2 therapies lift mood in chronic fatigue syndrome

CFS and depression. Could CFS and depression be one and the same? Proponents of that position point out the similarity of symptoms, loss of function, and—in at least some cases—favorable response to antidepressants. Opponents cite other factors such as:

• presence of sore throat, lymphadenopathy, and post-exercise fatigue
  
• differences in sleep patterns
  
• frequent absence of psychiatric illness before fatigue onset
  
• evidence of hypocortisolism (also seen in patients with melancholic depression) in some CFS patients.
  

Notably, other forms of depression (atypical depression) may also be associated with hypocortisolism, suggesting common pathophysiologic features.⁷ Another possibility is that the depression and anxiety experienced by CFS patients are a response to a chronic debilitating condition, as is seen in other chronic illnesses.⁸

Primary Care Workup

Complaints of long-lasting, debilitating fatigue should alert the primary care physician to CFS. Like somatization disorder, CFS requires a physical workup, though as few as 2% of CFS patients are found to have an undiagnosed medical illness that explains the symptoms.⁹ The evaluation’s goal is not so much to find out what’s causing the fatigue as to reassure the patient that all avenues are considered before the diagnosis is made. When this is accomplished well, the patient is likely to accept psychiatric referral or treatment, if needed.

Two-part initial evaluation. If the initial physical exam and laboratory work find no biomedical cause for the patient’s chronic fatigue symptoms, we recommend a two-part primary care evaluation. This includes a focused discussion with the patient about CFS (Table 2).¹⁰ Goals of the first session are to:

• establish a relationship that will survive difficult times
  
• teach the patient to think of complex medical problems as having psychological and social consequences, if not causes.
  

During the second encounter, the primary care physician may begin to consider whether he or she will need help managing the patient’s psychiatric/psychological problems. Some physicians enjoy work of a psychological nature, whereas others prefer to refer to mental health professionals. Primary care treatment or referral to a psychiatrist, psychologist, or other psychotherapist depends on both the physician and the individual patient.

Primary care physicians usually request a psychiatric consultation to confirm or rule out psychiatric conditions that exclude a CFS diagnosis (melancholic depression, bipolar disorder, schizophrenia, anorexia nervosa or bulimia, and recent substance abuse). They also may refer in cases of other common disorders with poorly explained symptoms such as fibromyalgia and chemical sensitivity disorder.

Table 2

Two-part initial primary care evaluation of chronic fatigue

First session Focus on initial history Introduce concept of a biopsychosocial approach to problem Help patient understand that the disorder has no clear-cut cause, but its effects can be anticipated and addressed Ask patient to bring a relative or friend to next appointment and to keep notes on symptoms and functional difficulties to discuss at the second session Second session Refine the history Note recent events Establish more-complete picture of patient’s everyday life with help of relative’s or friend’s observations Focus on identifying comorbid psychiatric conditions and helping patient cope with chronic illness Consider referring patient to a mental health professional

Case continued: High anxiety

Mr. A describes how fatigue is affecting his work and home life. He is especially worried that he will not be attentive enough to catch accounting errors by his employees.

Interestingly, his anxiety remits but fatigue continues when he goes on vacation. He has no history of melancholic depression, bipolar disorder, psychosis, or substance abuse.

Psychiatric Assessment

The referring physician should provide a full account of the medical workup. This:

• assures you that possible medical causes of fatigue have been excluded
  
• provides information on psychiatric history and previous treatments
  
• delineates information on initial treatment efforts.
  

Like the primary care workup, your assessment is more for gathering relevant data than for its interpretation. You will follow well-defined diagnostic criteria in making sense of the information, but the quality of your data depends on the patient’s willingness to describe his or her symptoms.

Realize how defensive a patient may feel about being given a vague and disputed diagnosis such as CFS. Because the diagnosis depends somewhat on examining his or her volitional contribution to the symptoms,⁶ your listening skills are key to building the patient-physician relationship. Taking the patient’s suffering seriously is essential and may provide great relief.

When you confirm a CFS diagnosis, the next step is to identify any frequently occurring psychiatric comorbidities, such as nonmelancholic depression, anxiety, and somatoform disorders.

Psychiatric Treatment

CBT and exercise. Only CBT and graded exercise therapy yielded “promising results” in a systematic review of all CFS treatments studied in 44 controlled treatment trials.¹¹ By comparison, evidence is inconclusive or insufficient to support the use of: