The epidemiology of fatigue and depression: a French primary-care study

Development of the Ghent Multidimensional Somatic Complaints Scale

The present study aimed at developing a new scale that operationalizes a hierarchical model of somatic complaints. First, 63 items representing a wide range of symptoms and sensations were compiled from somatic complaints scales and emotion literature. These complaints were rated by Belgian students (n = 307) and Belgian adults (n = 603). Exploratory factor analyses identified a gastrointestinal, cardiorespiratory, pain, temperature regulation, and fatigue factor. Next, the number of complaints was reduced to 18. Second, the short scale, called the Ghent Multidimensional Somatic Complaints Scale (GMSC), was administered to Belgian students (n = 735), Belgian adults (n = 664), and Turkish adults (n = 222). Confirmatory factor analysis confirmed that a higher-order model with five first-order and one second-order factor fitted best. Regression analyses demonstrated that the first-order factors were differentially related to anxiety, depression, anger, age, and gender. In sum, the GMSC scale offers the possibility to assess individual differences in somatic complaints from a hierarchical perspective.

Chronic fatigue of the small enterprise workers participating in an occupational health checkup center in southern Taiwan

PURPOSE

There has been increasing interest in the occupational health of workers in small enterprises, especially in developing countries. This study examines the association between psychosocial job characteristics and fatigue, and attempts to identify risk factors for fatigue among workers of small enterprises in southern Taiwan.

METHODS

A structured questionnaire was administered to workers receiving regular health examinations between August 2005 and January 2006. The questionnaire collected demographic information and data on working conditions, personal health status and life styles. It also collected information on psychosocial job characteristics, fatigue and psychological distress using three instruments.

RESULTS

A total of 647 workers with mean age of 43.7 were completed. Probable fatigue was found in 34.6% of the sample. Fatigue was found by multiple logistic regressions to be associated with the lack of exercise, working in shifts, depression score and lack of social support at workplace.

CONCLUSIONS

This study found associations between life style, psychosocial job characteristics and fatigue. Because the high prevalence of probable fatigue was found in such small enterprises, the authors suggest that a short interview with some quick questionnaires in health checkup for these small enterprise workers are helpful to early detect psychosocial and fatigue problems.

Assessment of fatigue in adults with disabilities

Fatigue is prevalent and can produce major public health consequences. Assessment of fatigue by the PM&R physician begins with a careful history and physical examination, complemented by pertinent rating scales and laboratory studies. In adults with disabilities, a wide variety of etiologies may lead to fatigue. Educating and providing resources about fatigue to patients can help open the discussion about this highly debilitating symptom.

The Relationship Between Spectral Changes in Heart Rate Variability and Fatigue

Fatigue is a prevalent problem in the workplace and a common symptom of many diseases. However, its relationship with the autonomic nervous system, specifically with sympathetic arousal, needs clarification. The objective of this study was to determine the association between fatigue and heart rate variability (HRV). HRV is regarded as an indicator of the autonomic regulation activity of heart rate, specifically sympathetic and parasympathetic activity. Spectral changes in low-frequency (LF; 0.04–0.15 Hz) and high-frequency (HF; 0.15–0.4 Hz) components of HRV have been reported to be associated with distressing conditions such as hemorrhagic shock, acute myocardial infarction, elevated anxiety, and depressed mood. While HRV changes have been found in persons with chronic fatigue syndrome, its association with fatigue in healthy individuals still needs clarification. HRV was assessed in a total of 50 participants who were asked to perform a task until becoming fatigued. Low-frequency HRV activity increased, while indices of parasympathetic modulation such as RMSSD and pNN50 remained stable as participants experienced fatigue, suggesting that fatigue in healthy individuals may be associated with increased sympathetic arousal. In addition, employing multiple regression analyses, we could positively associate the change in LF/HF HRV ratio from baseline to fatigue with factors such as emotional stability, warmth and tension and negatively associate it with social boldness and self-reported levels of vigor.

Diagnostic and treatment challenges of chronic fatigue syndrome: role of immediate-release methylphenidate

Chronic fatigue syndrome (CFS) is a distinct entity belonging to the group of persistent fatigue that can be challenging to diagnose and to treat. It is characterized by a combination of prolonged fatigue, other nonspecific somatic manifestations and neuropsychological symptoms, including difficulties with concentration, short-term memory and thinking, as well as impaired attention and slowed processing speed. Neurostimulants increasing dopamine and norepinephrine activity, such as bupropion, dextroamphetamine and recently immediate-release methylphenidate have been advocated to improve neurocognitive deficits. The use of immediate-release methylphenidate in CFS has been shown in one small study. Using the positive results of this study and the well-known beneficial effects of the drug on a range of similar cognitive symptoms in attention-deficit/hyperactivity disorder, this perspective addresses CFS and other related disorders and provides a discussion on the potential promising role of methylphenidate in the therapeutic armamentarium of CFS.

Fatigue in osteoarthritis: a qualitative study

Background

Fatigue is recognized as a disabling symptom in many chronic conditions including rheumatic disorders such as rheumatoid arthritis (RA) and lupus. Fatigue in osteoarthritis (OA) is not routinely evaluated and has only been considered in a very limited number of studies. To date, these studies have focused primarily on patients with OA under rheumatological care, which represent the minority of people living with OA. The purpose of this study was to increase our understanding of the fatigue experience in community dwelling people with OA.

Methods

In 2004, 8 focus groups were conducted with 28 men and 18 women (mean age 72.3) with symptomatic hip or knee OA recruited from a population-based cohort. Participants completed a self-administered questionnaire, which included demographics, measures of OA severity (WOMAC), depression (CES-D) and fatigue (FACIT). Sessions were audio taped and transcribed verbatim. Two researchers independently reviewed the transcripts to identify themes. Findings were compared and consensus reached.

