Update in psychiatric thinking & CFS - issues

A)  Update on the view of psychiatry on chronic fatigue syndrome.

Having just returned from the 2005 Royal Australian and New Zealand College of Psychiatry Congress held in Sydney, I am dismayed to report that the view of the psychiatrists at very high academic and political levels does not seem to have changed much over the years.  I have attended many of these large conferences since graduating as a psychiatrist.  Year after year I have attended lectures in which chronic fatigue syndrome has been called anything from "masked depression" to my personal favourite, "20th century hysteria". 

I had hoped that with all the current research and knowledge being disseminated that a more balanced and informed approach to the topic this year might be presented.  One particular lecture on "fatigue states" was frustratingly inaccurate. 

In this lecture, presented by an academic psychiatrist, the term "fatigue states, chronic fatigue and neuropsychiatric disorders", were used, seemingly interchangeably.  The term “neuropsychiatric disorders” has not been validated internationally but seems to be creeping into a lot of the Australasian literature.  He spoke about "the effective integration of neurosciences, neurology, psychiatry and psychology" and he spoke about "the potential for psychiatry to be embedded in medicine".  "Chronic fatigue" was described as a culture bound syndrome which is becoming international.  He then spoke about cross cultural studies of "somatic syndromes", stating that these disorders seem to be most common in Sydney and Manchester (U.K.).

One of his slides which had the heading 'Chronic fatigue/neurasthenia' defined this condition as having the following symptoms: physical and mental fatigue, musculoskeletal pain, headaches, neurocognitive symptoms and irritability. (These are not the diagnostic criteria used in any diagnostic system for chronic fatigue syndrome as they stand.) 

The next slide then tried to show the prevalence of these conditions, but not comparing apples with apples he showed a WHO primary care study in which the prevalence of "neurasthenia" was shown to be 5.4%.  An Indian study in the British Medical Journal in 2005 by Patel showed a 12.1% prevalence in women.  In the USA using CDC criteria for "chronic fatigue", (with an interesting footnote on the slide that there was "limited input from psychiatry"), there was a prevalence of 0.5 to 2.5%. 

He did state towards the end of his talk that the selective serotonin reuptake inhibitor class of drugs have not proven to be helpful in these conditions but did summarise the cognitive behaviour therapy trials of which there are more than 13.  He stated that the outcome of these has shown CBT to be "highly effective". 

B)  Depression and chronic fatigue syndrome. 

As the symptoms of depression and chronic fatigue syndrome have a significant degree of overlap there has been a long-term confusion about the separation of these two conditions as well as how to deal with coexisting illness.

It is important to note that depression is a major medical illness.  The prevalence of major depressive disorder over a lifetime has been estimated at 16.2% and over a twelve-month period as 6.6% in the USA.  By the year 2020 it is estimated that major depression will be the second most major cause of disability world wide under ischaemic heart disease.  Importantly, somatised depression can encompass virtually all symptoms of CFS.  Once depression has been treated it has been shown that of those patients with residual symptoms, 94% have physical symptoms.  The following physical symptoms are most commonly found in depression:  tiredness/lack of energy 85% (healthy - 40%), headache or head pains 64% (healthY - 48%), dizzy or faint 60% (healthy - 14%), partS of the body feel weak 57% (healthy - 23%), muscle pains/aches/rheumatism 53% (healthy 27%), stomach pains 51% (healthy - 20%) and chest pains 46% (healthy - 14%).  Depressed patients often present with numerous physical complaints.  As the number of physical complaints increases so does the likelihood of a mood disorder.  Thirty percent of patients with depression experience physical symptoms for more than five years before a proper diagnosis.  Chronic painful physical conditions are also highly correlated with major depression. 

In a study by Demitrak 63% of their chronic fatigue syndrome sample fulfill the criteria for major depressive disorder (mostly atypical), however, only 14% of DSM atypical depressives met the full CDC criteria for chronic fatigue syndrome. 

The following eight points I believe are important in sorting out the overlap and confusion between chronic fatigue syndrome and depression:

1. In chronic fatigue syndrome one of the difficulties has been the emphasis on fatigue as a primary symptom.  Fatigue is such a a common symptom seen in multiple medical and psychiatric illnesses that I believe it is unhelpful, particularly in the cross over between chronic fatigue syndrome and depression.  It is more useful to think of the fatigue as secondary to other symptoms such as chronic inflammation rather than primary. 
2. It is important to emphasise epidemics of chronic fatigue syndrome.  This is obviously not seen with depression.  There have been about 30 or so epidemics noted between 1934 and 1977. 
3. Noting the temporal order of psychiatric and physical symptoms is important.  Depression in chronic fatigue syndrome is more often than not secondary and is seen somewhat down the track of the illness. 
4. There are some differences in the somatic symptoms seen in the two conditions.  In chronic fatigue syndrome the relationship of fatigue to activity is highly important.  It is also important that activity worsens other symptoms such as sore throats, muscle pains, etc. 
5. Although the somatic symptoms are similar, the cognitive symptoms are where you see the greatest degree of difference.  In chronic fatigue syndrome you see less low self-esteem, less suicidal ideation, less hopelessness, less guilt, and less anhedonia (loss of pleasure).  In depression the loss of pleasure is both in the anticipation of the act and after its fulfillment whereas in chronic fatigue syndrome it is more a frustration at not being able to have the energy to do activities.  It is also important to note that in depression there is often a diurnal variation in the mood with the mood being worse in the morning. 
6. It is important to focus on the early versus the late symptoms.  In chronic fatigue syndrome there are often symptoms of toxicity including night sweats, sore throat and low-grade fevers.  These may disappear as the illness becomes chronic and therefore increasing the level of confusion between chronic fatigue syndrome and depression. 
7. It is important to focus on the variability of symptoms, both within and between episodes.  This huge degree of variation is the hallmark of chronic fatigue syndrome and is not seen in depression. 
8. It is important to focus on the biological knowledge that we do have that separates the two conditions.  For example, in chronic fatigue syndrome there is a high degree of association with neurally-mediated hypotension.  Significant also are the differences in the HPA axis.  In depression you see an increase in corticotropin-releasing hormone (CRH) which leads to an increase in adrenocorticotropic hormone (ACTH) which leads to an increase in cortisol and failure of suppression with dexamethasone.  In chronic fatigue syndrome you see a low CRH, a low cortisol and no abnormality in dexamethasone suppression. 

I feel it may be useful when looking at diagnostic criteria to include subtypes which are positive or negative for depression.  Including subtypes with a known postinfectious onset will also help differentiate from depression.  Also, keeping in mind the stages of the illness such as initial stage (0 - 6 months), recuperation stage, early chronic and late chronic, may also help differentiate chronic fatigue syndrome from depression. 

In summary, I can only reiterate that sadly, although psychiatry has a huge role to play in managing people with chronic fatigue syndrome, until my profession clearly takesm an interest in the current research they will at large not have the competence to deal successfully with this group of patients.

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