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MILITARYMEDICINE,182,7/8:e1747, 2017
Self-Management Strategies for Stress and Anxiety Used by
Nontreatment Seeking Veteran Primary Care Patients
Robyn L. Shepardson, PhD*†; Jennie Tapio, MA*; Jennifer S. Funderburk, PhD*†‡
ABSTRACT Introduction: One of the most common reasons individuals do not seek mental health treatment is a
preference to manage emotional concerns on their own. Self-management refers to the strategies that individuals use
on their own (i.e., without professional guidance) to manage symptoms. Little research has examined self-management
for anxiety despite its potential utility as the first step in a stepped care approach to primary care. The objectives of this Downloaded from https://academic.oup.com/milmed/article/182/7/e1747/4158597 by guest on 26 September 2022
study were to describe patients’ anxiety self-management strategies, identify which types were perceived to be effec-
tive, and explore potential correlates. Materials and Methods: This was an exploratory descriptive study (N = 182) of
nontreatment seeking Veterans Health Administration primary care patients (M = 58.3 years of age, SD = 14.9) who
reported current anxiety symptoms (≥8 on Generalized Anxiety Disorder-7). The Institutional Review Board approved
the study, and all participants provided informed consent. We assessed self-management strategies, anxiety and depres-
sion symptoms, and past-year treatment via telephone. Two independent raters coded strategies into 1 of 7 categories
(kappa = 0.85) and 23 subcategories (kappa M = 0.82, SD = 0.16). Results: Participants reported nearly universal
(98%) use of self-management, with an average of 2.96 (SD = 1.2) strategies used in the past 3 months, and 91% of
all strategies perceived as effective. Self-care (37.0%), cognitive (15.8%), and avoidance (15.1%) strategies were
reported most commonly; the most prevalent subcategories were exercise (11.0% of all strategies), redirecting thoughts
(9.1%), and family/friends (8.1%). Age and depression screen status were associated with self-management strategy
use. Conclusion: Our results demonstrate the ubiquity and high perceived effectiveness of self-management for
anxiety among Veteran primary care patients. Although avoidance strategies were fairly common, self-care strate-
gies, particularly exercising, and cognitive strategies, such as redirecting thoughts, were most prevalent in this
sample. Strengths of the study include its novelty, our sample of non-treatment seeking Veteran primary care
patients with current symptoms, and the open-ended format of the strategies questions. Limitations include reli-
ance on self-report data, dichotomous response options for the perceived effectiveness item, limited number of
potential correlates, and sampling from a single medical center. Overall, this research highlights the opportunity that
health care providers have to engage primary care patients around self-management to determine what strategies they
are using and how effective those strategies may be. Future directions include identification of the most effective and
feasible self-management strategies for anxiety to facilitate promotion of evidence-based self-management among pri-
mary care patients.
INTRODUCTION of literature.7–9 Self-management is self-directed and infor-
The majority of individuals with anxiety disorders do not mal, comprising the strategies individuals use on their own,
seek or receive formal mental health treatment.1 Among without professional guidance, to manage their symptoms.10
those perceiving a need for care, the most common reason In contrast, formal self-help interventions (e.g., workbooks
for not seeking treatment is desire to handle the problem on and websites) are designed around “a standardized psycho-
their own.2,3 This is especially true for those whose symp- logical treatment protocol,”7 often cognitive-behavioral prin-
3,4 6,7 7,9
toms are subthreshold, mild, or moderate in severity. ciples, and sometimes guided by a clinician. Thus,
Adults in the community with low to mild psychological self-management refers to “strategies people use to manage
distress4 (i.e., subthreshold symptoms) and those with affec- their lives and their health problems,” whereas self-help
tive or anxiety disorders5 report using self-management strat- refers to “the more structured, professionally led interven-
egies more often than formal treatment. tions.”11 In a stepped care model, in which the least intru-
Self-management has been defined as the daily activities sive treatment is provided first and intensity increases only
patients engage in to control the impact of a condition on when necessary,12 self-management would be step one and
6
their overall health. We must distinguish between self- formal self-help would be step two.
