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The nature of work is changing at whirlwind speed. Perhaps now more than ever before, job stress poses a threat to the health of workers and, in turn, to the health organizations.

Stress in Today's Workplace

The longer he waited, the more David worried. For weeks he had been plagued by aching muscles, loss of appetite, restless sleep, and a complete sense of exhaustion. At first he tried to ignore these problems, but eventually he became so short-tempered and irritable that his wife insisted he get a checkup. Now, sitting in the doctor's office and wondering what the verdict would be, he didn't even notice when Theresa took the seat beside him. They had been good friends when she worked in the front office at the plant, but he hadn't seen her since she left three years ago to take a job as a customer service representative. Her gentle poke in the ribs brought him around, and within minutes they were talking and gossiping as if she had never left.

"You got out just in time," he told her. "Since the reorganization, nobody feels safe. It used to be that as long as you did your work, you had a job. That's not for sure anymore. They expect the same production rates even though two guys are now doing the work of three. We're so backed up I'm working twelve-hour shifts six days a week. I swear I hear those machines humming in my sleep. Guys are calling in sick just to get a break. Morale is so bad they're talking about bringing in some consultants to figure out a better way to get the job done."

"Well, I really miss you guys," she said. "I'm afraid I jumped from the frying pan into the fire. In my new job, the computer routes the calls and they never stop. I even have to schedule my bathroom breaks. All I hear the whole day are complaints from unhappy customers. I try to be helpful and sympathetic, but I can't promise anything without getting my boss's approval. Most of the time I'm caught between what the customer wants and company policy. I'm not sure who I'm supposed to keep happy. The other reps are so uptight and tense they don't even talk to one another. We all go to our own little cubicles and stay there until quitting time. To make matters worse, my mother's health is deteriorating. If only I could use some of my sick time to look after her. No wonder I'm in here with migraine headaches and high blood pressure. A lot of the reps are seeing the employee assistance counselor and taking stress management classes, which seems to help. But sooner or later, someone will have to make some changes in the way the place is run." - (What workers say about stress on the job...)

Scope of Stress in the American Workplace

David's and Theresa's stories are unfortunate but not unusual. Job stress has become a common and costly problem in the American workplace, leaving few workers untouched. For example, studies report the following:

• One-fourth of employees view their jobs as the number one stressor in their lives.   -Northwestern National Life

•  Three-fourths of employees believe the worker has more on-the-job stress than a generation ago.   -Princeton Survey Research Associates

•  Problems at work are more strongly associated with health complaints than are any other life stressor-more so than even financial problems or family problems.   -St. Paul Fire and Marine Insurance Co

Fortunately, research on job stress has greatly expanded in recent years. But in spite of this attention, confusion remains about the causes, effects, and prevention of job stress. This booklet summarizes what is known about job stress and what can be done about it.

What is Job Stress?

Job stress can be defined as the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker. Job stress can lead to poor health and even injury.

The concept of job stress is often confused with challenge, but these concepts are not the same. Challenge energizes us psychologically and physically, and it motivates us to learn new skills and master our jobs. When a challenge is met, we feel relaxed and satisfied. Thus, challenge is an important ingredient for healthy and productive work. The importance of challenge in our work lives is probably what people are referring to when they say "a little bit of stress is good for you.

But for David and Theresa, the situation is different-the challenge has turned into job demands that cannot be met, relaxation has turned to exhaustion, and a sense of satisfaction has turned into feelings of stress. In short, the stage is set for illness, injury, and job failure.

What are the Causes of Job Stress?

Nearly everyone agrees that job stress results from the interaction of the worker and the conditions of work. Views differ, however, on the importance of worker characteristics versus working conditions as the primary cause of job stress. These differing viewpoints are important because they suggest different ways to prevent stress at work.

According to one school of thought, differences in individual characteristics such as personality and coping style are most important in predicting whether certain job conditions will result in stress-in other words, what is stressful for one person may not be a problem for someone else. This viewpoint leads to prevention strategies that focus on workers and ways to help them cope with demanding job conditions.

Although the importance of individual differences cannot be ignored, scientific evidence suggests that certain working conditions are stressful to most people. The excessive workload demands and conflicting expectations described in David's and Theresa's stories are good examples. Such evidence argues for a greater emphasis on working conditions as the key source of job stress, and for job redesign as a primary prevention strategy.

In 1960, a Michigan court upheld a compensation claim by an automotive assembly line worker who had difficulty keeping up with the pressures of the production line. To avoid falling behind, he tried to work on several assemblies at the same time and often got parts mixed up. As a result, he was subjected to repeated criticism from the foreman. Eventually he suffered a psychological breakdown.

By 1995, nearly one-half of the States allowed worker compensation claims for emotional disorders and disability due to stress on the job [note, however, that courts are reluctant to uphold claims for what can be considered ordinary working conditions or just hard work. - 1995 Workers Compensation Yearbook

NIOSH Approach to Job Stress

On the basis of experience and research, NIOSH (National Institute for Occupational Safety and Health) favors the view that working conditions play a primary role in causing job stress. However, the role of individual factors is not ignored. According to the NIOSH view, exposure to stressful working conditions (called job stressors) can have a direct influence on worker safety and health. But as shown below, individual and other situational factors can intervene to strengthen or weaken this influence. Theresa's need to care for her ill mother is an increasingly common example of an individual or situational factor that may intensify the effects of stressful working conditions. Examples of individual and situational factors that can help to reduce the effects of stressful working conditions include the following:

• Balance between work and family or personal life
• A support network of friends and coworkers
• A relaxed and positive outlook

(NIOSH Model of Job Stress)

Job Conditions That May Lead to Stress

• The Design of Tasks. Heavy workload, infrequent rest breaks, long work hours and shiftwork; hectic and routine tasks that have little inherent meaning, do not utilize workers' skills, and provide little sense of control. Example: David works to the point of exhaustion. Theresa is tied to the computer, allowing little room for flexibility, self-initiative, or rest.

• Management Style. Lack of participation by workers in decision- making, poor communication in the organization, lack of family-friendly policies. Example: Theresa needs to get the boss's approval for everything, and the company is insensitive to her family needs.

• Interpersonal Relationships. Poor social environment and lack of support or help from coworkers and supervisors. Example: Theresa's physical isolation reduces her opportunities to interact with other workers or receive help from them.

• Work Roles. Conflicting or uncertain job expectations, too much responsibility, too many "hats to wear." Example: Theresa is often caught in a difficult situation trying to satisfy both the customer's needs and the company's expectations.

• Career Concerns. Job insecurity and lack of opportunity for growth, advancement, or promotion; rapid changes for which workers are unprepared. Example: Since the reorganization at David's plant, everyone is worried about their future with the company and what will happen next.

• Environmental Conditions. Unpleasant or dangerous physical conditions such as crowding, noise, air pollution, or ergonomic problems. Example: David is exposed to constant noise at work.

Early Warning Signs of Stress

• Headache
• Sleep Disturbances
• Difficulty in Concentrating
• Short Temper
• Upset Stomach
• Job Dissatisfaction
• Low Morale

Job Stress and Health

Stress sets off an alarm in the brain, which responds by preparing the body for defensive action. The nervous system is aroused and hormones are released to sharpen the senses, quicken the pulse, deepen respiration, and tense the muscles. This response (sometimes called the fight or flight response) is important because it helps us defend against threatening situations. The response is preprogrammed biologically. Everyone responds in much the same way, regardless of whether the stressful situation is at work or home.

Short-lived or infrequent episodes of stress pose little risk. But when stressful situations go unresolved, the body is kept in a constant state of activation, which increases the rate of wear and tear to biological systems. Ultimately, fatigue or damage results, and the ability of the body to repair and defend itself can become seriously compromised. As a result, the risk of injury or disease escalates.

In the past 20 years, many studies have looked at the relationship between job stress and a variety of ailments. Mood and sleep disturbances, upset stomach and headache, and disturbed relationships with family and friends are examples of stress-related problems that are quick to develop and are commonly seen in these studies. These early signs of job stress are usually easy to recognize. But the effects of job stress on chronic diseases are more difficult to see because chronic diseases take a long time to develop and can be influenced by many factors other than stress. Nonetheless, evidence is rapidly accumulating to suggest that stress plays an important role in several types of chronic health problems-especially cardiovascular disease, musculoskeletal disorders, and psychological disorders.

