Screening for prolonged fatigue syndromes: validation of the SOFA scale

BACKGROUND

The identification of syndromes characterised by persistent and disabling mental and/or physical fatigue is of renewed interest in psychiatric epidemiology. This report details the development of two specific instruments: the SOFA/CFS for identification of patients with chronic fatigue syndrome (CFS) in specialist clinics and the SOFA/GP for identification of prolonged fatigue syndromes (PFS) in community and primary care settings.

METHODS

Patients with clinical diagnoses of CFS (n = 770) and consecutive attenders at primary care (n = 1593) completed various self-report questionnaires to assess severity of current fatigue-related symptoms and other common somatic and psychological symptoms. Quality receiver operating characteristic curves were used to derive appropriate cut-off scores for each of the instruments. Comparisons with other self-report measures of anxiety, depression and somatic distress are noted. Various multivariate statistical modelling techniques [latent class analysis (LCA), longitudinal LCA] were utilised to define the key features of PFS and describe its longitudinal characteristics.

RESULTS

The SOFA/CFS instrument performs well in specialist samples likely to contain a high proportion of patients with CFS disorders. Cut-off scores of either 1/2 or 2/3 can be used, depending on whether the investigators wish to preferentially emphasise false-negatives or false-positives. Patients from these settings can be thought of as consisting not only of those with a large number of unexplained medical symptoms, but also those with rather specific musculoskeletal and pain syndromes. The SOFA/GP instrument has potential cut-off scores of 1/2 or 2/3, with the latter preferred as it actively excludes all non-PFS cases (sensitivity = 81%, specificity = 100%). Patients with these syndromes in the community represent broader sets of underlying classes, with the emergence of not only musculoskeletal and multisymptomatic disorders, but also persons characterised by significant cognitive subjective impairment. Twelve-month longitudinal analyses of the primary care sample indicated that the underlying class structure was preserved over time. Comparisons with other measures of psychopathology indicated the relative independence of these constructs from conventional notions of anxiety and depression.

CONCLUSIONS

The SOFA/GP instrument (which is considerably modified from the SOFA/CFS in terms of anchor points for severity and chronicity) is preferred for screening in primary care and community settings. Patients with PFS and CFS present a range of psychopathology that differs in its underlying structure, cross-sectionally and longitudinally, from coventional notions of anxiety and depression.

A randomized, double-blind placebo-controlled trial of moclobemide in patients with chronic fatigue syndrome

BACKGROUND

Chronic fatigue syndrome is characterized by prolonged and disabling fatigue and a range of neuropsychiatric symptoms including depressed and/or irritable mood. To date, no medical or psychotropic therapies have provided clear symptomatic benefit.

METHOD

Ninety patients with chronic fatigue syndrome, diagnosed with our system that approximates CDC criteria, participated in a randomized, placebo-controlled, double-blind trial of 450 to 600 mg/day of moclobemide, a novel reversible inhibitor of monoamine oxidase-A.

RESULTS

Fifty-one percent (24/47) of patients receiving moclobemide improved compared with 33% (14/43) of patients receiving placebo (odds ratio = 2.16, 95% confidence interval [CI] = 0.9 to 5.1). Drug response was best characterized symptomatically by an increase in the subjective sense of vigor and energy rather than a reduction in depressed mood. The effect of moclobemide on subjective energy was detectable within the first 2 weeks of treatment and increased across the course of the study. The greatest reduction in clinician-rated disability was in patients with concurrent immunologic dysfunction (mean difference in standardized units of improvement = 0.8, 95% CI = 0.03 to 1.6).

CONCLUSION

Moclobemide produces some improvement in key symptoms experienced by patients with chronic fatigue syndrome. This effect is not dependent on the presence of concurrent psychological distress and is likely to be shared with other monoamine oxidase inhibitors.

The genetic aetiology of somatic distress

BACKGROUND

Somatoform disorders such as neurasthenia and chronic fatigue syndrome are characterized by a combination of prolonged mental and physical fatigue. This study aimed to investigate the heritability of somatic distress and determine whether this dimension is aetiologically distinct from measures of depression and anxiety.

METHOD

Measures of anxiety, depression, phobic anxiety, somatic distress and sleep difficulty were administered in a self-report questionnaire to a community-based sample of 3469 Australian twin individuals aged 18 to 28 years. Factor analysis using a Promax rotation, produced four factors: depression, phobic anxiety, somatic distress and sleep disturbance. Multivariate and univariate genetic analyses of the raw categorical data scores for depression, phobic anxiety and depression were then analysed in Mx1.47.

RESULTS

Univariate genetic analysis revealed that an additive genetic and non-shared environmental (AE) model best explained individual differences in depression and phobic anxiety scores, for male and female twins alike, but could not resolve whether additive genes or shared environment were responsible for significant familial aggregation in somatic distress. However, multivariate genetic analysis showed that an additive genetic and non-shared environment (AE) model best explained the covariation between the three factors. Furthermore, 33 % of the genetic variance in somatic distress was due to specific gene action unrelated to depression or phobic anxiety. In addition, 74% of the individual environmental influence on somatic distress was also unrelated to depression or phobic anxiety.

CONCLUSION

These results support previous findings that somatic symptoms are relatively aetiologically distinct both genetically and environmentally from symptoms of anxiety and depression.

An approach to managing depression in general practice

Detection of depression in primary care can be enhanced by use of self-report assessment forms. With the new classes of antidepressants, there is the opportunity to choose specific drug classes for different types of depressive disorders. Depression is frequently a relapsing illness. Treatment goals should include long term reduction of vulnerability factors. An active therapeutic partnership can be facilitated by providing accurate detailed information early in the course of the illness. Behavioural therapies, which focus on modification of the sleep-wake cycle, activity planning and reduction of substance abuse, are essential. Structured problem solving is the most accessible form of cognitive intervention that general practitioners can readily provide. More complex cognitive therapies are usually provided by mental health professionals or general practitioners with extensive training.

Are antidepressants all the same? Surveying the opinions of Australian psychiatrists

OBJECTIVE

Controlled trials do not suggest differences in efficacy between antidepressant compounds. Psychiatrists, however, frequently express the view that real differences do exist and are relevant to clinical practice. Since multiple comparative trials are not feasible, an alternative method for expanding the evidence base is to survey regularly the opinions of practising psychiatrists.

METHOD

Two surveys of psychiatrists' opinions were conducted. Participants in the first survey were drawn from contact with 'SPHERE: A National Depression Project', while those in the second survey responded to a brief questionnaire distributed with Australasian Psychiatry.

RESULTS

Reported volumes of scripts written, ratings of efficacy and tolerability, and preferences in specific clinical situations indicate that clinical psychiatrists now strongly prefer the newer antidepressant agents. They rate serotonin and noradrenalin re-uptake inhibitors (SNRIs) and selective serotonin re-uptake inhibitors (SSRIs) highest for antidepressant efficacy, serotonin receptor subtype 2 (5HT2) antagonists and some SSRIs highest for anti-anxiety efficacy, and some SSRIs and reversible inhibitors of monoamine oxidase inhibitor-A (RIMAs) lowest for side-effect burden. Further, SSRIs were their first preferences for most clinical situations. Serotonin and noradrenalin re-uptake inhibitors were the preferred choice for treatment-resistant depression and patients who had failed to respond to one SSRI. Serotonin receptor subtype 2 antagonists were the second choice to SSRIs for mixed anxiety and depression, and major depression with sleep disturbance. Reversible inhibitors of monoamine oxidase inhibitor-A were the second choice to SSRIs for adolescents with major depression, patients aged over 65 years, patients with serious medical illnesses and patients with chronic fatigue. Tricyclic antidepressants (TCAs) were the preferred choice for patients with chronic pain, and second choice to SSRIs for patients with major depression with panic disorder, postnatal disorders and patients with psychotic depression.