management and formal self-help, which have a large body Although most often studied in connection with chronic
medical conditions (e.g., diabetes), self-management has
many potential applications to mental health. It may be
*VA Center for Integrated Healthcare, Syracuse VA Medical Center, particularly appealing given greater stigma regarding help-
800 Irving Avenue (116C), Syracuse, NY 13210. seeking, patient preferences to deal with emotional prob-
†Department of Psychology, Syracuse University, Syracuse, NY 13244. 2,3
‡Department of Psychiatry, University of Rochester School of Medicine, lems on one’sown, and symptoms themselves (e.g.,
anhedonia and social anxiety) that impede help-seeking.10
Rochester, NY 14642. Self-management could feasibly serve as: an alternative to
All authors declare that they have no conflicts of interest.
doi: 10.7205/MILMED-D-16-00378 formal treatment for individuals who cannot or will not
MILITARY MEDICINE, Vol. 182, July/August 2017 e1747
Self-Management Strategies for Stress and Anxiety
engage, an adjunct for those engaged in formal treatment, METHOD
a low-intensity intervention for those with subthreshold Participants
symptoms who may not need formal treatment, and a com-
ponent of primary prevention and relapse prevention.10,13 Participants were primary care patients recruited from a Vet-
Most mental health self-management research focuses erans Health Administration (VHA) medical center in cen-
13 tral New York. Inclusion criteria were ≥18 years of age;
on formal self-help interventions. However, knowing what
patients do on their own to manage symptoms would help attended VHA primary care within the past year; history
providers understand the full scope of patients’ treatment of anxiety, defined as having an anxiety diagnosis in the
13 electronic medical record; and screened positive for current
plans and inform development of new resources. There have
been few studies investigating true self-management, and the (i.e., past 2 weeks) anxiety on the Generalized Anxiety Dis-
13–15 order-7 (GAD-7).28 Exclusion criteria were: received psycho-
majority of this research has focused on depression, with therapy/counseling through specialty mental health within the Downloaded from https://academic.oup.com/milmed/article/182/7/e1747/4158597 by guest on 26 September 2022
only a few studies examining anxiety. Morgan et al’s Delphi
16 past year; hearing impairment that may impede telephone
study identified expert recommendations, but did not screening; or cognitive impairment that may impede informed
examine strategies actually used by individuals with anxiety.
17,18 consent. Hearing and cognitive impairment were assessed via
Kemppainen et al examined strategies used specifically researcher judgment, and exclusions were rare (n = 6).
to manage human immunodeficiency virus (HIV)-related Of 1,006 Veterans reached by telephone, 378 (37.5%)
anxiety, with the most common being talking with family/
friends, watching television, taking walks, and praying. declined to hear about the study and/or complete eligibility
The lack of attention to self-management for anxiety is screening. Of 628 Veterans screened, 210 (33.4%) met eli-
a key gap in the literature given that anxiety disorders are gibility criteria (see parent study for details on participant
the most prevalent class of disorders,19 with a prevalence of flow29). Of those, 186 (88.6%) consented to participate and
20 enrolled in the study, but 4 never completed the telephone
20% in primary care and subthreshold symptoms being as
common, if not more common.21 Anxiety disorders and sub- survey. Therefore, the final sample comprised 182 Veterans,
threshold symptoms are associated with functional impair- who were mostly older males (see Table I).
ment and reduced quality of life.22,23 Despite this prevalence
and burden, anxiety is undertreated in primary care,24 due
in large part to many patients not perceiving a need for, or TABLEI. Participant Characteristics (N = 182)
1,2,5
seeking, formal treatment.