Health care expenditures are nearly 50% greater for workers who report high levels of stress.  - Journal of Occupational and Environmental Medicine

Job Stress and Health: What the Research Tells Us

Cardiovascular Disease

Many studies suggest that psychologically demanding jobs that allow employees little control over the work process increase the risk of cardiovascular disease.

Musculoskeletal Disorders

On the basis of research by NIOSH and many other organizations, it is widely believed that job stress increases the risk for development of back and upper- extremity musculoskeletal disorders.

Psychological Disorders

Several studies suggest that differences in rates of mental health problems (such as depression and burnout) for various occupations are due partly to differences in job stress levels. (Economic and lifestyle differences between occupations may also contribute to some of these problems.)

Workplace Injury

Although more study is needed, there is a growing concern that stressful working conditions interfere with safe work practices and set the stage for injuries at work.

Suicide, Cancer, Ulcers, and Impaired Immune Function

Some studies suggest a relationship between stressful working conditions and these health problems. However, more research is needed before firm conclusions can be drawn.  Source: Encyclopaedia of Occupational Safety and Health

Stress, Health, and Productivity

Some employers assume that stressful working conditions are a necessary evil-that companies must turn up the pressure on workers and set aside health concerns to remain productive and profitable in today's economy. But research findings challenge this belief. Studies show that stressful working conditions are actually associated with increased absenteeism, tardiness, and intentions by workers to quit their jobs-all of which have a negative effect on the bottom line.

Recent studies of so-called healthy organizations suggest that policies benefiting worker health also benefit the bottom line. A healthy organization is defined as one that has low rates of illness, injury, and disability in its workforce and is also competitive in the marketplace. NIOSH research has identified organizational characteristics associated with both healthy, low-stress work and high levels of productivity. Examples of these characteristics include the following:

• Recognition of employees for good work performance
• Opportunities for career development
• An organizational culture that values the individual worker
• Management actions that are consistent with organizational values

Stress Prevention and Job Performance

St. Paul Fire and Marine Insurance Company conducted several studies on the effects of stress prevention programs in hospital settings. Program activities included (1) employee and management education on job stress, (2) changes in hospital policies and procedures to reduce organizational sources of stress, and (3) establishment of employee assistance programs.

In one study, the frequency of medication errors declined by 50% after prevention activities were implemented in a 700-bed hospital. In a second study, there was a 70% reduction in malpractice claims in 22 hospitals that implemented stress prevention activities. In contrast, there was no reduction in claims in a matched group of 22 hospitals that did not implement stress prevention activities. - Journal of Applied Psychology

According to data from the Bureau of Labor Statistics, workers who must take time off work because of stress, anxiety, or a related disorder will be off the job for about 20 days. - Bureau of Labor Statistics

What Can Be Done About Job Stress?

The examples of Theresa and David illustrate two different approaches for dealing with stress at work.

Stress Management. Theresa's company is providing stress management training and an employee assistance program (EAP) to improve the ability of workers to cope with difficult work situations. Nearly one-half of large companies in the United States provide some type of stress management training for their workforces. Stress management programs teach workers about the nature and sources of stress, the effects of stress on health, and personal skills to reduce stress-for example, time management or relaxation exercises. (EAPs provide individual counseling for employees with both work and personal problems.) Stress management training may rapidly reduce stress symptoms such as anxiety and sleep disturbances; it also has the advantage of being inexpensive and easy to implement. However, stress management programs have two major disadvantages:

• The beneficial effects on stress symptoms are often short-lived.
• They often ignore important root causes of stress because they focus on the worker and not the environment.

Organizational Change. In contrast to stress management training and EAP programs, David's company is trying to reduce job stress by bringing in a consultant to recommend ways to improve working conditions. This approach is the most direct way to reduce stress at work. It involves the identification of stressful aspects of work (e.g., excessive workload, conflicting expectations) and the design of strategies to reduce or eliminate the identified stressors. The advantage of this approach is that it deals directly with the root causes of stress at work. However, managers are sometimes uncomfortable with this approach because it can involve changes in work routines or production schedules, or changes in the organizational structure.

As a general rule, actions to reduce job stress should give top priority to organizational change to improve working conditions. But even the most conscientious efforts to improve working conditions are unlikely to eliminate stress completely for all workers. For this reason, a combination of organizational change and stress management is often the most useful approach for preventing stress at work.

(Org change + Stress Management = A healthy workplace)

How to Change the Organization to Prevent Job Stress

• Ensure that the workload is in line with workers' capabilities and resources.
• Design jobs to provide meaning, stimulation, and opportunities for workers to use their skills.
• Clearly define workers' roles and responsibilities.
• Give workers opportunities to participate in decisions and actions affecting their jobs.
• Improve communications-reduce uncertainty about career development and future employment prospects.
• Provide opportunities for social interaction among workers.
• Establish work schedules that are compatible with demands and responsibilities outside the job.
  - American Psychologist

Preventing Job Stress - Getting Started

No standardized approaches or simple "how to" manuals exist for developing a stress prevention program. Program design and appropriate solutions will be influenced by several factors-the size and complexity of the organization, available resources, and especially the unique types of stress problems faced by the organization. In David's company, for example, the main problem is work overload. Theresa, on the other hand, is bothered by difficult interactions with the public and an inflexible work schedule.

Although it is not possible to give a universal prescription for preventing stress at work, it is possible to offer guidelines on the process of stress prevention in organizations. In all situations, the process for stress prevention programs involves three distinct steps: problem identification, intervention, and evaluation. These steps are outlined beginning on page 17. For this process to succeed, organizations need to be adequately prepared. At a minimum, preparation for a stress prevention program should include the following:

• Building general awareness about job stress (causes, costs, and control)
• Securing top management commitment and support for the program
• Incorporating employee input and involvement in all phases of the program
• Establishing the technical capacity to conduct the program (e.g., specialized training for in-house staff or use of job stress consultants)

Bringing workers or workers and managers together in a committee or problem-solving group may be an especially useful approach for developing a stress prevention program. Research has shown these participatory efforts to be effective in dealing with ergonomic problems in the workplace, partly because they capitalize on workers' firsthand knowledge of hazards encountered in their jobs. However, when forming such working groups, care must be taken to be sure that they are in compliance with current labor laws.*

*The National Labor Relations Act may limit the form and structure of employee involvement in worker-management teams or groups. Employers should seek legal assistance if they are unsure of their responsibilities or obligations under the National Labor Relations Act.

Steps Toward Prevention

Low morale, health and job complaints, and employee turnover often provide the first signs of job stress. But sometimes there are no clues, especially if employees are fearful of losing their jobs. Lack of obvious or widespread signs is not a good reason to dismiss concerns about job stress or minimize the importance of a prevention program.

Step 1 - Identify the Problem. The best method to explore the scope and source of a suspected stress problem in an organization depends partly on the size of the organization and the available resources. Group discussions among managers, labor representatives, and employees can provide rich sources of information. Such discussions may be all that is needed to track down and remedy stress problems in a small company. In a larger organization, such discussions can be used to help design formal surveys for gathering input about stressful job conditions from large numbers of employees.

Regardless of the method used to collect data, information should be obtained about employee perceptions of their job conditions and perceived levels of stress, health, and satisfaction. The list of job conditions that may lead to stress and the warning signs and effects of stress provide good starting points for deciding what information to collect.

Objective measures such as absenteeism, illness and turnover rates, or performance problems can also be examined to gauge the presence and scope of job stress. However, these measures are only rough indicators of job stress-at best.

Data from discussions, surveys, and other sources should be summarized and analyzed to answer questions about the location of a stress problem and job conditions that may be responsible-for example, are problems present throughout the organization or confined to single departments or specific jobs?