CONCLUSION

Psychiatrists believe that important differences do exist between available antidepressant compounds. Such opinions are divergent from limited controlled data but may be influenced by a wide range of factors other than direct clinical experience. The role of such surveys in ongoing evaluation of clinical practice is emphasised.

Enhancing the evidence base for clinical psychiatry: are practice surveys a useful tool?

Clinical practice guidelines for psychiatry are now being developed, but important deficits in the evidence base are apparent. For many of the new treatments, clinical decisions can be idiosyncratic or based on limited knowledge. There is a need not only to perform properly constructed trials, but also to make immediate use of less rigorous forms of evidence, such as clinical practice surveys. An example is a recent survey of psychiatrists' use of antidepressant drugs. Such surveys are now part of a wider movement towards a more coordinated system of practice-based outcome assessment.

Fatigue as related to anxiety and depression in a community-based sample of twins aged over 50

Measures of fatigue, anxiety and depression were administered in self-report questionnaire format to a community-based sample of 2703 Australian twins aged over 50. Factor analysis indicated that a two-factor solution was appropriate and demonstrated a clear separation between fatigue-related items and questionnaire items relating to anxiety and depression. Highly congruent factor structures were derived for male and female subjects.

The relationship between fatigue, psychological and immunological variables in acute infectious illness

OBJECTIVE

The aim of this paper is to explore the longitudinal relationships between physical and psychological symptoms and immunological factors following acute infective illnesses.

METHOD

Preliminary data from a prospective investigation of patients with serologically proven acute infectious illnesses due to Epstein-Barr virus (EBV), Ross River virus (RRV) or Q fever are reported. Patients were assessed within 4 weeks of onset of symptoms and then reviewed 2 and 4 weeks later. Physical illness data were collected at interview. Psychological and somatic symptom profiles were assessed by standardised self-report questionnaires. Cell-mediated immune (CMI) function was assessed by measurement of delayed-type hypersensitivity (DTH) skin responses.

RESULTS

Thirty patients who had been assessed and followed over the 4-week period (including 17 patients with EBV, five with RRV and eight with Q fever) were included in this analysis. During the acute phase, profound fatigue and malaise were the most common symptoms. Classical depressive and anxiety symptoms were not prominent. Initially, 46% of cases had no DTH skin response (i.e. cutaneous anergy) indicative of impaired cellular immunity. Over the 4-week period, there was a marked improvement in both somatic and psychological symptoms, although fatigue remained a prominent feature in 63% of subjects. The reduction in reported fatigue was correlated with improvement in the DTH skin response (p = 0.001) and with improvement in General Health Questionnaire (GHQ) scores (p < 0.01).

CONCLUSIONS

Acute infectious illnesses are accompanied by a range of nonspecific somatic and psychological symptoms, particularly fatigue and malaise rather than anxiety and depression. Although improvement in several symptoms occurs rapidly, fatigue commonly remains a prominent complaint at 4 weeks. Resolution of fatigue is associated with improvement in cell-mediated immunity.

Increasing general practitioner skills with patients with serious mental illness

This report describes a clinical training program designed to increase general practitioner involvement with a public mental health service. The program involved one half-day clinical session per week and one two-hour formal training seminar per month, over a six-month period. Prior to training, participants demonstrated major clinical and theoretical skill deficits when assessing patients with serious mental illnesses. While specific knowledge of psychiatry increased by the end of the training program, little change in clinical interview skills was evident. Current initiatives to enhance general practitioner involvement in mental health care may be hampered if these skill deficits are not directly addressed in relevant shared care programs.

Fatigue in selected primary care settings: sociodemographic and psychiatric correlates

OBJECTIVES

To determine the prevalence and sociodemographic and psychiatric correlates of prolonged fatigue syndromes among patients in primary care.

DESIGN

Prospective questionnaire survey.

PATIENTS AND SETTING

Adults over 18 years attending three general practices in metropolitan Sydney and one on the Central Coast, north of Sydney.

