2 therapies lift mood in chronic fatigue syndrome

• immunoglobulins or hydrocortisone
  
• most psychotropics—including all classes of antidepressants.
  

CBT and graded exercise protocols have been used successfully in adult^12,13 and adolescent¹⁴ CFS patients. Treatment is done in two steps:

• Patients learn about their illness, develop a realistic assessment of their limitations, and come to understand that physical activity will not harm them.
  
• Patients begin graded exercises designed to slowly extend their exercise tolerance and widen their range of daily activities.
  

Compared with controls, adult and adolescent CFS patients’ fatigue and overall functioning improved significantly, and the adolescents’ school attendance improved.

Trained psychologists usually do this work, and your role is to be aware of the key part this approach plays in managing CFS patients and to set up appropriate referrals.

Case continued: Relief and acceptance

Mr. A continues to see you and a therapist for treatment of mild depression and severe anxiety. His behavioral therapy focuses on helping him cope with how his illness limits his relationship to work and family. His therapist also explores with him the personal meanings of his new situation, his feelings about issues such as dependence, and limitations imposed on his life goals.

You start a trial of fluoxetine (up to 40 mg/d for several months) with minimal benefit. You then try nortriptyline, 25 mg nightly, and clonazepam, 0.5 mg bid. Although these drugs can be sedating, Mr. A reports feeling no more fatigued than he was before taking them. He improves slightly after 7 months but not enough that he wants to continue the medication.

Medications. Neither psychiatric nor other medication classes have shown efficacy in treating CFS core symptoms.¹⁵ One recent study¹⁶ found citalopram helped reduce chronic fatigue, but the study was small and uncontrolled. Although the subjects had chronic fatigue, not all met the formal definition of CFS for study inclusion.

Medication does play an important role in treating comorbid anxiety and depression. Usual psychopharmacologic strategies are appropriate. As in Mr. A’s case, most psychiatrists use SSRIs as first-line medications, but side effects are probably the most useful guide to medication choice.

Case continued: Additional treatment

Because medication has had little effect on Mr. A’s anxiety and depressed mood, you suggest adding a graded exercise program to his treatment plan. He improves steadily over time and says he is pleased. Although progress is slow, he finds it reassuring to be accomplishing realistic goals. He realizes that you and the therapist do not have the answer to his illness, but he trusts you and is comforted that you accept his condition and are willing to listen and help.

Related resources

• Afari N, Buchwald D. Chronic fatigue syndrome: a review. Am J Psychiatry 2003;160:221-36.
  
• Reid S, Chalder T, Cleare A, et al. Chronic fatigue syndrome. Clin Evid 2004;12:1578-93.
  
• Centers for Disease Control and Prevention. Chronic fatigue syndrome. https://www.cdc.gov/ncidod/diseases/cfs/.
  
• International Association for Chronic Fatigue Syndrome. https://www.aacfs.org.
  

Drug brand names

• Citalopram • Celexa, others
  
• Clonazepam • Lorazepam, others
  
• Fluoxetine • Prozac
  
• Nortriptyline • Aventyl, others
  

Disclosure

The authors report no financial relationship with any company whos products are mentioned in this article or with manufacturers of competing products.