• Hold group discussions with employees.
• Design an employee survey.
• Measure employee perceptions of job conditions, stress, health, and satisfaction.
• Collect objective data.
• Analyze data to identify problem locations and stressful job conditions.

  Survey design, data analysis, and other aspects of a stress prevention program may require the help of experts from a local university or consulting firm. However, overall authority for the prevention program should remain in the organization.

Step 2 - Design and Implement Interventions. Once the sources of stress at work have been identified and the scope of the problem is understood, the stage is set for design and implementation of an intervention strategy.

In small organizations, the informal discussions that helped identify stress problems may also produce fruitful ideas for prevention. In large organizations, a more formal process may be needed. Frequently, a team is asked to develop recommendations based on analysis of data from Step 1 and consultation with outside experts.

Certain problems, such as a hostile work environment, may be pervasive in the organization and require company-wide interventions. Other problems such as excessive workload may exist only in some departments and thus require more narrow solutions such as redesign of the way a job is performed. Still other problems may be specific to certain employees and resistant to any kind of organizational change, calling instead for stress management or employee assistance interventions. Some interventions might be implemented rapidly (e.g., improved communication, stress management training), but others may require additional time to put into place (e.g., redesign of a manufacturing process).

Before any intervention occurs, employees should be informed about actions that will be taken and when they will occur. A kick-off event, such as an all-hands meeting, is often useful for this purpose.

• Target source of stress for change.
• Propose and prioritize intervention strategies.
• Communicate planned interventions to employees.
• Implement interventions.

Step 3 - Evaluate the Interventions. Evaluation is an essential step in the intervention process. Evaluation is necessary to determine whether the intervention is producing desired effects and whether changes in direction are needed.

Time frames for evaluating interventions should be established. Interventions involving organizational change should receive both short- and long-term scrutiny. Short-term evaluations might be done quarterly to provide an early indication of program effectiveness or possible need for redirection. Many interventions produce initial effects that do not persist. Long-term evaluations are often conducted annually and are necessary to determine whether interventions produce lasting effects.

Evaluations should focus on the same types of information collected during the problem identification phase of the intervention, including information from employees about working conditions, levels of perceived stress, health problems, and satisfaction. Employee perceptions are usually the most sensitive measure of stressful working conditions and often provide the first indication of intervention effectiveness. Adding objective measures such as absenteeism and health care costs may also be useful. However, the effects of job stress interventions on such measures tend to be less clear-cut and can take a long time to appear.

• Conduct both short- and long-term evaluations.
• Measure employee perceptions of job conditions, stress, health, and satisfaction.
• Include objective measures.
• Refine the intervention strategy and return to Step 1.

The job stress prevention process does not end with evaluation. Rather, job stress prevention should be seen as a continuous process that uses evaluation data to refine or redirect the intervention strate

Stress Prevention Programs: What Some Organizations Have Done

Example 1 - A Small Service Organization

A department head in a small public service organization sensed an escalating level of tension and deteriorating morale among her staff. Job dissatisfaction and health symptoms such as headaches also seemed to be on the rise. Suspecting that stress was a developing problem in the department
she decided to hold a series of all-hands meetings with employees in the different work units of the department to explore this concern further. These meetings could be best described as brainstorming sessions where individual employees freely expressed their views about the scope and sources of stress in their units and the measures that might be implemented to bring the problem under control.

Using the information collected in these meetings and in meetings with middle managers, she concluded that a serious problem probably existed and that quick action was needed. Because she was relatively unfamiliar with the job stress field, she decided to seek help from a faculty member at a local university who taught courses on job stress and organizational behavior.

After reviewing the information collected at the brainstorming sessions, they decided it would be useful for the faculty member to conduct informal classes to raise awareness about job stress-its causes, effects, and prevention-for all workers and managers in the department. It was also decided that a survey would be useful to obtain a more reliable picture of problematic job conditions and stress-related health complaints in the department. The faculty member used information from the meetings with workers and managers to design the survey. The faculty member was also involved in the distribution and collection of the anonymous survey to ensure that workers felt free to respond honestly and openly about what was bothering them. He then helped the department head analyze and interpret the data.

Analysis of the survey data suggested that three types of job conditions were linked to stress complaints among workers:

• Unrealistic deadlines
• Low levels of support from supervisors
• Lack of worker involvement in decision-making.

Example 2 - A Large Manufacturing Company

Although no widespread signs of stress were evident at work, the corporate medical director of a large manufacturing company thought it would be useful to establish a stress prevention program as a proactive measure. As a first step he discussed this concept with senior management and with union leaders. Together, they decided to organize a labor-management team to develop the program. The team comprised representatives from labor, the medical/employee assistance department, the human resources department, and an outside human resources consulting firm. The consulting firm provided technical advice about program design, implementation, and evaluation. Financial resources for the team and program came from senior management, who made it clear that they supported this activity. The team designed a two-part program. One part focused on management practices and working conditions that could lead to stress. The second part focused on individual health and well-being.

To begin the part of the program dealing with management practices and job conditions, the team worked with the consulting firm to add new questions about job stress to the company's existing employee opinion survey. The survey data were used by the team to identify stressful working conditions and to suggest changes at the work group and/or organizational level. The employee health and well-being part of the program consisted of 12 weekly training sessions. During these sessions, workers and managers learned about common sources and effects of stress at work, and about self-protection strategies such as relaxation methods and improved health behaviors. The training sessions were offered during both work and nonwork hours.

The team followed up with quarterly surveys of working conditions and stress symptoms to closely monitor the effectiveness of this two-part program.

These examples are based on adaptations of actual situations. For other examples of job stress interventions, see the Conditions of Work Digest, Vol. 11/2, pp. 139-275. This publication may be obtained by contacting the ILO Publications Center at P.O. Box 753, Waldorf, MD 20604 (Telephone: 301-638-3152). Or call NIOSH at 1-800-35-NIOSH.

Need Additional Information?

More about NIOSH
National Institute for Occupational Safety and Health (NIOSH)
4676 Columbia Parkway
Cincinnati, Ohio 45226-1998
1-800-35-NIOSH
Outside the U.S.: 1-513-533-8328
www.cdc.gov/niosh

More Information about Job Stress
The Encyclopaedia of Occupational Health and Safety, 4th Edition
(ISBN 92-2-109203-8) Contains a comprehensive summary of the latest scientific information about the causes and effects of job stress (see Vol. 1, Chapter 5, Mental Health; Vol. 2, Chapter 34, Psychosocial and Organizational Factors).

International Labour Office (ILO) Publications Center
P.O. Box 753
Waldorf, MD 20604
1-301-638-3152

Sources Used in Preparing This Document

1995 Workers' Compensation Year Book
Elisburg D [1995]. Workplace stress: legal developments, economic pressures, and violence. In: Burton JF, ed. 1995 Workers' Compensation Year Book. Horsham, PA: LRP Publications, pp. I-217-I-222.

American Psychologist
Sauter SL, Murphy LR, Hurrell JJ, Jr. [1990]. Prevention of work-related psychological disorders. American Psychologist 45(10):1146-1158.

Bureau of Labor Statistics
BLS [1996]. Bureau of Labor Statistics Homepage [www.bls.gov]. Tabular data, 1992-96: Number and percentage distribution of nonfatal occupational injuries and illnesses involving days away from work, by nature of injury or illness and number of days away from work. Date accessed: 1998.

Encyclopaedia of Occupational Health and Safety
Sauter S, Hurrell J, Murphy L, Levi L [1997]. Psychosocial and organizational factors. In: Stellman J, ed. Encyclopaedia of Occupational Health and Safety. Vol. 1. Geneva, Switzerland: International Labour Office, pp. 34.1-34.77.

Families and Work Institute
Bond JT, Galinsky E, Swanberg JE [1998]. The 1997 national study of the changing workforce. New York, NY: Families and Work Institute.

Journal of Applied Psychology
Jones JW, Barge BN, Steffy BD, Fay LM, Kuntz LK, Wuebker LJ [1988]. Stress and medical malpractice: organizational risk assessment and intervention. Journal of Applied Psychology 73(4):727-735.