In summary, given patients’ preference for self- Variable Nor Mean (SD) %
management over formal self-help interventions or tradi- Male Sex 154 84.6
25
tional treatment, exploring the self-management strategies Age (Years) 58.3 (14.9)
that patients use and find effective is an important initial step Age Group
toward identifying how best to promote use of effective self- 18–44 36 19.8
management in primary care. This could be incorporated as 45–64 78 42.9
part of population-based stepped care.4,10 Primary care team 65 or Older 68 37.4
GAD-7Score 14.2 (3.7)
members could promote evidence-based self-management Anxiety Symptom Severity
strategies,16 especially with patients with subthreshold or (Calculated on the Basis of GAD-7 Score)
mild symptoms who may not need treatment or who are Mild 23 12.6
not interested in, ready for, or able to access treatment. Moderate 75 41.2
We conducted an exploratory, descriptive study examin- Severe 84 46.2
Positive Depression Screen 99 54.4
ing self-management strategies for stress and anxiety in a (Calculated on the Basis of PHQ-2 Score)
sample of nontreatment seeking Veteran primary care patients Used Psychotropic Medications in Past Year 91 50.0
a
(N = 182) experiencing current anxiety. This was a second- Prescriber of Psychotropic Medications
ary analysis using data from a larger study. Our primary aim Primary Care Provider 64 71.1
was to describe self-management strategies used by patients Psychiatrist or Other Mental 26 28.9
Health Specialist
with anxiety and to identify which types of strategies were Number of Self-Management 2.96 (1.2)
perceived as effective. We sampled Veteran primary care Strategies Reported (Out of 5)
patients given the high prevalence of anxiety in the primary 0 3 1.6
care population20 and Veterans in particular.26,27 An addi- 1 16 8.8
tional exploratory aim was to identify correlates of using 2 46 25.3
3 59 32.4
various strategies, as prior research on self-management for 4 37 20.3
depression and HIV-related anxiety found differences by sex 5 21 11.5
4,15,17,18
and age. We explored sex, age, anxiety symptom GAD-7, Generalized Anxiety Disorder-7; PHQ-2, Patient Health
severity, depression screen status, and psychotropic medica- Questionnaire-2. aAmong those reporting use of psychotropic medications;
tion use as potential correlates. 1 participant did not respond to prescriber question.
e1748 MILITARY MEDICINE, Vol. 182, July/August 2017
Self-Management Strategies for Stress and Anxiety
Procedure pants rate how much they have been bothered by low mood
Data for this study were collected within a larger study of and anhedonia over the last 2 weeks on a Likert-type scale
anxiety treatment preferences among nontreatment seekers.29 from 0 = not at all to 3 = nearly every day. Total scores of
We sent potentially eligible Veterans a recruitment letter 3 or higher constitute a positive depression screen.30
introducing the study (with opt out instructions) and advis-
ing that research staff would call in 7 to 10 days. Recruit- Strategies for Managing Anxiety
ment calls included a brief screening for current anxiety Self-management strategies were assessed using an open-
using the GAD-220 followed by the GAD-728 and for spe- ended question: “What strategies have you tried in the past
cialty mental health care utilization within the past year. 3 months to deal with stress and anxiety?” Before asking
Those scoring <3 on the GAD-2 or <8 on the GAD-7 were this, interviewers first defined stress as “feeling like you are
ineligible; these cutoffs were selected on the basis of past overwhelmed or have to deal with more than you are used Downloaded from https://academic.oup.com/milmed/article/182/7/e1747/4158597 by guest on 26 September 2022
20
research. For those eligible and interested, we described to or able to deal with” and anxiety as “thoughts or feelings
the study and obtained verbal informed consent to partici- of worry, nervousness, uneasiness, or fear about what might
pate. A 15-minute telephone survey designed specifically for happen in the future,” and asked participants to think about
this study was administered, for which participants received the past 3 months only (to limit recall errors). Participants
$5. Participants were invited to complete a follow-up mailed were permitted to list up to five strategies, and for each one
survey on treatment preferences for the larger study.29 they reported, were asked if that strategy works for them
(yes/no). Finally, their strategies were summarized in a list,
Measures and they were asked which has been the most helpful in
Demographics dealing with stress and anxiety.
