Recommendations on stress management

Objective: To provide updated, evidence-based recommendations for health ca re professionals concerning the effects of stress management on the prevent ion and control of hypertension in otherwise healthy adults (except pregnan t women). Options: Alternatives to stress management include other nonpharmacologic i nterventions and medical therapy; these options are not mutually exclusive. Outcomes: The health outcome considered was reduction of blood pressure. Th ere is little evidence to date that stress management prevents death or vas cular events. Because of insufficient evidence, no economic outcomes were c onsidered. Evidence: A systematic search of the literature (which yielded, among other sources, 3 meta-analyses) was conducted for the period 1966-1997 with the terms essential hypertension, treatment, psychological, behavioural, cognit ive, relaxation, meditation, biofeedback and stress management. Other relev ant evidence was obtained from the reference lists of the articles identifi ed, from the personal files of the authors and through contacts with expert s. The articles were reviewed, classified according to study design and gra ded according to level of evidence. Values: A high value was placed on the avoidance of cardiovascular morbidit y and premature death caused by uncontrolled hypertension. Benefits, harms and costs: The magnitude of the reduction in blood pressure obtained with multicomponent, individualized cognitive behavioural interve ntion for stress management was comparable in some studies to that obtained with weight loss or drugs; single-component interventions such as biofeedb ack or relaxation were less effective. The adverse effects of stress-manage ment techniques are minimal, but the cost for effective interventions is su bstantial, similar initially to drug costs; continuing costs are probably m inimal. Recommendations: (1) In patients with hypertension, the contribution of str ess should be considered. (2) For hypertensive patients in whom stress appe ars to be an important issue, stress management should be considered as an intervention. Individualized cognitive behavioural interventions are more l ikely to be effective than single-component interventions. Validation: These recommendations were reviewed by all of the sponsoring or ganizations and by participants in a satellite symposium of the fourth Inte rnational Conference on Preventive Cardiology. They have not been clinicall y tested. Sponsors: The Canadian Hypertension Society, the Canadian Coalition for Hig h Blood Pressure Prevention and Control, the Laboratory Centre for Disease Control at Health Canada, and the Heart and Stroke Foundation of Canada.