Journal of Occupational and Environmental Medicine
Goetzel RZ, Anderson DR, Whitmer RW, Ozminkowski RJ, Dunn RL, Wasserman J, Health Enhancement Research Organization (HERO) Research Committee [1998]. The relationship between modifiable health risks and health care expenditures: an analysis of the multi-employer HERO health risk and cost database. Journal of Occupational and Environmental Medicine 40(10).

Northwestern National Life (now ReliaStar Financial Corporation)
Northwestern National Life Insurance Company [1991]. Employee burnout: America's newest epidemic. Minneapolis, MN: Northwestern National Life Insurance Company. Northwestern National Life Insurance Company [1992]. Employee burnout: causes and cures. Minneapolis, MN: Northwestern National Life Insurance Company.

Princeton Survey Research Associates
Princeton Survey Research Associates [1997]. Labor day survey: state of workers. Princeton, NJ: Princeton Survey Research Associates.

St. Paul Fire and Marine Insurance Company
St. Paul Fire and Marine Insurance Company [1992]. American workers under pressure technical report. St. Paul, MN: St. Paul Fire and Marine Insurance Company.

Yale University
Barsade S, Wiesenfeld B, The Marlin Company [1997]. Attitudes in the American workplace III. New Haven, CT: Yale University School of Management.

Source: National Institute for Occupational Safety and Health (NIOSH)
DHHS (NIOSH) Publication No. 99-101

Reviewed by athealth on February 8, 2014.

We feel stressed when the demands of life and our skills and resources for coping are out of balance. We have short-term and long-term stress. Missing the bus or arguing with a spouse can cause short-term stress. Single parenting or financial hardship can lead to long-term stress. Even some of our happiest times can be stressful, like during the holidays or having a baby.

Some of the most common stressful life events include:

• death of a spouse
• death of a close family member
• divorce
• losing your job
• major personal illness or injury
• marital separation
• marriage
• pregnancy
• retirement
• spending time in jail

Social conditions such as living in poverty and dealing with racism can expose people to ongoing stress. So can discrimination or harassment at work. Stress caused by trauma, intimate partner violence, or an abusive or troubled home life during childhood can have potent and long-lasting effects on a woman's mental health. In fact, childhood sexual abuse,which is more frequent among girls, may have effects that last into adulthood - ranging from depression and anxiety to posttraumatic stress disorder (PTSD).

More familiar to many women is day-today stress. Stress that builds up can take a toll on your physical and mental health.Did you know that you are more likely to catch a cold during times of high stress? Long-term stress can put you at risk of more serious health problems, like depression or hypertension. Or make health problems you already have worse.

SIGNS OF ROLE STRAIN AND STRESS  Juggling multiple roles is a fact of life for most women today. Sometimes, our roles as wives, partners, mothers, workers, and caregivers can feel like they are competing for our time and en-ergy. Role strain and stress can happen easily if you take on too much, set stan-dards that are too high, and/or don't get the support you need. But life roles can enhance and support each other, too. Research suggests that multiple roles are better for you than having just one. Look out for these signs that you are spreading yourself too thin: anxiety depression feeling you don't have control, or a need for too much control forgetfulness headaches lack of energy lack of focus low morale not being able to get things done poor self-esteem short temper trouble sleeping upset stomach withdrawal

At the same time, not all stress is bad.Just enough stress keeps you focused and helps you to perform your best, such as the stress you might feel before speaking in front of a group of people. It also can prompt you to change a situation for the better, such as leaving a dead-end job. But any stress can affect your health.Pay attention to your body for signs that stress is building up. And try these tips to keep stress in check:

• Take time each day to relax and unwind, even if only for a few minutes.
• Aim for 7 to 9 hours of sleep every night.
• Eat healthy foods, which give you energy.
• Make time for physical activity, which relieves tension and boosts mood.
• Talk to friends and loved ones. They are good listeners and might offer a different way of seeing things.
• Make time to do things you enjoy and that fulfill you.
• Set limits. Be realistic about what you can handle at work and in your personal life. Talk to your boss if work demands are too big to handle alone.If you feel overburdened, ask family and friends for help and say "no"to requests for your time and energy.Women often put the needs of others before their own.

Source: Adapted from The Healthy Woman: A Complete Guide for All Ages
U.S. Department of Health and Human Services, Office on Women's Health
2008

Reviewed by athealth on February 8, 2014.

What should you do if someone tells you they are thinking about suicide?

If someone tells you they are thinking about suicide, you should take their distress seriously, listen nonjudgmentally, and help them get to a professional for evaluation and treatment. People consider suicide when they are hopeless and unable to see alternative solutions to problems. Suicidal behavior is most often related to a mental disorder (depression) or to alcohol or other substance abuse. Suicidal behavior is also more likely to occur when people experience stressful events (major losses, incarceration). If someone is in imminent danger of harming himself or herself, do not leave the person alone. You may need to take emergency steps to get help, such as calling 911. When someone is in a suicidal crisis, it is important to limit access to firearms or other lethal means of committing suicide.

What are the most common methods of suicide?

Firearms are the most commonly used method of suicide for men and women, accounting for 60 percent of all suicides. Nearly 80 percent of all firearm suicides are committed by white males. The second most common method for men is hanging; for women, the second most common method is self-poisoning including drug overdose. The presence of a firearm in the home has been found to be an independent, additional risk factor for suicide. Thus, when a family member or health care provider is faced with an individual at risk for suicide, they should make sure that firearms are removed from the home.

Why do men commit suicide more often than women do?

More than four times as many men as women die by suicide; but women attempt suicide more often during their lives than do men, and women report higher rates of depression. Men and women use different suicide methods. Women in all countries are more likely to ingest poisons than men. In countries where the poisons are highly lethal and/or where treatment resources scarce, rescue is rare and hence female suicides outnumber males.

Who is at highest risk for suicide in the U.S.?

There is a common perception that suicide rates are highest among the young. However, it is the elderly, particularly older white males that have the highest rates. And among white males 65 and older, risk goes up with age. White men 85 and older have a suicide rate that is six times that of the overall national rate. Some older persons are less likely to survive attempts because they are less likely to recuperate. Over 70 percent of older suicide victims have been to their primary care physician within the month of their death, many did not tell their doctors they were depressed nor did the doctor detect it. This has led to research efforts to determine how to best improve physicians' abilities to detect and treat depression in older adults.

Are gay and lesbian youth at high risk for suicide?

With regard to completed suicide, there are no national statistics for suicide rates among gay, lesbian or bisexual (GLB) persons. Sexual orientation is not a question on the death certificate, and to determine whether rates are higher for GLB persons, we would need to know the proportion of the U.S. population that considers themselves gay, lesbian or bisexual. Sexual orientation is a personal characteristic that people can, and often do choose to hide, so that in psychological autopsy studies of suicide victims where risk factors are examined, it is difficult to know for certain the victim's sexual orientation. This is particularly a problem when considering GLB youth who may be less certain of their sexual orientation and less open. In the few studies examining risk factors for suicide where sexual orientation was assessed, the risk for gay or lesbian persons did not appear any greater than among heterosexuals, once mental and substance abuse disorders were taken into account.

With regard to suicide attempts, several state and national studies have reported that high school students who report to be homosexually and bisexually active have higher rates of suicide thoughts and attempts in the past year compared to youth with heterosexual experience. Experts have not been in complete agreement about the best way to measure reports of adolescent suicide attempts, or sexual orientation, so the data are subject to question. But they do agree that efforts should focus on how to help GLB youth grow up to be healthy and successful despite the obstacles that they face. Because school based suicide awareness programs have not proven effective for youth in general, and in some cases have caused increased distress in vulnerable youth, they are not likely to be helpful for GLB youth either. Because young people should not be exposed to programs that do not work, and certainly not to programs that increase risk, more research is needed to develop safe and effective programs.

Are African American youth at great risk for suicide?

Historically, African Americans have had much lower rates of suicides compared to white Americans. However, beginning in the 1980s, the rates for African American male youth began to rise at a much faster rate than their white counterparts. The most recent trends suggest a decrease in suicide across all gender and racial groups, but health policy experts remain concerned about the increase in suicide by firearms for all young males. Whether African American male youth are more likely to engage in "victim-precipitated homicide" by deliberately getting in the line of fire of either gang or law enforcement activity, remains an important research question, as such deaths are not typically classified as suicides.