Results

Mean pain, disability, depression and fatigue scores were 8.7/20, 27.8/68, 15.4/60, and 30.9/52, respectively. Participants described their fatigue as exhaustion, being tired and "coming up against a brick wall". Participants generally perceived fatigue as different from sleepiness and distinguished physical from mental fatigue. Factors believed to increase fatigue included OA pain and pain medications, aging, various types of weather and poor sleep. Mental health was identified as both affecting fatigue and being affected by fatigue. Participants described fatigue as impacting physical function, and their ability to participate in social activities and to do household chores. Rest, exercise, and avoiding or getting assistance with activities were cited as ways of coping. Participants generally did not discuss their fatigue with anyone except their spouses.

Conclusion

Participants with OA described experiencing notable amounts of fatigue and indicated that it had a substantial impact on their lives. Further research is required to better understand the role of fatigue in OA in order to identify strategies to reduce its impact.

Twin analyses of fatigue

Prolonged fatigue equal to or greater than 1 month duration and chronic fatigue equal to or greater than 6 months duration are both commonly seen in clinical practice, yet little is known about the etiology or epidemiology of either symptom. Chronic fatigue syndrome (CFS), while rarer, presents similar challenges in determining cause and epidemiology. Twin studies can be useful in elucidating genetic and environmental influences on fatigue and CFS. The goal of this article was to use biometrical structural equation twin modeling to examine genetic and environmental influences on fatigue, and to investigate whether these influences varied by gender. A total of 1042 monozygotic (MZ) twin pairs and 828 dizygotic (DZ) twin pairs who had completed the University of Washington Twin Registry survey were assessed for three fatigue-related variables: prolonged fatigue, chronic fatigue, and CFS. Structural equation twin modeling was used to determine the relative contributions of additive genetic effects, shared environmental effects, and individual-specific environmental effects to the 3 fatigue conditions. In women, tetrachoric correlations were similar for MZ and DZ pairs for prolonged and chronic fatigue, but not for CFS. In men, however, the correlations for prolonged and chronic fatigue were higher in MZ pairs than in DZ pairs. About half the variance for both prolonged and chronic fatigue in males was due to genetic effects, and half due to individual-specific environmental effects. For females, most variance was due to individual environmental effects.

Fatigue after treatment for early stage breast cancer: a controlled comparison

BACKGROUND

Evidence suggests that fatigue may be a greater problem for cancer survivors than people without cancer. The present study sought to determine whether fatigue was greater in women who had completed treatment for early-stage breast cancer relative to a demographically matched comparison group of women with no cancer history.

METHODS

As part of a larger study, women with stage 0-II breast cancer were recruited before the start of chemotherapy and radiotherapy (n = 100) or radiotherapy only (n = 121). Fatigue was assessed at the end of treatment and 2, 4, and 6 months later. An age- and geographically matched sample of women with no history of cancer was recruited and assessed for comparison purposes.

RESULTS

Relative to comparison subjects, breast cancer survivors reported more days of fatigue in the past week at all 4 study assessments (P < .05). These differences appeared to be clinically meaningful in that a greater percentage of patients than nonpatients earned scores in the abnormal range on this measure at each assessment (P < .05). Additional analyses indicated that differences in fatigue between patients and comparison subjects were attributable primarily to heightened fatigue in women who received both chemotherapy and radiotherapy.

CONCLUSIONS

Findings suggest that fatigue is a greater problem for breast cancer survivors in the 6 months after completion of chemotherapy than for women with no cancer history. Future research should include longer-term follow-up to determine the persistence of fatigue in this population of survivors.

Physical activity and feelings of energy and fatigue: epidemiological evidence

Approximately 20% of adults worldwide report persistent fatigue. Physical activity is a healthful behaviour that has promise for combating feelings of fatigue and low energy. This article summarises the epidemiological literature that examined the association between physical activity and feelings of energy and fatigue. Twelve population-based studies conducted between January 1945 and February 2005 that concurrently measured physical activity and feelings of energy and fatigue were located. All of the studies suggested that there was an association between physical activity and a reduced risk of experiencing feelings of low energy and fatigue when active adults were compared with sedentary peers (odds ratio = 0.61; 95% CI 0.52, 0.72). The effect was heterogeneous and varied according to study design and the energy/fatigue measure used in the study. Because epidemiological comparisons cannot establish direction of causality, standard criteria for evaluating strength of evidence in epidemiological studies (i.e. strength of association, temporal sequence, consistency, dose response and biological plausibility) were used to judge whether the observed association between physical activity and feelings of energy and fatigue suggest causality in the absence of adequate experimental evidence. There was agreement among the studies suggesting a strong, consistent, temporally appropriate dose-response relationship between physical activity and feelings of energy and fatigue. No compelling evidence has confirmed any plausible biological mechanisms that explain the apparent protective effect of physical activity against feelings of low energy and fatigue. Nonetheless, the epidemiological evidence is sufficiently strong to justify better controlled prospective cohort studies and randomised controlled trials.

Assessment of fatigue in patients with ankylosing spondylitis

In this study, we evaluated fatigue by using the multidimensional assessment of fatigue (MAF) index in 68 ankylosing spondylitis (AS) patients. To determine the disease activity, functional status and quality of life, bath ankylosing spondylitis disease activity index (BASDAI), bath ankylosing spondylitis functional index (BASFI) and Short Form 36 (SF36) were used respectively. Mander enthesis index (MEI) was used for evaluation of enthesitis. The mean age of the patients was 37.7 (11.1) years. The prevalence of fatigue was 76.5%. There were significant correlations between MAF and BASDAI (P < 0.001), BASFI (P < 0.001), MEI (P = 0.048), pain (P = 0.001), hemoglobin (P = 0.001), ESR (P = 0.035), dorsal Schober's (P = 0.009), occiput-wall distance (P = 0.048). Also MAF was correlated with all dimensions of SF36 except for social function and emotional role. BASFI was found to be the most significant correlated (P = 0.002) parameter with MAF. This study suggests that fatigue is an important symptom in AS and it seemed to occur in severe AS patients. It should appropriately be measured with respect to its intensity with appropriate measures, such as MAF. Moreover, fatigue may increase functional disability, which is already present as a feature of the disease.

