this knowledge, that stress is health-damaging and it’s responsive to that.

Susan Dentzer: Last word to you Doctor Johnson.

Dr. Suzanne Bennett Johnson: Yes, I would say integrative care and empower people to make it happen.

Susan Dentzer: Great. Well thanks to all of you and thanks to all of you in the audience, everyone for joining our conversation today. For more details about Stress in America: Our Health at Risk, please visit www.stressinamerica.org. Thanks for being with us, thanks to all of our panelists and have a great day.