Is suicide related to impulsiveness?

Impulsiveness is the tendency to act without thinking through a plan or its consequences. It is a symptom of a number of mental disorders, and therefore, it has been linked to suicidal behavior usually through its association with mental disorders and/or substance abuse. The mental disorders with impulsiveness most linked to suicide include borderline personality disorder among young females, conduct disorder among young males and antisocial behavior in adult males, and alcohol and substance abuse among young and middle-aged males. Impulsiveness appears to have a lesser role in older adult suicides. Attention deficit hyperactivity disorder that has impulsiveness as a characteristic is not a strong risk factor for suicide by itself. Impulsiveness has been linked with aggressive and violent behaviors including homicide and suicide. However, impulsiveness without aggression or violence present has also been found to contribute to risk for suicide.

Is there such a thing as "rational" suicide?

Some right-to-die advocacy groups promote the idea that suicide, including assisted suicide, can be a rational decision. Others have argued that suicide is never a rational decision and that it is the result of depression, anxiety and fear of being dependent or a burden. Surveys of terminally ill persons indicate that very few consider taking their own life, and when they do, it is in the context of depression. Attitude surveys suggest that assisted suicide is more acceptable by the public and health providers for the old who are ill or disabled, compared to the young who are ill or disabled. At this time, there is limited research on the frequency with which persons with terminal illness have depression and suicidal ideation, whether they would consider assisted suicide, the characteristics of such persons, and the context of their depression and suicidal thoughts, such as family stress, or availability of palliative care. Neither is it yet clear what effect other factors such as the availability of social support, access to care, and pain relief may have on end-of-life preferences. This public debate will be better informed after such research is conducted.

What biological factors increase risk for suicide?

Researchers believe that both depression and suicidal behavior can be linked to decreased serotonin in the brain. Low levels of a serotonin metabolite, 5-HIAA, have been detected in cerebral spinal fluid in persons who have attempted suicide, as well as by postmortem studies examining certain brain regions of suicide victims. One of the goals of understanding the biology of suicidal behavior is to improve treatments. Scientists have learned that serotonin receptors in the brain increase their activity in persons with major depression and suicidality, which explains why medications that desensitize or down-regulate these receptors (such as the serotonin reuptake inhibitors, or SSRIs) have been found effective in treating depression. Currently, studies are underway to examine to what extent medications like SSRIs can reduce suicidal behavior.

Can the risk for suicide be inherited?

There is growing evidence that familial and genetic factors contribute to the risk for suicidal behavior. Major psychiatric illnesses, including bipolar disorder, major depression, schizophrenia, alcoholism and substance abuse, and certain personality disorders, which run in families, increase the risk for suicidal behavior. This does not mean that suicidal behavior is inevitable for individuals with this family history; it simply means that such persons may be more vulnerable and should take steps to reduce their risk, such as getting evaluation and treatment at the first sign of mental illness.

Does depression increase the risk for suicide?

Although the majority of people who have depression do not die by suicide, having major depression does increase suicide risk compared to people without depression. The risk of death by suicide may, in part, be related to the severity of the depression. New data on depression that has followed people over long periods of time suggests that about 2% of those people ever treated for depression in an outpatient setting will die by suicide. Among those ever treated for depression in an inpatient hospital setting, the rate of death by suicide is twice as high (4%). Those treated for depression as inpatients following suicide ideation or suicide attempts are about three times as likely to die by suicide (6%) as those who were only treated as outpatients. There are also dramatic gender differences in lifetime risk of suicide in depression. Whereas about 7% of men with a lifetime history of depression will die by suicide, only 1% of women with a lifetime history of depression will die by suicide.

Another way about thinking of suicide risk and depression is to examine the lives of people who have died by suicide and see what proportion of them were depressed. From that perspective, it is estimated that about 60% of people who commit suicide have had a mood disorder (e.g., major depression, bipolar disorder, dysthymia). Younger persons who kill themselves often have a substance abuse disorder in addition to being depressed.

Does alcohol and other drug abuse increase the risk for suicide?

A number of recent national surveys have helped shed light on the relationship between alcohol and other drug use and suicidal behavior. A review of minimum-age drinking laws and suicides among youths age 18 to 20 found that lower minimum-age drinking laws was associated with higher youth suicide rates. In a large study following adults who drink alcohol, suicide ideation was reported among persons with depression. In another survey, persons who reported that they had made a suicide attempt during their lifetime were more likely to have had a depressive disorder, and many also had an alcohol and/or substance abuse disorder. In a study of all nontraffic injury deaths associated with alcohol intoxication, over 20 percent were suicides.

In studies that examine risk factors among people who have completed suicide, substance use and abuse occurs more frequently among youth and adults, compared to older persons. For particular groups at risk, such as American Indians and Alaskan Natives, depression and alcohol use and abuse are the most common risk factors for completed suicide. Alcohol and substance abuse problems contribute to suicidal behavior in several ways. Persons who are dependent on substances often have a number of other risk factors for suicide. In addition to being depressed, they are also likely to have social and financial problems. Substance use and abuse can be common among persons prone to be impulsive, and among persons who engage in many types of high risk behaviors that result in self-harm. Fortunately, there are a number of effective prevention efforts that reduce risk for substance abuse in youth, and there are effective treatments for alcohol and substance use problems. Researchers are currently testing treatments specifically for persons with substance abuse problems who are also suicidal, or have attempted suicide in the past.

What does "suicide contagion" mean, and what can be done to prevent it?

Suicide contagion is the exposure to suicide or suicidal behaviors within one's family, one's peer group, or through media reports of suicide and can result in an increase in suicide and suicidal behaviors. Direct and indirect exposure to suicidal behavior has been shown to precede an increase in suicidal behavior in persons at risk for suicide, especially in adolescents and young adults.

The risk for suicide contagion as a result of media reporting can be minimized by factual and concise media reports of suicide. Reports of suicide should not be repetitive, as prolonged exposure can increase the likelihood of suicide contagion. Suicide is the result of many complex factors; therefore media coverage should not report oversimplified explanations such as recent negative life events or acute stressors. Reports should not divulge detailed descriptions of the method used to avoid possible duplication. Reports should not glorify the victim and should not imply that suicide was effective in achieving a personal goal such as gaining media attention. In addition, information such as hotlines or emergency contacts should be provided for those at risk for suicide.

Following exposure to suicide or suicidal behaviors within one's family or peer group, suicide risk can be minimized by having family members, friends, peers, and colleagues of the victim evaluated by a mental health professional. Persons deemed at risk for suicide should then be referred for additional mental health services.

Is it possible to predict suicide?

At the current time there is no definitive measure to predict suicide or suicidal behavior. Researchers have identified factors that place individuals at higher risk for suicide, but very few persons with these risk factors will actually commit suicide. Risk factors include mental illness, substance abuse, previous suicide attempts, family history of suicide, history of being sexually abused, and impulsive or aggressive tendencies. Suicide is a relatively rare event and it is therefore difficult to predict which persons with these risk factors will ultimately commit suicide.

Source: National Institute of Mental Health (NIMH)
December 1999
Updated: January 03, 2000

Reviewed by athealth on February 8, 2014.

Suicide is a major public health concern. Around 30,000 people die by suicide each year in the United States. More people die by suicide each year than by homicide.

Suicide is tragic. But it is often preventable. Knowing the risk factors for suicide and who is at risk can help reduce the suicide rate.

Who is at risk for suicide?

Suicide does not discriminate. People of all genders, ages, and ethnicities are at risk for suicide. But people most at risk tend to share certain characteristics. The main risk factors for suicide are:

• Depression, other mental disorders, or substance abuse disorder
• A prior suicide attempt
• Family history of a mental disorder or substance abuse
• Family history of suicide
• Family violence, including physical or sexual abuse
• Having guns or other firearms in the home
• Incarceration, being in prison or jail
• Being exposed to others' suicidal behavior, such as that of family members, peers, or media figures.

