Introduction

Lifestyle and behavior are at the root of many of the challenges facing the health care system. Seven out of 10 deaths among Americans each year are from chronic diseases. Heart disease, cancer and stroke account for more than 50 percent of all deaths each year.1 In 2005, 133 million Americans — almost one out of every two adults — had at least one chronic illness.2 While many of these diseases and conditions can be prevented or controlled with a healthy lifestyle, the Stress in America™ survey finds a population whose behavioral health and stress management needs are not being adequately addressed by our health care system.

A health care system falling short

There appears to be general agreement that persistent, high stress is unhealthy, yet Americans struggle to manage the relationship between stress and health in their lives. They consistently report stress levels that are higher than what they believe to be healthy. Those who are already managing the burden of either high stress or chronic illness report their stress is on the rise. And younger Americans are showing warning signs for a future of poor health — higher-than-average stress levels, unhealthy strategies for managing stress and inadequate behavioral health support. Overall, survey findings reveal a nation that is not getting what it wants or needs from the health care system to help manage stress and support healthy lifestyles.

Percentage Reporting Doing an Excellent or Very Good JobFindings from the Stress in America survey draw important connections among patient-provider interactions, stress and wellness. A closer look reveals a system that is not meeting many specific patient needs — especially those related to behavioral health that could aid in the prevention and management of chronic illness. Few Americans (19 percent) describe their health care as good quality; likewise, fewer describe their health care as focused on education (12 percent), prevention (13 percent) or mental health needs (9 percent). Only one in 10 would describe their health care as coordinated among different providers.

Despite the connection between behavior and disease prevention, only 10 percent describe their health care as focused on behavior or lifestyle issues that can impact their health. Vast majorities of adults do not associate their health care with their mental health. Only 9 percent say that “addressing their mental health needs” describes the health care they receive.

Thirty-one percent of adults say that “addressing their mental health needs” does not describe their health care at all.

While Americans consistently report living with stress that is higher than what they believe is healthy and as many as one in five (20 percent) say their stress is extreme or high (an 8, 9 or 10 on a 10-point scale where 1 is “little or no stress” and 10 is “a great deal of stress”), they do not believe the health care they receive provides support that could help them manage their stress and make lifestyle and behavior changes. On average, more than half of Americans (53 percent) say that their health care provider offers little or no support to help them manage their stress — even among those living with high stress (52 percent). Yet, when individuals report that they do receive a great deal or a lot of support from their health care provider for managing stress or making lifestyle or behavior changes, they appear to be doing better.

Americans reported their mean stress level as a 4.9 on a 10-point scale, while they define a healthy level of stress as a 3.6 on the same scale. Twenty percent of Americans reported stress levels that are extreme (an 8, 9 or 10 on a 10-point scale).

Only 22 percent of Americans say that their health care provider supports them in managing their stress.

Twenty-nine percent say their health care provider supports them in making lifestyle or behavior changes that can improve their health.

People who do not receive support from their health care provider for managing stress or making lifestyle or behavior changes are more likely to say their stress increased in the past year than those who do get support (38 percent with little or no support vs. 29 percent with a great deal or a lot of support).

People appear to value discussions with health care professionals about stress management and lifestyle and behavior changes that could improve their health. When asked about the importance people place on having specific conversations with their health care provider about their health and wellness, discrepancies appear between what people think is important and the frequency with which they are discussing these issues, regardless of who starts the conversation.

Importance vs. FrequencyFor many adults, conversations with their health care provider about stress, lifestyle and behavior are not happening at all. Twenty-one percent report that they never talk with their provider about lifestyle or behavior changes that could improve their health, 27 percent never discuss progress they are making toward their lifestyle and behavior goals, 33 percent never discuss ways to manage stress and 38 percent never discuss their mental health.

Forty-six percent of adults think it is extremely or very important to discuss barriers they may face as they follow treatment recommendations, while only 25 percent of adults report that these conversations are happening often or always.

Forty-two percent of adults think it is extremely or very important to discuss lifestyle or behavior changes that could improve their health, while only 28 percent of adults report that these conversations are happening often or always.