Fatigue in the U.S. Workforce: Prevalence and Implications for Lost Productive Work Time

OBJECTIVE

The objective of this study was to estimate fatigue prevalence and associated health-related lost productive time (LPT) in U.S. workers.

METHODS

Fatigue prevalence, LPT due to fatigue, and LPT for any health-related reason (in hours and dollars) were measured in a national cross-sectional telephone survey of U.S. workers.

RESULTS

The 2-week period prevalence of fatigue was 37.9%. Of workers with fatigue, 65.7% reported health-related LPT compared with 26.4% of those without fatigue. Workers with fatigue cost employers 136.4 billion dollars annually in health-related LPT, an excess of 101.0 billion dollars compared with workers without fatigue. Fatigue frequently co-occurs with other conditions and, when present, is associated with a threefold increase, on average, in the proportion of workers with condition-specific LPT.

CONCLUSIONS

Fatigue is prevalent in the U.S. workforce. When occurring with other health conditions, it is associated with significantly more condition-specific LPT.

Costs in primary care of investigating symptoms suspicious of cancer in a defined population

OBJECTIVES

To calculate total cost of investigating symptoms related to one of the four most common cancers: prostate, breast, colorectal, and pulmonary. Special attention was given to two non-specific and common symptoms: vertigo/dizziness and tiredness/fatigue.

DESIGN

Retrospective examination of patient records in a defined population.

SETTING

Primary health care (PHC) and hospital care.

MAIN OUTCOME MEASURES

Investigation costs of selected ICD codes.

RESULTS

In total 6812 patients with 14,541 ICD codes were investigated to a total cost per registered ICD code, with one of the selected diagnostic measures, of SEK 800. Some 50% of the costs were due to X-ray examinations of which colonic X-ray was the most expensive single procedure. Symptoms related to colorectal cancer were the most expensive to investigate with vertigo/dizziness and tiredness/fatigue examined separately. Tiredness/fatigue symptoms cost SEK 395 and vertigo/dizziness SEK 197 per registered code to investigate and none of them yielded a detected malignancy. The incidence of cancer was 0.7%. The average cost of diagnosing one malignancy was SEK 236,700, if all diagnostic activities could be justified only for detection of malignancies.

CONCLUSION

A high cost of diagnosing malignancy can be expected and justified, but many symptoms presented in PHC, such as tiredness/fatigue and vertigo/dizziness, have a relatively high investigation cost but detected no case of cancer in this study.

Fatigue and shift work

Shift work is a ubiquitous phenomenon and its adverse effects on workers' physical and mental health have been documented. In the sleep literature, differentiating between the symptoms of fatigue and sleepiness, and developing appropriate objective and subjective measures, have become very important endeavors. From such research, fatigue and sleepiness have been shown to be distinct and independent phenomena. However, it is not known whether shift work differentially affects fatigue and sleepiness. In an attempt to answer this question, 489 workers from a major Ontario employer completed a series of subjective, self-report questionnaires, including the Fatigue Severity Scale (FSS) and the Epworth Sleepiness Scale. Workers were separated into four groups based on the frequency with which they are engaged in shift work (never, fewer than four times per month, 1-2 days per week, 3 days or more per week). The frequency of shift work was found to have a significant effect on subjective fatigue, but not on subjective sleepiness. Compared with the subjects who never had a shift schedule, those who worked in a shift for 3 days or more had significantly higher mean score of the FSS. In agreement with previous results, a low correlation was found between workers' subjective fatigue and sleepiness scores, providing further support for the concept of fatigue and sleepiness as distinct and independent phenomena. Future research should address the possibility of using the FSS as an indicator when the frequency of shift work has become high enough to adversely affect work performance or cause health problems.

Fatigue and psychiatric illness in a large community sample of persons with multiple sclerosis

BACKGROUND

Fatigue and depression are among the most common and disabling symptoms in multiple sclerosis (MS), but the nature and extent of the relationships between fatigue and psychiatric disorders in MS patients remain poorly understood.

METHODS

A mail survey was completed by 739 members of the King County (WA) MS Association. Fatigue was evaluated by questions from the Modified Fatigue Impact Scale (MFIS), depressive symptoms by the Center for Epidemiologic Studies Depression Scale (CES-D), substance-use disorders from the PRIME-MD. Information on demographics, employment and characteristics of MS was also collected. Logistic regression was used to identify covariates significantly associated with disabling fatigue. Receiver operating characteristic (ROC) curve analysis evaluated the sensitivity and specificity of fatigue for depression.

RESULTS

Twenty-five percent of this community-dwelling sample reported that their activities were often or almost always limited by fatigue. Seventy-six percent of subjects with disabling fatigue had significant depressive symptoms (CES-D >16), compared with 31% of those without disabling fatigue. Depression was strongly associated with fatigue, after controlling for age, gender, marital status, and severity, course and duration of illness. In logistic regression analysis, subjects with clinically significant depressive symptoms (CES-D >16) were much more likely to report disabling fatigue: OR = 6.24 (4.16, 9.35). Anxiety and substance-use disorders did not have the same strong associations with fatigue. Fatigue was highly sensitive and specific for clinically significant depressive symptoms.

CONCLUSIONS

Disabling fatigue is strongly associated with clinically significant depressive symptoms. Patients who report disabling fatigue should be screened for depression.

Prevalence of chronic fatigue and chronic fatigue syndrome in Korea: community-based primary care study

There have been many epidemiological and clinical researches on chronic fatigue (CF) and chronic fatigue syndrome (CFS) since the 1990s, but such studies have been quite limited in Korea. The aim of this study was to investigate the point prevalence of CF and CFS in patients who visited community-based eight primary care clinics in Korea. The study subjects were 1,648 patients aged 18 yr and over who visited one of eight primary care clinics in Korea between the 7th and 17th of May 2001. The physicians determined the status of the subjects through fatigue-related questionnaires, medical history, physical examination, and laboratory tests. The subjects were categorized into no fatigue, prolonged fatigue, CF and then CF were further classified to medically explained CF (Physical CF and Psychological CF) and medically unexplained CF (CFS and idiopathic chronic fatigue). The point prevalence of CF and CFS were 8.4% (95% CI 7.1-9.7%) and 0.6% (95% CI 0.2-1.0%). Medically explained CF was 80.5% of CF, of which 57.1% had psychological causes. The clinical characteristics of CFS were distinguished from explained CF. CF was common but CFS was rare in community-based primary care settings in Korea.