We obtained participants’ age and sex from the electronic Data Analysis
medical record. We created an age group variable (18–44,
45–64, and 65 or older) on the basis of standard VHA age Qualitative
group conventions. We categorized the self-management strategies to facilitate
interpretation. We coded strategies at two levels: category
Telephone Screening (n = 7) and subcategory (n = 23). We used five categories
Generalized Anxiety Disorder-7 from Proudfoot et al’s study15 of self-management strategies
Current anxiety symptoms were assessed using the GAD-7, for depression: self-care, cognitive, connectedness, pleasur-
a reliable and valid28 self-report questionnaire that performs able activities, and achievement. We added a sixth category
well as a screening tool for the most common anxiety disor- of avoidance given the ubiquity of avoidance as a coping
ders in primary care.20 The first two items of the GAD-7, strategy for anxiety. A small number of strategies did not fit
the GAD-2,20 were used as an initial screener to reduce with any of the six main categories and were thus coded as
respondent burden. Participants rate how much they have other. After discussing the categories and types of strategies
been bothered by seven problems over the last 2 weeks on a that would fall into each (see Table II), the first and second
Likert-type scale from 0 = not at all to 3 = nearly every day. authors independently coded the categories for five partici-
Wecreated a categorical variable for anxiety symptom sever- pants. We then compared our coding for calibration pur-
ity on the basis of existing cutoffs: mild (total scores; 8–9), poses and discussed the few discrepancies until agreement
moderate (10–14), and severe (15–21).28 Cronbach’s alpha was reached on final coding. We then independently coded
was 0.67. the categories for all remaining participants, and finally,
discussed all discrepancies until agreement was reached
Past-Year Treatment on final coding.
Two items assessed receipt of mental health treatment in Next, the strategies within each category were further
the past year. We created dichotomous variables indicating organized into subcategories to facilitate identification of
receipt of psychotherapy/counseling in the past year, used themes. Table II displays the categories and subcategories
as part of the exclusion criteria, and use of psychotropic as well as three example quotations (verbatim) illustrating
medication in the past year, used for descriptive purposes each subcategory. The first and second authors both repeat-
and exploratory analyses. edly read through the strategies by category and created a
list of the subcategories that emerged from the strategies
Telephone Survey themselves. We compared our proposed subcategories and
finalized the list. We then repeated the coding procedure
Patient Health Questionnaire-2 described above, but with subcategories.
Mood was assessed using the Patient Health Questionnaire-2 We computed Cohen’s kappa32 to assess interrater agree-
30
(PHQ-2), a reliable and valid measure that is widely used ment. Kappas were calculated for the original independent
and recommended as a brief screen for depression.31 Partici- coding from the first and second authors (excluding data
MILITARY MEDICINE, Vol. 182, July/August 2017 e1749
Self-Management Strategies for Stress and Anxiety
TABLEII. Frequency of Categories and Subcategories of Self-Management Strategies (N = 538) and Example Quotations Illustrating
Each Subcategory
a b
Category N % Subcategory N % Examples
Self-Care 199 37.0
Exercise 58 29.2 1) Go for Walks 2) Yoga 3) Running/Working Out
Formal Relaxation 41 20.6 1) Breathing Techniques, Take Deep Breaths 2) Guided Meditation Using Apps
3) Guided Imagery
Medication 40 20.1 1) Take a Valium 2) Anti-Anxiety Meds 3) Pain Pills
Informal Relaxation 22 11.1 1) Try to Relax 2) Watch TV in Evenings to Relax 3) Sit and Relax on
Back Deck
Sleep 13 6.5 1) Taking a Nap 2) Go to Bed Early/Earlier 3) Sleep, Lay Down