Thirty-seven percent think it is extremely or very important to discuss progress made toward lifestyle and behavior change goals, while only 25 percent report that these conversations are happening often or always.

Thirty-two percent think it is extremely or very important to discuss managing stress, as well as to discuss mental health, while only 17 percent report that these conversations are happening often or always.  

At the tipping point

Many living with high stress are at a tipping point, faced with potential physical and emotional health challenges if they are not able to get the support they need to manage their stress well. If untreated, consistently high stress could become a chronic condition, which can result in serious health problems including anxiety, insomnia, muscle pain, high blood pressure and a weakened immune system.3 Research shows that stress can even contribute to the development of major illnesses, such as heart disease, depression and obesity, or exacerbate existing illnesses.4

Rather than helping those at the tipping point — or preventing others from reaching it — the health care system is not providing people with the care needed to manage stress, prevent disease and live well. People who say their stress is high (an 8, 9 or 10 on a 10-point scale) also report increasing stress levels and are less likely to say they are achieving other aspects of well-being.

More than two-thirds of adults with high stress (69 percent) say their stress has increased in the past year compared with only 13 percent of people with low stress (a 1, 2 or 3 on a 10-point scale) and 35 percent of Americans overall.

Thirty-one percent of adults with high stress say that they never discuss ways to manage stress with their health care provider and 30 percent report their health care provider does not support them at all in managing their stress.

When asked if "addressing mental health needs" describes the health care they receive, only a third (33 percent) of those with high stress agree.

Only 17 percent of those with high stress say that they are doing an excellent or very good job of managing their stress, compared with 59 percent of those with low stress and 37 percent of people nationwide.

How well are you managing stress?Adults with high stress are also less likely than those with low stress to say they are doing an excellent or good job at reaching healthy living goals like eating healthy (30 percent vs. 41 percent), being physically active (21 percent vs. 41 percent) and getting enough sleep (30 percent vs. 43 percent).

The lack of support that people living with high stress receive from the health care system is reflected in their evaluation of the system — people living with high stress are less likely than people with low stress to give their health care an “A” grade (28 percent vs. 38 percent).

While those living with high stress are already at risk, many express interest in discussing these issues with their health care provider. Unfortunately, wide gaps appear between the value they place on these issues and the frequency with which these conversations actually take place.

Forty-eight percent of those with high stress think it is extremely or very important to discuss how to manage stress with their provider, while only 26 percent report that these conversations are happening often or always.

Forty-seven percent of those with high stress think it is extremely or very important to discuss their mental health, yet only 27 percent report that these conversations are happening often or always.

Forty-nine percent of those with high stress think it is extremely or very important to discuss making lifestyle and behavior changes, but only 36 percent report that these conversations are happening often or always.

Overall, those who say they manage their stress well appear to be doing better in terms of their overall health and wellness than those who do not, which could suggest the need for additional emphasis on stress management and lifestyle and behavior change as part of the health care dialogue.

Importance vs. Frequency of ConversationsDespite the challenges they experience in achieving stress management goals, more people living with high stress than people nationwide say that managing their stress is extremely or very important (73 percent vs. 64 percent).

People who report that they are doing an excellent or very good job managing their stress also report lower stress — an average level of 3.6 — than those who say they are doing a fair or poor job at managing their stress — an average level of 6.8.

In addition, how well people are managing their stress is connected to increases in stress. Those who manage their stress poorly are far more likely to say their stress increased in the past year compared with those who manage their stress well (57 percent vs. 21 percent).5

People who report that they manage their stress poorly are also more likely to rely on unhealthy and sedentary behaviors to manage stress such as napping (36 percent vs. 26 percent who manage stress well), eating (36 percent vs. 18 percent) and drinking alcohol (21 percent vs. 9 percent).