The reporting of specific physical symptoms for mental distress in general practice

OBJECTIVE

Do patients report specific physical symptoms in the presence of mental distress, taking into account the presence of somatic disease?

METHODS

Cross-sectional data were collected from 1458 participants in eight general practices in The Netherlands. Electronic patient records provided information on somatic disease. Questionnaires included the Hospital Anxiety and Depression Scale (HADS) to measure mental distress and the Physical Symptom Checklist (PSC).

RESULTS

Patients reporting mental distress reported all types of physical symptoms more often than did patients without mental distress. Multivariate analyses in women, corrected for the presence of somatic disease, did not substantially change the univariate pattern. Odds ratios were particularly high (>6) for feeling tired or having low energy, fatigue without exertion and forgetfulness.

CONCLUSION

It is the level of mental distress rather than gender or somatic disease that accounts for the reporting of any physical symptom. Fatigue might be an exception, but here, the classification as "physical" rather then "mental" is somewhat ambiguous.

Measurement and prediction of subjective fatigue following traumatic brain injury

Numerous outcome studies have found fatigue to be a common problem following traumatic brain injury (TBI). This study examined the magnitude, causes and impact of fatigue following TBI using three subjective fatigue scales, and investigated its relationship with demographic and injury-related factors, and mood. Forty-nine controls and 49 TBI participants (36.2% with GCS score of 13-15, 29.8% with GCS score of 9-12, and 34% with GCS score of 3-8) were seen at a mean of approximately 8 months post injury. All participants completed three subjective fatigue measures, including the Fatigue Severity Scale (FSS), Visual Analogue Scale-Fatigue (VAS-F) and Causes of Fatigue Questionnaire (COF). TBI participants reported a significantly greater impact of fatigue on their lifestyle on the FSS relative to controls, and reported activities requiring physical and mental effort as more frequent causes of fatigue on the COF. There were, however, no significant group differences on subscales of the VAS-F. Greater time since injury and higher education levels were associated with higher fatigue levels, independent of the effects of mood. Injury severity and age were not found to be significant predictors of subjective fatigue severity in TBI participants.

Fatigue in the elderly population

Fatigue in the elderly population is a complex phenomenon. Although a number of factors contributing to the fatigue have been identified, its basic mechanism remains elusive. Additional research on prevalence, identification, diagnosis, severity of fatigue, and associated factors and the role of exercise as an effective treatment modality could lead to a better understanding of the causal factors.

Mental health status and leisure-time physical activity contribute to fatigue intensity in patients with spondylarthropathy

OBJECTIVE

To examine the relationship between disease-related variables, leisure-time physical activity (LTPA), and mental health status with fatigue severity in patients with spondylarthropathy (SpA).

METHODS

Sixty-six SpA patients completed questionnaires assessing disease activity (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI]), functional ability (Bath Ankylosing Spondylitis Functional Index), and health-related quality of life (Short Form 36). LTPA patterns, demographics, and disease-related data were obtained by interview. A clinical examination determined tender point count. Fatigue was assessed with the BASDAI fatigue item.

RESULTS

The mean BASDAI fatigue score was 5.5 (SD=2.7) with 59% of the sample obtaining a score > or =5. Disease activity, functional disability, and worse mental health contributed to greater fatigue (R2=0.56). The relationship between exercise duration and fatigue intensity was moderated by mental health status. For patients with poorer mental health scores, exercise did not influence fatigue severity. However, for patients reporting better mental health status, engaging in more LTPA decreased fatigue severity.

CONCLUSION

In addition to increased disease activity and functional disability, greater fatigue severity in SpA is associated with poorer mental health status. Integrating regular leisure physical activity into the comprehensive treatment of SpA may be useful for modulating fatigue.

Sociodemographic and symptom correlates of fatigue in an adolescent primary care sample

PURPOSE

To describe the prevalence of prolonged fatigue, chronic fatigue syndrome (CFS)-like illness, and associated symptom patterns in adolescents attending primary care.

METHODS

The design was cross-sectional. A questionnaire designed by the authors assessing fatigue and associated symptoms was administered to 901 adolescents (aged 11-18 years) attending 12 primary care clinics in the Chicago area. Prevalence rates for prolonged fatigue and CFS-like illness were calculated. Univariate comparisons involving sociodemographic data and fatigue severity were made between adolescents with and without prolonged fatigue, and sociodemographic and symptom predictors of prolonged fatigue were identified using logistic regression analysis.

RESULTS

Prolonged fatigue (> or = 1 month) occurred at a rate of 8.0% and CFS-like illness occurred at a rate of 4.4%. Adolescents with prolonged fatigue were significantly older and also reported greater fatigue severity than those without fatigue. Findings from logistic regression indicated that, in addition to increasing age, headaches, muscle pains, fever, and fatigue made worse by exercise were significantly associated with prolonged fatigue.

CONCLUSIONS

Abnormal fatigue is a disabling and prevalent condition in adolescents in primary care. It is associated with a number of additional symptoms, many of which may have viral origins.

Diabetes, employment and fatigue-related complaints: a comparison between diabetic employees, "healthy" employees, and employees with other chronic diseases

The work situation and fatigue-related complaints of employees with diabetes (N = 141) were compared with "healthy" employees (N = 8946) and employees with other chronic diseases (N = 1883). Baseline data from a Dutch Cohort Study on Fatigue at Work were used to test differences in background variables, work characteristics, lifestyle factors, and fatigue-related complaints. Odds ratios were calculated for prolonged fatigue, the need for recovery, burnout, and psychological distress. Results showed that employees with diabetes work more daytime hours and work less overtime than the other groups. If they have no comorbidity, they are no more likely to report fatigue-related complaints than "healthy" employees, except for a depressed mood. Comorbidity (the presence of one or more additional chronic diseases) is associated with increased fatigue-related complaints. Therefore, this group will need special attention from professionals.