RESULTS

Of 1593 patients, 25% had prolonged fatigue, while 37% had psychological disorder. Of the patients with fatigue, 70% had both fatigue and psychological disorder, while 30% had fatigue only. The factors associated with prolonged fatigue were concurrent psychological disorder, female gender, lower socioeconomic status and fewer total years of education. Patients with fatigue were more likely to have a current depressive disorder.

CONCLUSIONS

Prolonged fatigue/neurasthenia syndromes are common in Australian primary care settings, and are commonly associated with current depressive disorders. Such syndromes, however, do not fit readily into current international psychiatric classification systems.

Chronic fatigue syndrome: current perspectives on evaluation and management

OBJECTIVE

To describe clinical and laboratory guidelines for assessment and management of patients presenting with chronic fatigue syndrome (CFS).

DATA SOURCES

Relevant international consensus diagnostic criteria and research literature on the epidemiology, pathophysiology, concurrent medical and psychological disturbance and clinical management of CFS.

CONCLUSIONS

Medical and psychiatric morbidity should be carefully assessed and actively treated, while unnecessary laboratory investigations and extravagant treatment regimens should be avoided. No single infective agent has been demonstrated as the cause of CFS, and immunopathological hypotheses remain speculative. The aetiological role of psychological factors is debated, but they do predict prolonged illness. The rate of spontaneous recovery appears to be high. Effective clinical management requires a multidisciplinary approach, with consideration of the medical, psychological and social factors influencing recovery.

From nurture to network: examining links between perceptions of parenting received in childhood and social bonds in adulthood

OBJECTIVE

The authors' goal was to consider the extent to which key characteristics of their parents influence children's later socialization in terms of social networks and intimate relationships and thus to examine whether there is evidence of such continuity.

DATA COLLECTION

The authors reviewed the pertinent literature and then examined studies using a measure of key dimensions of the parenting received in childhood (the Parental Bonding Instrument) as well as measures of adult social networks.

FINDINGS

The literature review revealed evidence of links (more evident in women) between perceptions of having received uncaring parenting and deficiencies in diffuse social bonds, which could reflect a causal process, a general response bias, or methodological limitations. By contrast, studies using the Parental Bonding Instrument and a specific measure of adult intimate bonds failed to find links between perceptions of parenting received in childhood and the quality of current intimate relationships unless there was extreme deprivation of parental care; in that case, the current intimate relationship was more likely to be rated as uncaring.

CONCLUSIONS

These findings refine the view that early socialization experiences shape and dictate interpersonal relationships in adulthood. Any deficiencies in parent-child relationships, except, perhaps, gross parental deprivation, appear capable of modification by a range of experiences (particularly subsequent interpersonal relationships).

Unilateral or bilateral electroconvulsive therapy for depression? A survey of practice and attitudes in Australia and New Zealand

OBJECTIVE

We report the findings of the first survey of the practice of electroconvulsive therapy (ECT) for the treatment of depression in Australia and New Zealand. The major aim was to examine the frequency of use of unilateral and bilateral electrode placement, as bilateral ECT has been recently recommended as the treatment of choice by the Royal College of Psychiatrists (UK).

DESIGN

A questionnaire about details of ECT given in the second half of 1989 was forwarded to the medical superintendents of 130 psychiatric hospitals and units in Australia and New Zealand.

RESULTS

Reports were received from 96 psychiatric institutions representing a response rate of 74%. In these units, 915 patients were treated with ECT during the study period. In contrast to depressed patients in the United Kingdom or the United States, a majority of Australian and New Zealand patients given ECT were found to receive unilateral ECT (63%). There were marked regional differences in practice, with patients in New South Wales being more likely to receive unilateral ECT, and those in Queensland and New Zealand bilateral ECT. In the majority of units, bilateral ECT was not considered to be indicated in preference to unilateral ECT for either severe, suicidal or psychotic depression.

CONCLUSION

The discrepancies between regional practices probably reflect the current uncertainty regarding the balance between the relative efficacy and morbidity of these two forms of treatment. Until these central issues of relative efficacy and morbidity are clarified, it would be inappropriate for local professional bodies to recommend a preferred mode of ECT administration.