The risk for suicidal behavior also is associated with changes in brain chemicals called neurotransmitters, including serotonin, which is also associated with depression. Lower levels of serotonin have been found in the brains of people with a history of suicide attempts.

Many people have some of these risk factors but do not attempt suicide. Suicide is not a normal response to stress. It is however, a sign of extreme distress, not a harmless bid for attention.

What about gender?

Men are more likely to die by suicide than women, but women are more likely to attempt suicide. Men are more likely to use deadlier methods, such as firearms or suffocation. Women are more likely than men to attempt suicide by poisoning.

What about children?

Children and young people are at risk for suicide. Year after year, suicide remains one of the top three leading causes of death for young people ages 15 to 24.

What about older adults?

Older adults are at risk for suicide, too. In fact, white males age 85 and older consistently have the highest suicide rate than any other age and ethnic group.

What about different ethnic groups?

Among ethnicities, American Indians and Alaska Natives tend to have the highest rate of suicides, followed by non-Hispanic Whites. Hispanics tend to have the lowest rate of suicides, while African Americans tend to have the second lowest rate.

How can suicide be prevented?

Effective suicide prevention is based on sound research. Programs that work take into account people's risk factors and promote interventions that are appropriate to specific groups of people. For example, research has shown that mental and substance abuse disorders are risk factors for suicide. Therefore, many programs focus on treating these disorders in addition to addressing suicide risk specifically.

Psychotherapy, or "talk therapy," can effectively reduce suicide risk. One type is called cognitive behavioral therapy (CBT). CBT can help people learn new ways of dealing with stressful experiences by training them to consider alternative actions when thoughts of suicide arise.

Another type of psychotherapy called dialectical behavior therapy (DBT) has been shown to reduce the rate of suicide among people with borderline personality disorder, a serious mental illness characterized by unstable moods, relationships, self-image, and behavior. A therapist trained in DBT helps a person recognize when his or her feelings or actions are disruptive or unhealthy, and teaches the skills needed to deal better with upsetting situations.

Some medications may also help. For example, the antipsychotic medication clozapine is approved by the U.S. Food and Drug Administration for suicide prevention in people with schizophrenia. Other promising medications and psychosocial treatments for suicidal people are being tested.

Still other research has found that many older adults and women who die by suicide saw their primary care providers in the year before death. Training doctors to recognize signs that a person may be considering suicide may help prevent even more suicides.

What should I do if someone I know is considering suicide?

If you know someone who is considering suicide, do not leave him or her alone. Try to get your loved one to seek immediate help from his or her doctor or the nearest hospital emergency room, or call 911. Remove any access he or she may have to firearms or other potential tools for suicide, including medications.

If you are in crisis

Call the toll-free National Suicide Prevention Lifeline at
1-800-273-TALK (8255), available 24 hours a day, 7 days a week.

The service is available to anyone. All calls are confidential.

NIH Publication No. TR 11-7697
2010

Reviewed by athealth on February 8, 2014.

Every year, millions of people are affected by both mass violence and natural disasters, such as earthquakes, floods, hurricanes, tornados, and wildfires. Survivors face the danger of death or physical injury and the possible loss of their homes, possessions, and communities. Such stressors place survivors at risk for behavioral and emotional readjustment problems.

This fact sheet considers three questions often asked by survivors: What psychological problems might one experience as a result of surviving a disaster? What factors increase the risk of readjustment problems? What can survivors do to reduce the risk of negative psychological consequences and to best recover from disaster stress?

What psychological problems might one experience as a result of surviving a disaster?

Most child and adult survivors experience one or more of these normal stress reactions for several days:

• Emotional reactions: temporary (i.e., for several days or a couple of weeks) feelings of shock, fear, grief, anger, resentment, guilt, shame, helplessness, hopelessness, or emotional numbness (difficulty feeling love and intimacy or difficulty taking interest and pleasure in day-to-day activities)
• Cognitive reactions: confusion, disorientation, indecisiveness, worry, shortened attention span, difficulty concentrating, memory loss, unwanted memories, self-blame
• Physical reactions: tension, fatigue, edginess, difficulty sleeping, bodily aches or pain, startling easily, racing heartbeat, nausea, change in appetite, change in sex drive
• Interpersonal reactions in relationships at school, work, in friendships, in marriage, or as a parent: distrust; irritability; conflict; withdrawal; isolation; feeling rejected or abandoned; being distant, judgmental, or over-controlling

Most disaster survivors only experience mild, normal stress reactions. Disaster experiences may even promote personal growth and strengthen relationships. However, as many as one out of every three disaster survivors experience some or all of the following severe stress symptoms, which may lead to lasting Posttraumatic Stress Disorder (PTSD), anxiety disorders, or depression:

• Dissociation (feeling completely unreal or outside yourself, like in a dream; having "blank" periods of time you cannot remember)
• Intrusive reexperiencing (terrifying memories, nightmares, or flashbacks)
• Extreme attempts to avoid disturbing memories (such as through substance use)
• Extreme emotional numbing (completely unable to feel emotion, as if empty)
• Hyper-arousal (panic attacks, rage, extreme irritability, intense agitation)
• Severe anxiety (paralyzing worry, extreme helplessness, compulsions or obsessions)
• Severe depression (complete loss of hope, self-worth, motivation, or purpose in life)

What factors increase the risk of readjustment problems?

Survivors are at greatest risk for severe stress symptoms and lasting readjustment problems if any of the following are either directly experienced or witnessed during or after the disaster:

• Loss of loved ones or friends
• Life threatening danger or physical harm (especially to children)
• Exposure to gruesome death, bodily injury, or dead or maimed bodies
• Extreme environmental or human violence or destruction
• Loss of home, valued possessions, neighborhood, or community
• Loss of communication with or support from close relations
• Intense emotional demands (e.g., rescue personnel and caregivers searching for possibly dying survivors or interacting with bereaved family members)
• Extreme fatigue, weather exposure, hunger, or sleep deprivation
• Extended exposure to danger, loss, emotional/physical strain
• Exposure to toxic contamination (such as gas or fumes, chemicals, radioactivity)

Some individuals have a higher than typical risk for severe stress symptoms and lasting PTSD, including those with a history of:

• Exposure to other traumas (such as severe accidents, abuse, assault, combat, rescue work)
• Chronic medical illness or psychological disorders
• Chronic poverty, homelessness, unemployment, or discrimination
• Recent or subsequent major life stressors or emotional strain (such as single parenting)

Disaster stress may revive memories of prior trauma, and may intensify preexisting social, economic, spiritual, psychological, or medical problems.

What can survivors do to reduce the risk of negative psychological consequences and to best recover from disaster stress?

Researchers are beginning to conduct studies to answer this question. Observations by disaster mental-health specialists who assist survivors in the wake of disaster suggest that the following steps help to reduce stress symptoms and to promote postdisaster readjustment.*

Protect: Find a safe haven that provides shelter; food and liquids; sanitation; privacy; and chances to sit quietly, relax, and sleep at least briefly.

Direct: Begin setting and working on immediate personal and family priorities to enable you and your significant others to preserve or regain a sense of hope, purpose, and self-esteem.

Connect: Maintain or reestablish communication with family, peers, and counselors in order to talk about your experiences. Take advantage of opportunities to "tell your story" and to be a listener to others as they tell theirs, so that you and they can release the stress a little bit at a time.

Select: Identify key resources, such as FEMA (Federal Emergency Management Agency), the Red Cross, the Salvation Army, or the local and state health departments, for clean-up, health, housing, and basic emergency assistance.

Taking each day one at a time is essential in disaster's wake. Each day is a new opportunity to FILL-UP:

• Focus Inwardly on what's most important to you and your family today;
• Look and Listen to learn what you and your significant others are experiencing, so you'll remember what is important and let go of what's not;
• Understand Personally what these experiences mean to you, so that you will feel able to go on with your life and even grow personally.

* The construct "Protect, Direct, Connect, Select" was developed by Diane Myers, unpublished manuscript.