Mental fatigue, work and sleep

OBJECTIVE

The study examined the multivariate relationship between mental fatigue and different work-related (work load, work hours) and background/life style factors, as well as disturbed sleep.

METHODS

A total of 5720 healthy employed men and women living in the greater Stockholm area participated in a questionnaire study on cardiovascular risk factors. The data were analysed using a multiple logistic regression analysis with self-rated fatigue as the dependent variable.

RESULTS

Fatigue was predicted by disturbed sleep (4.31; 3.50-5.45, high immersion in work (4.17; 2.93-5.94), high work demands (2.39; 1.54-3.69), social support, being a female, being a supervisor and high age. Shift work, work hours (including overtime) and influence at work did not become significant predictors. With control for work demands a high number of work hours was associated with lower fatigue.

CONCLUSION

Disturbed sleep is an important predictor of fatigue, apparently stronger than previously well-established predictors such as work load, female gender, lack of exercise, etc.

Fatigue and psychological distress--exploring the relationship in women treated for breast cancer

Disabling fatigue and psychological symptoms of depression or anxiety are commonly reported by women with treated breast cancer. However, most instruments designed to assess fatigue do not assess concurrent psychological symptoms. This study compared the characteristics of two conceptually different, self-report instruments assessing fatigue to determine the extent to which common psychological symptoms co-exist with the symptom of fatigue in women treated for breast cancer. Women attending an oncology day-care facility for adjuvant treatment of breast cancer or ongoing surveillance post-treatment, completed two self-report questionnaires. The Somatic and Psychological Health REport-34 items (SPHERE) and the Functional Assessment of Cancer Therapy-Fatigue (FACT-F subscale-13 items). One hundred and nine women (mean age 52.8 years) completed both questionnaires and total scores on both fatigue assessment scales, FACT-F and SOMA-6, were highly correlated (r = 0.72, P < 0.001). Using the SPHERE case criteria, prolonged fatigue (37% [40/109]) and psychological distress 31% (34/109) were common in women treated for breast cancer. However, those who reported fatigue were much more likely to also report psychological symptoms (22/40 vs. 12/69, X(2) = 16.7: degrees of freedom (df)=1; P < 0.001) and the levels of fatigue on the FACT-F were not significantly different between those who reported "fatigue only" and those who reported "psychological distress only" (18.8 vs. 17.8, P = 0.79). Thus the recent emphasis on recording fatigue during and following treatments for cancer needs to be accompanied by concurrent measurement of psychological symptoms.

Educational attainment, positive psychological mediators, and resources for health and vitality in older adults

OBJECTIVES

To further explain the relationship of education to health by a prospective examination of positive psychological states as mediators. Furthermore, to examine the resources of desirable events, self-esteem, and social support as possible mediators between positive psychological states and subsequent health and vitality.

METHODS

Four in-home interviews were conducted at 6-month intervals with a probability sample of 1,277 older adults (aged 55 and older); multiple regression was used to estimate mediating effects.

RESULTS

Positive states mediated the education relationship to both symptoms and vitality, independent of negative states; the resource measures did not mediate the positive state-health relationship.

DISCUSSION

Higher education level appears to increase the likelihood of being serene and happy, and healthy and vital, in later years; positive psychological states appeared to have both a promotion function (for vitality) and protective function (against health symptoms); self-esteem showed promise as a possible mediator of the effects of psychological states on health.

Chronic fatigue and sociodemographic characteristics as predictors of psychiatric disorders in a community-based sample

OBJECTIVES

To explore the roles of chronic fatigue and sociodemographic characteristics (eg, parental status, work status, socioeconomic status, sex, age, marital status, and ethnicity) as predictors of psychiatric disorders.

METHODS

A stratified random sample of 18,675 adults residing in diverse neighborhoods in Chicago completed a telephone-screening questionnaire. A control group without chronic fatigue (N = 74) and a group of individuals with chronic fatigue (N = 227) were identified and administered a semi-structured psychiatric interview. Stepwise logistic regression analyses predicting occurrence of current and lifetime psychiatric disorders according to chronic fatigue status and sociodemographics were conducted on this overall sample of 301 participants.

RESULTS

Chronic fatigue, low socioeconomic status, and unemployment were among significant predictors of overall Axis I psychiatric disorders. Chronic fatigue functioned as a predictor for mood and anxiety disorders (including posttraumatic stress disorder), but did not function as a predictor for somatoform disorders, substance abuse/dependence, and eating disorders. Low socioeconomic status and unemployment were significantly associated with current psychiatric disorder, and low socioeconomic status was also significantly associated with mood and anxiety disorders. Women were significantly more likely to experience mood disorder, and minorities (eg, African Americans, Latinos, and individuals of other ethnicity) were significantly more likely to report posttraumatic stress disorder.

CONCLUSIONS

Results support prior findings for increased rates of psychiatric disorder among individuals with chronic fatigue and highlight the roles of low socioeconomic status, unemployment, being a woman, and being classified as a minority in their association with certain psychiatric disorders.

An epidemiological approach to study fatigue in the working population: the Maastricht Cohort Study

In 1998, a large scale prospective cohort study of prolonged fatigue in the working population was started in the Netherlands. The ultimate goal of this Maastricht Cohort Study was to identify risk factors involved in the aetiology and natural course of prolonged fatigue in the working population and to develop preventive measures and treatments that can be used in occupational health settings. In this paper, a conceptual model for epidemiological research on prolonged fatigue is presented. This model is the basis for the Maastricht Cohort Study. Alongside the model and design, the characteristics of the study population, the prevalence and one year cumulative incidence of prolonged fatigue, as well as its relation with secondary health outcomes (psychological distress, need for recovery, and burnout) are presented. Furthermore, model, design, and the presented results are discussed.