Health Care 13 6.5 1) TENS Machine 2) Acupuncture 3) Therapy for Back Pain Downloaded from https://academic.oup.com/milmed/article/182/7/e1747/4158597 by guest on 26 September 2022
Eating/Drinking 12 6.0 1) Eat Ice Cream 2) Drink Warm Milk at Night 3) Eating More at Night
Cognitive 85 15.8
Redirect Thoughts 48 56.5 1) Refocus Thoughts 2) Focus on the Positive 3) Keep Thoughts on More
Positive Things 4) Look at the Bright Side
Other Cognitive 19 22.4 1) Try to Calm Down 2) Just Kind of Deal With It 3) Personal Reflection
Religion/Spirituality 18 21.2 1) Prayers Every Day and Before Bed 2) Read Bible 3) Listen to Sermons
Avoidance 81 15.1
Other Avoidance 40 49.4 1) Don’t Talk to People 2) Isolate Self, Don’t Leave Home 3) Avoiding Anxiety
Provoking Things
Substance Use 29 35.8 1) Smoking Marijuana 2) Have an Extra Beer 3) Chain Smoke
Keep Busy 12 14.8 1) Keep Self Busy 2) Stay Busy Working 3) Busy Myself With Other Things
Connectedness 79 14.7
Family/Friends 43 54.4 1) Long Conversations With Wife 2) Spend Time With Children/Family
3) Talking About It With Friend
Community 19 24.1 1) Go Out and Help the Community 2) Volunteer at the VA 3) Going to Church
Pets 9 11.4 1) Petting My Dog 2) Visiting With the Neighbor’s Dog 3) Adopted a Dog
Social 8 10.1 1) Go Out and Be Among People 2) Talk With People 3) Visit With Others
Pleasurable Activities 69 12.8
Outdoor Activities 23 33.3 1) Go Fishing 2) Ride Motorcycle 3) Get Outdoors and Fish/Hunt
Indoor Activities 21 30.4 1) Cooking 2) Reading a Good Book 3) Puzzles
Media 15 21.7 1) Watch TV 2) Playing Video Games 3) Play Poker on Computer
Music 10 14.5 1) Listening to Music 2) Music 3) Play Guitar, Listen to Music
Achievement 16 3.0
Household 14 87.5 1) Cleaning 2) Lawn Work 3) Work on Projects at Home
Other Achievement 2 12.5 1) Force Myself to Do Things Actively 2) Make List of Priorities/Things
Can Take Care Of
Other — 9 1.7 1) Scream and Holler 2) Making Sure Everything Is Secure 3) Take a Hammer
to Things in the Garage
aPercent is among all 7 categories. Denominator is 538, the total number of strategies reported. bPercent is among only those subcategories within a particu-
lar category. Denominator is the N for the category.
from the five participants used for calibration). Kappa for within-cell sample sizes were inadequate) except for num-
coding the categories was 0.85, indicating substantial agree- ber of strategies, for which independent samples t-tests
ment.33 Kappas for coding the subcategories (within the six or one-way analyses of variance were used as appropriate.
main categories) ranged from 0.60 for achievement to 0.98 Given the exploratory nature of these analyses and the num-
for avoidance, for a mean of 0.82 (SD = 0.16). ber of comparisons being conducted (five per variable), we
applied a Bonferroni-type correction to keep the family-wise
Quantitative error rate at 0.05, resulting in an alpha of 0.01.
We computed descriptive statistics for all variables. For our
exploratory aim of identifying correlates of strategy use, we RESULTS
examined differences in category and number of strategies Table I displays participant characteristics including GAD-7
reported, as well as within each subcategory (except achieve- score (range: 8–21), anxiety symptom severity, depression
ment, which was excluded because of a very low n), by five screen status, and psychotropic medication use in past year.
variables: age group (18–44, 45–64, or 65 or older), sex
(male or female), psychotropic medication use in past year
(yes or no), anxiety symptom severity (mild, moderate, or NumberandTypeofSelf-ManagementStrategies
severe), and depression screen status (positive or negative). Table I displays the mean number of self-management strat-
We report the results of χ2tests (or Fisher’s exact test if egies reported (median = 3, range: 0–5) and proportion who
e1750 MILITARY MEDICINE, Vol. 182, July/August 2017
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