Source: National Center for PTSD Fact Sheet
by Bruce H. Young, LCSW, Julian D. Ford, PhD, and Patricia J. Watson, PhD

Reviewed by athealth on February 8, 2014.

The short-term symptoms of emotional damage on a child are usually obvious. The child, caught in a conflict between warring parents, and not wishing to offend either one, daily walks a tightrope between them. Over time, children of high-conflict divorce learn what pleases each parent and conduct themselves accordingly. They say what each parent wants to hear, and it is not unusual for the child to join in criticism of whichever parent is not present at the time. It is common for such children to tell each parent that they want to live with that parent. All of the child's energy goes into surviving in the battle between the parents. Is it any wonder that teachers soon report an attention deficit and that school grades fall? Is it any surprise that the child shows great suppressed anger and starts to act aggressively toward playmates? Can you blame a child for being angry at being put in an impossible position by people over whom the child has no control?

The long-term emotional damage to children as a result of the improper conduct of their parents during a divorce inhibits their ability to lead happy and productive lives within the society. The alienated child will have a skewed view of adults and of the gender of the parent who is the victim of the alienation. The abandoned child will find it hard to fully trust as an adult, especially those who should be very close and deeply loved. Indeed some abandoned children may spend their early adult years in the unhealthy search for a mate who will serve in the role of the parent who has abandoned the child. The child who witnesses abuse, physical or verbal, is far more likely to so abuse family members later in life.

Children who walk a tightrope, telling each parent what that parent wants to hear, over time lose touch with their own true feelings and needs. They have lost part of their grasp on reality. Such a loss can produce serious emotional disorders that may - without serious therapeutic interventions - last a lifetime. At the least, it is likely that these children will find it difficult to establish a lifelong love relationship.

Adapted from The Child Custody Book: How to Protect Your Children and Win Your Case, by Judge James W. Stewart. Available at online and local bookstores or directly from Impact Publishers, Inc., PO Box 6016, Atascadero, CA 93423-6016, http://www.bibliotherapy.com/ or phone 1-800-246-7228.

Reviewed by athealth on February 8, 2014.

At least 54 million Americans over age 20 have prediabetes. Before people develop type 2 diabetes, they usually have "prediabetes." That means their blood glucose levels are higher than normal, but not yet high enough to be called diabetes. People with prediabetes are more likely to develop diabetes within 10 years, and they are more likely to have a heart attack or stroke. The good news is there is now scientific proof that they can delay or prevent the disease and its devastating complications.

The key to diabetes prevention is taking small steps toward living a healthier life, according to the National Diabetes Education Program (NDEP), a program of the U.S. Department of Health and Human Services. Everyone can benefit from the rewards of avoiding diabetes and its serious complications such as heart attack, stroke, blindness, kidney failure, or losing a foot or leg.

The Diabetes Prevention Program's Clinical Trial, a landmark study sponsored by the National Institutes of Health, showed that people with pre-diabetes lowered their risk of developing diabetes by more than half by getting 30 minutes of physical activity five days a week and losing five to seven percent of their body weight.

If you are over 45 and over-weight, you are at increased risk for pre-diabetes. Here are five small steps you can take today to live a healthier life and prevent or delay diabetes:

• Find out if you are at risk: The first step is to find out if you are at risk for diabetes or if you have pre-diabetes. Talk to your health care provider at your next visit.
• Set realistic goals: You don't have to knock yourself out to delay or prevent diabetes. Start by making small changes. For example, try to get 15 minutes of physical activity a day this week. Each week add five minutes until you build up to the recommended 30 minutes a day, most days.
• Make better food choices: Try to eat more fruits and vegetables (five to nine servings a day), beans, and grains. Reduce the amount of fat in your diet. Choose grilled or baked foods instead of fried.
• Record your progress: Write down everything you eat and drink. Keeping a food diary is one of the most effective ways to lose weight and keep it off. Review this diary with your health care provider.
• Keep at it: Making even modest lifestyle changes can be tough in the beginning. Try adding one new healthy change a week. Always get back on track, even if you fall off a few times. The key is just to keep at it.

National Diabetes Education Program - 2006

Reviewed by athealth on February 8, 2014.

When you take care of your body, you likely strive to eat right, stay active, and take care to look your best. Your mental health needs similar care. In fact, to be healthy overall, you need to take care of both your body and mind - the two are closely connected. If you neglect caring for one, the other will suffer. These ideas will help you to care for both mind and body:

• Build self-esteem. Good self-esteem is linked to mental well-being, happiness, and success in many areas of life.It protects mental health during tough times. One way to build self- esteem is to value who you are and what you do. This is hard to do if you judge yourself by other people's standards or rely on others to make you feel good about yourself. Instead, accept the qualities - both strengths and weaknesses - that make you unique.
• Set realistic standards and goals. Take pride in your achievements, both small and big. Positive thinking also boosts self-esteem. This comes naturally to some people. But it's a skill you can learn, too. Many people are lifted up by their spirituality. It can shape beliefs and values and be a source of comfort in hard times. It can be good to tune out the outside world and connect with the spirit within you.
• Find value and purpose in life. People who pursue goals based on their own values and dreams enjoy stronger mental well-being. Think about your values and dreams. What makes you happy? What do you care deeply about? What are you good at? If you could change one thing in the world,what would it be? What do you dream about? How do you want your friends and family to remember you? Use your answers to set short-term and long-terms goals for yourself. Keep your goals realistic. Review them every once in a while, and make changes as your values and priorities change.

DO I HAVE A PROBLEM WITH ALCOHOL? Many women drink alcohol to cope with stress. But some women drink too much. Alcohol abuse and addiction cause stress in a job and family. Answer these questions to help find out if you might have a problem: Have you ever felt you should cut down on your drinking? Have people criticized your drinking? Have you ever felt bad or guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? Talk with your doctor about your drinking if you answered "yes" to one or more questions. Even if you answered "no" to all the questions, talk to your doctor if drinking is causing you problems with your job, relationships, health, work, or the law.

• Learn healthy ways to cope with hard times. How do you react to stress,change, or hardship? Do you see setbacks as failures or merely bumps in the road? Do you avoid problems or look for solutions? Do you obsess about issues without taking action to resolve them? If your style needs improving, take heart: Positive coping styles and traits can be learned with some effort. If you have trouble improving thinking patterns on your own, a mental health professional can help. You might also benefit from life-skills classes. For example, parenting classes can prepare new mothers for what to expect. Being informed helps people to understand, control, and deal with situations that are new and stressful.
• Build healthy relationships. We need healthy relationships to grow, thrive,and sustain us in hard times. They also protect from loneliness and isolation, which can lead to depression.Surround yourself with people who encourage and support you. You might draw strength from your ethnic or cultural community. Relationships thatcause you to feel neglected, shameful, disrespected, or afraid are not healthy. Keep in mind that just as you need people, you are needed by others.Reach out and connect.

Source: Adapted from The Healthy Woman: A Complete Guide for All Ages
U.S. Department of Health and Human Services, Office on Women's Health
2008

Reviewed by athealth on February 8, 2014.

For many parents, bringing up the subject of alcohol is no easy matter. Your young teen may try to dodge the discussion, and you yourself may feel unsure about how to proceed. To make the most of your conversation, take some time to think about the issues you want to discuss before you talk with your child. Consider too how your child might react and ways you might respond to your youngster's questions and feelings. Then choose a time to talk when both you and your child have some "down time" and are feeling relaxed.

You don't need to cover everything at once. In fact, you're likely to have a greater impact on your child's decisions about drinking by having a number of talks about alcohol use throughout his or her adolescence. Think of this talk with your child as the first part of an ongoing conversation.

And remember, do make it a conversation, not a lecture! You might begin by finding out what your child thinks about alcohol and drinking.

Your Child's Views about Alcohol

Ask your young teen what he or she knows about alcohol and what he or she thinks about teen drinking. Ask your child why he or she thinks kids drink. Listen carefully without interrupting. Not only will this approach help your child to feel heard and respected, but it can serve as a natural "lead-in" to discussing alcohol topics.