Millennials take on the world...of stress

Across the country, younger Americans are facing life challenges that are shaping their outlook about the future. Research about social trends in the U.S. reveals a challenging pattern for younger Americans: 39 percent of adults ages 18 to 29 self-identify as being low or lower middle class and have faced economic hardships like having trouble paying rent or medical bills, losing their jobs and having to cut back spending in the past year.6 High unemployment is also an issue for this group. In August 2012, the unemployment rate for adults ages 18 to 29 was nearly 13 percent, exceeding the national average of 8 percent. 7,8

Younger Americans' Stress Management GoalsAt the same time Millennials9 are navigating challenges in many areas of their lives, the Stress in America survey found that this generation reports stress at levels that exceed the national average and is less satisfied than other generations with the quality of health care — both physical and mental — that they receive. They report being less likely to be successful in reaching their stress management goals, do not believe they are doing enough to manage their stress, and do not have the support they need to make lifestyle and behavior changes to improve their health and help them cope.

On a 10-point scale where 1 is “little or no stress” and 10 is “a great deal of stress,” Millennials report an average stress level of 5.4 compared with the national average of 4.9.

Millennials are less likely than people nationwide to give their health care an “A” grade (25 percent vs. 31 percent).

Forty-four percent of Millennials say discussing healthy lifestyle or behavior changes with their health care provider is very or extremely important, but only 25 percent say these discussions occur often or always. There is also a big gap between the importance placed on discussions about stress management and the frequency of such discussions (33 and 19 percent, respectively).

Only 23 percent think that their health care provider supports them a lot or a great deal in their desire to make healthy lifestyle and behavior changes, and just 17 percent say the same about their health care provider’s support for stress management.

Sixty-one percent of Millennials say managing their stress is very important or important, but just 29 percent of Millennials report doing an excellent or very good job managing stress, compared with 35 percent of Gen Xers, 38 percent of Boomers and 50 percent of Matures.

More than half of Millennials (51 percent) say they are doing enough to manage stress compared with 61 percent of people overall, including 55 percent of Gen Xers, 67 percent of Boomers and 72 percent of Matures.

Millennials are more likely to report resorting to unhealthy or sedentary behaviors such as eating to manage stress (36 percent vs. 25 percent nationally) and playing video games or surfing the Internet (41 percent vs. 29 percent nationally).

Millennials are also more likely than older Americans to say that they have been told by a health care provider that they have depression or an anxiety disorder:

  • Nineteen percent of Millennials, 14 percent of Gen Xers, 12 percent of Boomers and 11 percent of Matures have been told they have depression.
  • Twelve percent of Millennials, 8 percent of Gen Xers, 7 percent of Boomers and 4 percent of Matures have been told they have an anxiety disorder.
The chronic illness-stress connection

Frequency of Health Care Visits vs. Amount of SupportThe Stress in America survey shows people living with a chronic illness consistently report higher levels of stress than adults on average. This year’s survey also finds that they are less likely to receive health care that is focused on helping them make lifestyle and behavior changes that have the potential to improve their health. Survey findings are consistent with other research showing that the chronically ill do not receive the level of care they need to be healthy: For example, half of Americans living with a chronic illness do not receive optimal care because their appointments are too short.10 Stress in America survey findings reveal a similar pattern where people with chronic illness report visiting their health care provider more often than the rest of the population, but they do not seem to get the care they want or need — especially for stress management.

Although they see their health care provider more frequently than those without a chronic illness, many of those living with a chronic illness do not believe that their health care provider supports them a great deal or a lot in managing stress. Fifty-one percent of those living with a chronic illness see their health care provider three or more times annually compared with only 17 percent of those without a chronic illness. Despite more frequent visits, only one-quarter (25 percent) of those with a chronic illness say that their health care provider helps them manage stress a great deal or a lot.

The disconnect that people living with a chronic illness report concerning the types of conversations they value having with their health care provider and the frequency with which those conversations occur are consistent with the rest of the population.

  • Thirty-five percent of people living with a chronic illness think it is extremely or very important to discuss how to manage stress, while only 19 percent report that these conversations are happening often or always.
  • Forty-eight percent of people living with a chronic illness think it is extremely/very important to discuss lifestyle or behavior changes that could improve their health, while only 34 percent report that these conversations are happening often or always.

Those living with a chronic illness are more likely to report relying on sedentary behaviors to manage stress, such as watching TV or movies for more than two hours a day (38 percent vs. 28 percent) and eating to manage stress (28 percent vs. 20 percent without a chronic illness).

