Insights from Former Surgeon General Vivek Murthy

Rising Stress: Causes and Remedies

BY SUSAN CHACKO, CIT

As the 19th Surgeon General of the United States between 2014 and 2017, Vivek Murthy worked to address many public-health challenges such as the Ebola and Zika viruses, the Flint water crisis, the opioid crisis, obesity, mental illness, and tobacco-related disease. He issued the first-ever Surgeon General’s report to address substance-use disorders and the wider range of health problems and consequences related to alcohol and drug misuse in the United States. Murthy visited NIH recently to share his concerns about another growing health problem: the increase in psychological stress across America.

In September 2017, Murthy, the invited speaker for the Stephen Straus lecture, and NIH Director Francis Collins discussed the public-health consequences of psychological stress and fielded questions submitted in advance by NIH staff as well as by viewers watching the conversation on Facebook Live.

Murthy talked about the cross-country listening tour he took soon after he became Surgeon General to understand how communities were addressing public-health issues. He saw families in pain because they had lost children to the opioid crisis and then were shunned by their community afterward. In Flint, Michigan, he met parents worried that they had allowed their children to drink lead-tainted water. He met students and discovered that 95 percent of them had suffered unbearable stress in the previous month. Everywhere, he saw people experience severe emotional pressures that they often did not know how to handle.

Reported stress levels are on the rise, Murthy said. In a 2015 survey, 24 percent of adults reported extreme psychological stress, an increase from 18 percent just one year earlier. A third of Americans said that they were more stressed than in the previous year.

“Not all stress is bad,” Murthy said. He differentiated short-term adaptive stress that enhances performance from long-term chronic stress that increases the risk of chronic diseases such as heart disease, cancer, anxiety, and depression.

Money, work, relationships, and health: Murthy and Collins agreed that these were the main contributors to stress. The “always-on” workplaces, the “relentless 24/7 work culture,” and continuously available technology make for overextended people.

Strong social connections are one powerful antidote to stress, said Murthy. But, he cautioned, social media can sometimes provide only the illusion of connections and not support. For example, using social media as a means to organize meetings with friends can be helpful, but checking one’s Facebook feed on a lonely Friday evening is likely to make one feel even lonelier because of the “fictionalized, partial myth” of other glamorous happy lives that are often displayed on social media.

Social support can be helpful in alleviating psychological stress caused by illness. Illness, whether personal or family, is more stressful to deal with alone than when family, friends, and health-care providers are providing compassionate support.

But there are other tools in the anti-stress toolbox including exercise, sleep, meditation, and even music. “Exercise is far more important than we understand and can function as an acute antidepressant,” said Murthy.

Sleep allows the brain to regenerate and body tissues to heal; improves decision-making, learning, and creative abilities; and is connected to reduced rates of obesity, diabetes, hypertension, and heart disease. Murthy stressed the profound importance of sleep especially for children. “Kids who don’t sleep are likely not to pay attention in classrooms and [likely to] get in fights,” he said.

Meditation, another stress-reduction tool, is often “stereotyped as an Indian yogi, cross-legged for hours, chanting a mantra,” said Murthy. But there are many kinds of meditation that can have a powerful calming response. Unfortunately, there is less research on how meditation—versus medication—can be used to control chronic diseases such as diabetes and hypertension. Designing studies to evaluate meditation can be difficult, Murthy pointed out, but the anecdotal evidence is strong enough to warrant further exploration.

Murthy gave an example of how meditation helped a middle school in California with high suspension rates and a high amount of violence. School officials tried counseling and sports programs, to no effect. Finally, “almost out of desperation, they decided to implement a meditation program at the school,” Murthy said. The students were skeptical at first, but over the course of a year the school became noticeably calmer and had a drastically reduced suspension rate and lower teacher absenteeism. Students were enthusiastically and voluntarily participating in the meditation program.

“Music [also] has a powerful ability to change how we perceive the world and activate a relaxation response,” said Murthy, citing a McGill University study that indicated music can be better than drugs at reducing anxiety. The response to music is indeed “all in your head,” he said. “But what’s in your head matters.”

More research at the detailed molecular level is certainly needed. “We cannot allow the typical seven to 10 years” for research to percolate into practice, said Murthy. “When it comes to stress, we need a fundamental culture shift. We need the involvement of doctors, parents, schools, [and] policy makers,” as happened with the tobacco crisis, when a cultural shift caused a dramatic drop in smoking across America.

We know that long-term childhood stress arising from physical, emotional, or sexual violence against the children themselves or against their family members is positively correlated with later development of alcoholism, cancer, and even visible changes in the brain. Occasional stress, however, can increase emotional resilience. Murthy compared these different responses to working out in the gym: Everyone should lift weights and increase their strength, but [they] should work out intermittently with adequate support, good nutrition, and sleep.

Health-care providers are rarely prepared to help patients with stress and are not even trained to address stress in their own lives. “What’s valued in medicine is medical knowledge,” Murthy observed, but clinicians need to lead by example. Collins and Murthy reminisced gloomily about their own medical training in which stress management was rarely, if ever, mentioned, and doctors were admired for their ability to carry on without sleep.

Murthy ended by saying, “We need to go beyond addressing stress in our own lives to reaching out to reduce stress in others’ lives, via social connections, compassion, kindness.” He spoke about the possibility of a culture in which the ability to contribute, to generate creative ideas, and a willingness to work hard were supported by the family, the teachers, the community, and neighbors. “We need to create a culture that values and supports everyone.”

The Stephen Straus lecture series was established to honor Stephen E. Straus (1946–2007), the founding director (1999–2006) of the National Center for Complementary and Alternative Medicine, which was renamed the National Center for Complementary and Integrative Health in 2014. To watch a videocast of the conversation, “A Nation Under Pressure: The Public Health Consequences of Stress in America,” held on Thursday, September 7, 2017, go to https://videocast.nih.gov/launch.asp?23443.

VIVEK E. MURTHY, M.D.

19th Surgeon General of the United States (2014–2017)

Born: Huddersfield, England

Grew up: Miami

Education: Harvard University, Cambridge, Mass. (B.S. in biochemical sciences); Yale University, New Haven, Conn. (M.D. and M.B.A.)

Training: Internal medicine residency at Brigham and Women’s Hospital (Boston)

Research: Vaccine development; participation of women and minorities in clinical trials

Path to Surgeon General: As the child of immigrants from India, Murthy was first exposed to medicine in his parents’ medical clinic in Miami. He was inspired by watching his parents’ supporting the emotional as well as the medical needs of patients and their families. Murthy has treated thousands of patients and trained medical professionals as a physician, conducted scientific research, co-founded several nonprofits, started a technology company, and built a physicians organization that supports comprehensive health reform. “All these experiences didn’t seem to come together until I became Surgeon General,” he said during his visit to NIH. As Surgeon General, he heard the stories of people from all corners of America, which deepened his love for this country.

“I got more than I gave because the education I received was from people all over the country who taught me what an extraordinary nation we are and how our people, despite all the challenges we have, are still rooted in the fundamental sense of kindness and compassion and decency.”