Fatigue in multiple sclerosis: definition, pathophysiology and treatment

Fatigue is a common disabling symptom of multiple sclerosis (MS). It is often considered a state of exhaustion distinct from depressed mood or physical weakness. Fatigue can be assessed by either self-report scales or performance-based measures; however, neither method captures all features of fatigue. Fatigue in MS frequently leads to unemployment. It is associated with a sense of loss of control over one's environment, low positive affect, psychological distress and neurological impairment. To date there is no reproducible neuroimaging marker or biological correlate that has been identified. Proposed pathological mechanisms of fatigue in MS include neuronal factors such as dysfunction of premotor, limbic, basal ganglia or hypothalamic areas; disruption of the neuroendrocrine axis leading to low arousal; alteration in serotoninergic pathways; changes in neurotransmitter levels; and altered CNS functioning caused by a disruption of the immune response. Treatment of fatigue is best approached in a multidisciplinary fashion that incorporates nonpharmacological interventions as well as medication. Amantadine and modafinil are among the most commonly used medications for fatigue associated with MS. Both medications have been studied with positive results in controlled clinical trials. Additional research towards measurement and pathogenesis of fatigue will hopefully lead to improved therapies.

Psychometric qualities of a brief self-rated fatigue measure: The Fatigue Assessment Scale

OBJECTIVE

The main aim of this study was to examine the dimensionality and psychometric qualities of a new 10-item fatigue measure, the Fatigue Assessment Scale (FAS).

METHODS

As part of a longitudinal study, the respondents, all workers with at least 20 working hours per week, completed the FAS, four related fatigue measures, a depression questionnaire, and an emotional stability scale.

RESULTS

The FAS had a high internal consistency. The pattern of correlations and factor analysis showed good convergent and divergent validity. The FAS correlated strongly with the other fatigue scales. In a factor analysis of the five fatigue questionnaires, the FAS had the highest factor loading on a clear one-factor solution. Moreover, factor analyses revealed that fatigue, on the one hand, and depression and emotional stability, on the other hand, are separate constructs. Finally, it was shown that 8 out of the 10 FAS items were unbiased concerning gender; two had a uniform bias.

CONCLUSIONS

The FAS represents a potentially valuable assessment instrument with promising internal consistency reliability and validity. Gender bias in the FAS does not have consequences for use of the FAS.

Fatigue and sleep disturbance in patients with cancer, patients with clinical depression, and community-dwelling adults

This study compared the severity of fatigue in patients with cancer to the fatigue reported by depressed psychiatric patients and community-dwelling adults. Data were collected for this study during the process of validating a new fatigue assessment tool, the Brief Fatigue Inventory (BFI). The sample included 354 cancer patients, 72 psychiatric patients, and 290 non-patient volunteers. Study subjects reported severity of fatigue and the degree to which fatigue interfered with various aspects of life. Data were also collected on sleep disturbance and demographic variables that might correlate with fatigue. The psychiatric patients reported significantly higher levels of fatigue and fatigue-related interference than the cancer patients, who reported more severe fatigue and interference than the community subjects. The sleep disturbance scores of the cancer patients and the community subjects were significantly correlated with fatigue severity. Although the majority of the psychiatric patients reported sleep disturbance, their sleep disturbance scores were not significantly associated with fatigue severity.

Cross-cultural differences in the epidemiology of unexplained fatigue syndromes in primary care

BACKGROUND

Unexplained fatigue has been extensively studied but most of the samples used were from Western countries.

AIMS

To present international data on the prevalence of unexplained fatigue and fatigue as a presenting complaint in primary care. Method Secondary analysis of the World Health Organization study of psychological problems in general health care. A total of 5438 primary care attenders from 14 countries were assessed with the Composite International Diagnostic Interview.

RESULTS

The prevalence of unexplained fatigue of 1-month duration differed across centres, with a range between 2.26 (95% CI 1.17-4.33) and 15.05 (95% CI 10.85-20.49). Subjects from more-developed countries were more likely to report unexplained fatigue but less likely to present with fatigue to physicians compared with subjects from less developed countries.

CONCLUSIONS

In less-developed countries fatigue might be an indicator of unmet psychiatric need, but in more-developed countries it is probably a symbol of psychosocial distress.

Distinguishing between excessive daytime sleepiness and fatigue: toward improved detection and treatment

INTRODUCTION

Excessive daytime sleepiness (EDS) and fatigue occur in high percentages in the general population. They are common complaints in primary care and in specialty medicine. Although they may represent distinct or overlapping phenomena, the general medical literature does not normally distinguish between EDS and fatigue. Despite their prevalence, both EDS and fatigue are identified and treated in a relatively small proportion of those affected. The similarity of EDS and fatigue may create diagnostic ambiguity and thereby contribute to under-identification and under-treatment. Fatigue, in particular, is thought to be difficult to manage when it is identified.

METHODS

The literature was searched for reviews, meta-analysis and similar levels of papers focused on EDS or fatigue.

RESULTS

EDS and fatigue are operationalized in ways that contribute to blurring rather than to distinguishing between them. Existing measures of both EDS and fatigue may also contribute to their misidentification. Effective treatments for both symptoms have been established. Behavioral interventions are effective and underutilized.

DISCUSSION

We suggest more precise operationalization of EDS and fatigue, leading to a refinement of existing measures or development of new tools, a structured interview with fatigue and EDS sections in the clinical setting, and more consideration for behavioral interventions.