Adults with a chronic illness are also less likely than those without a chronic illness to say they are doing enough to manage their stress (59 percent vs. 66 percent).

Stress is climbing for people living with a chronic illness who receive little or no support from a health care provider to either manage their stress or make lifestyle and behavior changes.

  • Forty-one percent of people living with a chronic illness who receive little or no support from their health care provider say their stress increased in the past year, compared with 32 percent of people living with a chronic illness who receive a great deal or a lot of support from their health care provider.
  • These individuals are also less likely than those who do get support to say they are doing enough to manage their stress — 68 percent of people with a chronic illness who say they receive a great deal or a lot of support from their health care provider report they are doing enough to manage stress compared with 54 percent of those who say they receive little or no support.

Chronic Illness Support Stress in America survey findings suggest that the relationship between patients and their health care providers is connected to patients’ ability to manage stress well and, ultimately, connected to the health of the nation. This year’s survey shows a country that is facing persistent, ongoing stress levels that are higher than what individuals believe is healthy. Yet many Americans who experience prolonged stress are not making the lifestyle changes necessary to reduce stress and ultimately prevent health problems. And even though research has shown that chronic stress is treatable,11 the Stress in America survey shows that only a small number (12 percent) of Americans are referred to mental health professionals by their primary care physicians and fewer, 6 percent, have seen a mental health professional to manage their stress.

The confluence of persistent stress, inability to effectively manage stress, and interactions with a health care system that is not helping people develop the skills necessary to manage stress and make behavioral and lifestyle changes is contributing to our nation’s health problems. Chronic diseases account for 75 cents of every dollar spent on health care12, and many people report that their health care providers do not adequately support them in their desire to manage stress and make healthy lifestyle and behavior changes.13

Stronger support for stress management and lifestyle and behavior change could help improve Americans’ health. Yet, despite the importance people place on these needs, the health care system is falling short. If left unaddressed, this disconnect between untreated stress and chronic illness could contribute to a continued and unnecessary increase in the number of chronically ill Americans, along with a further escalation in health care costs.

As we continue to explore the impact of stress on America, it is critical that we embrace the psychological and behavioral health solutions to the challenges facing the health of the country.

References

1Kung, H. C., Hoyert, D. L., Xu, J. Q., & Murphy, S. L. (2008). Deaths: final data for 2005. National Vital Statistics Reports, 56(10).

2Wu, S. Y., & Green, A. (2000). Projection of chronic illness prevalence and cost inflation. Santa Monica, CA: RAND Health.

3Baum, A., & Polsusnzy, D. (1999). Health psychology: Mapping biobehavioral contributions to health and illness. Annual Review of Psychology, 50, 137–163.

4Ibid.

5 “Well” means those that manage their stress very good or excellent, and “poor” is those that manage their stress fairly or poorly.

6Morin, R., & Motel, S. (2012, September 10). A third of Americans now say they are in the lower classes. Pew Social & Demographic Trends – Public Opinion Polling, Survey Research, & Demographic Data Analysis

7Generation Opportunity. (2012, September 7). Young Americans Suffer 12.7 Percent Unemployment. Generation Opportunity — This is our time—let’s go! 

8U.S. Department of Labor, Bureau of Labor Statistics. (2012). The employment situation—August 2012

9The four generations included in the Stress in America survey are defined as Millennials n=340 (18- to 33-year-olds), Gen X n=397 (34- to 47-year-olds), Boomers n=1040 (48- to 66-year-olds), and Matures n=243 (67 years and older).

10Wagner, E. H., Austin, B. T., & Von Korff, M. (1996). Organizing care for patients with chronic illness. Milbank Quarterly. 74(4), 511–544.

11McEwen, B. S. (2004). Protection and damage from acute and chronic stress: Allostasis and allostatic overload and relevance to the pathophysiology of psychiatric disorders. Annals of the New York Academy of Sciences, 1032, 1–7.

12National Center for Chronic Disease Prevention and Health Promotion. (2009). Chronic diseases: The power to prevent, the call to control.  

13Triple Solution for a Healthier America. The impact of chronic diseases on healthcare. (n.d.).