Important Facts about Alcohol

Although many kids believe that they already know everything about alcohol, myths and misinformation abound. Here are some important facts to share:

• Alcohol is a powerful drug that slows down the body and mind. It impairs coordination; slows reaction time; and impairs vision, clear thinking, and judgment.
• Beer and wine are not "safer" than hard liquor. A 12-ounce can of beer, a 5-ounce glass of wine, and 1.5 ounces of hard liquor all contain the same amount of alcohol and have the same effects on the body and mind.
• On average, it takes 2 to 3 hours for a single drink to leave a person's system. Nothing can speed up this process, including drinking coffee, taking a cold shower, or "walking it off."
• People tend to be very bad at judging how seriously alcohol has affected them. That means many individuals who drive after drinking think they can control a car-but actually cannot.
• Anyone can develop a serious alcohol problem, including a teenager.

Good Reasons Not to Drink

In talking with your child about reasons to avoid alcohol, stay away from scare tactics. Most young teens are aware that many people drink without problems, so it is important to discuss the consequences of alcohol use without overstating the case.

Some good reasons why teens should not drink:

• You want your child to avoid alcohol. Clearly state your own expectations about your child's drinking. Your values and attitudes count with your child, even though he or she may not always show it.
• To maintain self-respect. Teens say the best way to persuade them to avoid alcohol is to appeal to their self-respect- let them know that they are too smart and have too much going for them to need the crutch of alcohol. Teens also are likely to pay attention to examples of how alcohol might lead to embarrassing situations or events-things that might damage their self-respect or alter important relationships.
• Drinking is illegal. Because alcohol use under the age of 21 is illegal, getting caught may mean trouble with the authorities. Even if getting caught doesn't lead to police action, the parents of your child's friends may no longer permit them to associate with your child.
• Drinking can be dangerous. One of the leading causes of teen deaths is motor vehicle crashes involving alcohol. Drinking also makes a young person more vulnerable to sexual assault and unprotected sex. And while your teen may believe he or she wouldn't engage in hazardous activities after drinking, point out that because alcohol impairs judgment, a drinker is very likely to think such activities won't be dangerous.
• You have a family history of alcoholism. If one or more members of your family has suffered from alcoholism, your child may be somewhat more vulnerable to developing a drinking problem.
• Alcohol affects young people differently than adults. Drinking while the brain is still maturing may lead to long-lasting intellectual effects and may even increase the likelihood of developing alcohol dependence later in life.

The "Magic Potion" Myth

The media's glamorous portrayal of alcohol encourages many teens to believe that drinking will make them "cool," popular, attractive, and happy. Research shows that teens who expect such positive effects are more likely to drink at early ages. However, you can help to combat these dangerous myths by watching TV shows and movies with your child and discussing how alcohol is portrayed in them. For example, television advertisements for beer often show young people having an uproariously good time, as though drinking always puts people in a terrific mood. Watching such a commercial with your child can be an opportunity to discuss the many ways that alcohol can affect people-in some cases bringing on feelings of sadness or anger rather than carefree high spirits.

How to Handle Peer Pressure.

It's not enough to tell your young teen that he or she should avoid alcohol-you also need to help your child figure out how. What can your daughter say when she goes to a party and a friend offers her a beer? (See "Help Your Child Say No.") Or what should your son do if he finds himself in a home where kids are passing around a bottle of wine and parents are nowhere in sight? What should their response be if they are offered a ride home with an older friend who has been drinking? Brainstorm with your teen for ways that he or she might handle these and other difficult situations, and make clear how you are willing to support your child. An example: "If you find yourself at a home where kids are drinking, call me and I'll pick you up-and there will be no scolding or punishment." The more prepared your child is, the better able he or she will be to handle high-pressure situations that involve drinking.

Mom, Dad, Did You Drink When You Were a Kid?

This is the question many parents dread-yet it is highly likely to come up in any family discussion of alcohol. The reality is that many parents did drink before they were old enough to legally do so. So how can one be honest with a child without sounding like a hypocrite who advises, "Do as I say, not as I did"?

This is a judgment call. If you believe that your drinking or drug use history should not be part of the discussion, you can simply tell your child that you choose not to share it. Another approach is to admit that you did do some drinking as a teenager, but that it was a mistake-and give your teen an example of an embarrassing or painful moment that occurred because of your drinking. This approach may help your child better understand that youthful alcohol use does have negative consequences.

Adapted from Make a Difference: Talk to Your Child about Alcohol
National Institute on Alcohol Abuse and Alcoholism
NIH Publication No. 06-4314
Revised 2006

Reviewed by athealth on February 8, 2014.

Technology and youth seem destined for each other. They are both young, fast paced, and ever changing. In the last 20 years there has been an explosion in new technology. This new technology has been eagerly embraced by young people and has led to expanding knowledge, social networks, and vocabulary that includes instant messaging ("IMing"), blogging, and text messaging.

Electronic aggression is any type of harassment or bullying that occurs through e-mail, a chat room, instant messaging, a website (including blogs), or text messaging.

New technology has many potential benefits for youth. With the help of new technology, young people can interact with others across the United States and throughout the world on a regular basis. Social networking sites like Facebook and MySpace also allow youth to develop new relationships with others, some of whom they have never even met in person. New technology also provides opportunities to make rewarding social connections for those youth who have difficulty developing friendships in traditional social settings or because of limited contact with same-aged peers. In addition, regular Internet access allows teens and pre-teens to quickly increase their knowledge on a wide variety of topics.

However, the recent explosion in technology does not come without possible risks. Youth can use electronic media to embarrass, harass, or threaten their peers. Increasing numbers of adolescents are becoming victims of this new form of violence - electronic aggression. Research suggests that 9% to 35% of young people report being victims of this type of violence. Like traditional forms of youth violence, electronic aggression is associated with emotional distress and conduct problems at school.

Examples of Electronic Aggression

• Disclosing someone else's personal information in a public area (e.g., website) in order to cause embarrassment.
• Posting rumors or lies about someone in a public area (e.g., discussion board).
• Distributing embarrassing pictures of someone by posting them in a public area (e.g., website) or sending them via e-mail.
• Assuming another person's electronic identity to post or send messages about others with the intent of causing the other person harm.
• Sending mean, embarrassing, or threatening text messages, instant messages, or e-mails.

Sidebar:There appears to be a link between ADHD and bullying. A 2008 study conducted in Sweden, showed that children with ADHD are four times more likely than their peers to bully other children, and they are almost ten times as likely than other children to be bullied.

Talk to your child

Parents and caregivers often ask children where they are going and who they are going with when they leave the house. You should ask these same questions when your child goes on the Internet. Because children are reluctant to disclose victimization for fear of having their Internet and cellular phone privileges revoked; develop solutions to prevent or address victimization that do not punish the child.

Develop rules

Together with your child, develop rules about acceptable and safe behaviors for all electronic media. Make plans for what they should do if they become a victim of electronic aggression or know someone who is being victimized. The rules should focus on ways to maximize the benefits of technology and decrease its risks.

Explore the Internet

Visit the websites your child frequents, and assess the pros and cons. Remember, most websites and on-line activities are beneficial. They help young people learn new information, interact with others, and connect with people who have similar interests.

Talk with other parents and caregivers

Talk to other parents and caregivers about how they have discussed technology use with their children. Ask about the rules they have developed and how they stay informed about their child's technology use.

Connect with the school

Parents and caregivers are encouraged to work with their child's school and school district to develop a class for parents and caregivers that educates them about school policies on electronic aggression, recent incidents in the community involving electronic aggression, and resources available to parents and caregivers who have concerns. Work with the school and other partners to develop a collaborative approach to preventing electronic aggression.

Educate yourself

Stay informed about the new devices and websites your child is using. Technology changes rapidly, and many developers offer information to keep people aware of advances. Continually talk with your child about "where they are going" and explore the technology yourself.

Technology is not going away, and forbidding young people to access electronic media may not be a good long-term solution. Together, parents and children can come up with ways to maximize the benefits of technology and decrease its risks.

Centers for Disease Control and Prevention 2008

Reviewed by athealth on February 8, 2014.