No excess fatigue in young adult survivors of childhood cancer

Clinical reports suggest that many survivors of childhood cancer experience fatigue as a long-term effect of their treatment. To investigate this issue further, we assessed the level of fatigue in young adult survivors of childhood cancer. We compared the results with a group of young adults with no history of cancer. The impact of demographic, medical and treatment factors and depressive symptoms on survivors' fatigue was studied. Participants were 416 long-term survivors of childhood cancer (age range 16-49 years, 48% of whom were female) who had completed treatment an average of 15 years previously and 1026 persons (age range 16-53 years, 55% female) with no history of cancer. All participants completed the Multidimensional Fatigue Inventory (MFI-20), a self-report instrument consisting of five scales (general fatigue, physical fatigue, mental fatigue, reduced activity, reduced motivation) and the Center for Epidemiologic Studies Depression Scale (CES-D). Small differences were found in the mean scores for the different dimensions of fatigue between the long-term survivors and controls (range effect sizes -0.34 to 0.34). Women experienced more fatigue than men. Logistic regression revealed that being female and unemployed were the only demographic characteristics explaining the various dimensions of fatigue. With regard to medical and treatment factors, diagnosis and severe late effects/health problems were associated with fatigue. Finally, depression was significantly associated with fatigue on all subscales. Our clinical practice suggests a difference in fatigue in young adult childhood cancer survivors and their peers. This could not be confirmed in this study using the MFI-20. The well known correlation between fatigue and depression was confirmed in our study. Further research is needed to clarify the undoubtedly complex somatic and psychological mechanisms responsible for the development, maintenance and treatment of fatigue in childhood cancer survivors.

Communicating fatigue in general practice and the role of gender

The aim of this study has been to obtain more insight into the health condition of fatigued patients, their expectations when visiting the general practitioner (GP), the way they communicate, and possible gender differences. Data consisted of 579 patient questionnaires and 440 video-observations of these patients and 31 GPs. Results showed that fatigue is a common health problem but seldom on the agenda in general practice. More women indicated symptoms of fatigue than men did. Fatigued patients' health was worse than that of non-fatigued patients, and they expected more biomedical and especially psychosocial communication. Furthermore, male fatigued patients expected more biomedical communication than fatigued female patients did. While the GPs accommodated their verbal behavior to fatigued patients by giving more psychosocial information and more counseling, they were not more affective towards the fatigued than towards the non-fatigued patients. Female GPs were more affective than their male colleagues, and they used gender-specific communication strategies to explore the patient's agenda. It seems necessary to use a gender-sensitive approach in communication research.

Fatigue in multiple sclerosis: reciprocal relationships with physical disabilities and depression

OBJECTIVE

To explore relations of fatigue, physical disabilities, and depression in patients with multiple sclerosis (MS) cross-sectionally and over time.

METHODS

Ninety-eight MS patients were interviewed twice at an interval of a year. Relationships of physical and mental fatigue, and reduced activity and motivation with depression and physical disabilities were established cross-sectionally by regression analyses and longitudinally by structural equation modelling.

RESULTS

Cross-sectionally, physical fatigue was related with physical disabilities, and mental fatigue was associated with depression. Prospectively, physical fatigue was a predictor of the physical disabilities of a year later. The reverse relationship of physical disabilities predicting the physical fatigue of one year later was, however, not significant, while depression predicted this physical fatigue and reduced activity of a year later. Depression did not predict the later mental fatigue nor was depression predicted by preceding fatigue experiences.

CONCLUSIONS

Fatigue in MS should be studied over time as relationships of fatigue with physical and mental health change during the course of a year. Moreover, differentiating in fatigue experiences sheds light on the relationship of fatigue with physical and mental health.

Self-care for fatigue in patients With HIV

PURPOSE/OBJECTIVES

To identify when fatigue is reported as a problem by people who are HIV positive, what the perception of fatigue is, and which self-care behaviors are used and with what efficacy.

DESIGN

Multisite descriptive study.

SETTING

University-based AIDS clinics, community-based organizations, and homecare agencies located in cities across the United States, in Norway, and through a university Web site.

SAMPLE

Convenience sample of 422 self-identified people who are HIV positive.

MAIN RESEARCH VARIABLES

Symptom description, symptom relief, symptom help, and self-care strategies.

FINDINGS

The sixth most reported symptom in this study, fatigue, was treated with a variety of self-designed strategies. In only three instances was consultation with a healthcare provider (i.e., physician) or an injection (medication not defined) mentioned. The most frequently used interventions were supplements, vitamins, and nutrition followed by sleep and rest; exercise; adjusting activities, approaches, and thoughts; distraction; and complementary and alternative therapies. In addition to self-designed strategies, the media and friends and family were sources of information.

CONCLUSIONS

Fatigue was reported less frequently in this study than in other HIV-, AIDS-, or cancer-related studies. This may be an artifact of the study design. The use of informal networks for assistance, let alone the prevalence of unrelieved fatigue, indicates the need for more attention to this problem among people with AIDS.

IMPLICATIONS FOR NURSING

Careful assessment of the pattern of fatigue and its onset, duration, intervention, and resolution is required if the varied types of fatigue are to be identified and treated successfully.

Fatigue and psychological distress in the working population: psychometrics, prevalence, and correlates

OBJECTIVE

The purposes of this study were: (1) to explore the relationship between fatigue and psychological distress in the working population; (2) to examine associations with demographic and health factors; and (3) to determine the prevalence of fatigue and psychological distress.

METHODS

Data were taken from 12,095 employees. Fatigue was measured with the Checklist Individual Strength, and the General Health Questionnaire (GHQ) was used to measure psychological distress.

RESULTS

Fatigue was fairly well associated with psychological distress. A separation between fatigue items and GHQ items was shown. No clear, distinct pattern of associations was found for fatigue vs. psychological distress with respect to demographic factors. The prevalence was 22% for fatigue and 23% for psychological distress. Of the employees reporting fatigue, 43% had fatigue only, whereas 57% had fatigue and psychological distress.

CONCLUSIONS

The results indicate that fatigue and psychological distress are common in the working population. Although closely associated, there is some evidence suggesting that fatigue and psychological distress are different conditions, which can be measured independently.

Relationship as an inherent component in healthy women's fatigue

The notion of fatigue has remained ambiguous despite more than 100 years of study. Fatigue is recognized as subjective in nature, and it is studied and clinically managed as primarily intrapersonal in scope, with treatment approaches often based in an established, if unfounded, hierarchy of assumptions. When a physiologic cause for fatigue is not identifiable, fatigue complaints often are considered illegitimate. This article builds on data from the literature and from the author's previous work in women's fatigue and relatedness to suggest that interpersonal relationships may serve to exacerbate healthy women's fatigue experiences. The importance of relationship to women's life experience and the inherently relational character of women's fatigue are discussed. The author proposes the importance of including interpersonal experiences as a component of the definition of fatigue for healthy women.

Coping and illness cognitions: chronic fatigue syndrome

The chronic fatigue syndrome (CFS) is described, and research on coping with this illness reviewed and analysed. CFS is a severely disabling illness of unknown etiology, which has occurred in epidemic forms all over the world. However, the number of sufferers has dramatically increased over previous years. The heterogeneous symptomatology of CFS was reviewed, and diagnostic criteria were discussed. The difficulty in establishing causality was emphasized. An interaction of factors appears most likely to be associated with illness onset and maintenance. As the mediating factor could be sufferers' coping behavior, the existing coping literature was reviewed. There might be an association between coping and physical and psychological well-being. Finally, recommendations are made for longitudinal research on coping and coping effectiveness, and for the development of therapeutic interventions.

Patient factors related to the presentation of fatigue complaints: results from a women's general health care practice

The aim of this study was to examine which patient-related factors predicted: (1) fatigue, (2) the intention to discuss fatigue and (3) the actual discussion of fatigue during consultation with a GP in a women's general health care practice. Patients were asked to complete two questionnaires: one before and one after consultation. The patient-related factors included: social-demographic characteristics; fatigue characteristics; absence of cognitive representations of fatigue; nature of the requests for consultation; and other complaints. Some 74% of the 155 respondents reported fatigue. Compared to the patients that were not fatigued, the fatigued patients were more frequently employed outside the home, had higher levels of general fatigue, and a higher need for emotional support from their doctor. A minority (12%) intended to discuss fatigue during consultation. Of the respondents returning the second questionnaire (n = 107), 22% reported actually discussing their fatigue with the GP while only 11% had intended to do so. In addition to the intention to discuss fatigue during consultation, the following variables related to actually discussing fatigue: living alone, caring for young children, higher levels of general fatigue, absence of cognitions with regard to the duration of the fatigue, and greater psychological, neurological, digestive, and/or musculoskeletal problems as the reason for consultation. Fatigue was found to be the single reason for consultation in only one case. It is concluded that fatigue does not constitute a serious problem for most patients and that discussion of fatigue with the GP tends to depend on the occurrence of other psychological or physical problems and the patient's social context.

Fatigue in the Danish general population. Influence of sociodemographic factors and disease

OBJECTIVE

To measure the levels of fatigue in the general population, and to examine how disease and sociodemographic factors influence fatigue.

DESIGN

Cross sectional questionnaire study in the Danish general population.

SUBJECTS

A random, age stratified sample of 1608 people aged 20-77 with an equal gender distribution (response rate 67%).

MAIN OUTCOME MEASURES

Five fatigue scales from the questionnaire Multidimensional Fatigue Inventory: General Fatigue, Physical Fatigue, Reduced Activity, Reduced Motivation and Mental Fatigue.

RESULTS

Fatigue scores were skewed towards absence of fatigue. The General Fatigue and Physical Fatigue scales showed the highest fatigue levels while the Reduced Motivation scale showed lowest levels. Gender differences in fatigue scores were small, but the variability among women was higher-that is, more women had high scores. A multiple linear regression analysis showed that respondents of low social status and respondents with a depression had high fatigue scores on all scales, independent of other factors. Chronic somatic disease had an independent direct effect on Mental Fatigue, but for the rest of the scales, the effect of somatic disease depended on age, gender and/or whether the person was living alone. For example, General and Physical Fatigue decreased with age among healthy people, whereas scores on these scales increased with age among those with a somatic disease.

CONCLUSIONS

Physical and mental diseases play essential parts for the level of fatigue and as modulators of the associations between sociodemographic factors and fatigue. These interactions should be taken into account in future research on fatigue and sociodemographic factors and when data from clinical studies are compared with normative data from the general population.

Fatigue in an older population

OBJECTIVES

Fatigue is a common symptom that has not been studied well in the older populations. The purpose of this pilot study was to examine the epidemiology of fatigue symptoms in relation to demographic and medical characteristics of older patients in a long-term care setting.

DESIGN

A cross-sectional interviewer-assisted survey.

PARTICIPANTS/SETTING

A total of 199 ambulatory older residents of a single residential care facility.

MEASUREMENTS

Along with medical and demographic characteristics, the survey included mental status (Folstein), activities of daily living (Katz and Lawton), depression (Yesavage GDS), a 3-minute walk, a 7-item pain scale, and the modified Piper Fatigue Scale.

RESULTS

One-hundred ninety-nine (65%) of 308 potential subjects completed the study (mean age 88 years, 82% female). Of these 199 subjects, 195 (98%) reported some fatigue symptoms (median duration 44 weeks). Significant (P < .0005) relationships were found between fatigue and GDS (r = 0.57), 3-minute walk (r = -0.29), Lawton IADLs (r = 0.31), pain (r = 0.36), and number of medications (r = 0.26). No significant relationships were found between fatigue and age, sex, Folstein score, or number of medical diagnoses. Multivariate regression analysis identified GDS, pain, number of medications and 3-minute walk as significant predictors of fatigue intensity (multiple R = 0.68, r2 = 0.46, P < .02).

CONCLUSIONS

Fatigue is a symptom often found among older residents of a residential facility and has important implications for quality of life. Fatigue is poorly recognized and probably undertreated in older people.

What is behind "I'm so tired"? Fatigue experiences and their relations to the quality and quantity of external stimulation

In the present study, it is hypothesized that both low quality and high quantity of external stimulation are related to elevated levels of fatigue. This is proposed by the Quality-Quantity model for understanding fatigue (QQuF model). The relations between the quality and quantity of external information and the Multidimensional Fatigue Inventory (MFI-20) are examined. Moreover, the role of depression (measured with the CES-D) in relation to the QQuF model is explored. The results show low quality of external stimulation, that is, low "attractiveness of external stimulation," relating to all five dimensions of fatigue. A high quantity of external stimulation, that is, high "experienced overload," related primarily to general and mental fatigue. The QQuF model was only slightly moderated by depression, but depression directly and strongly related to all dimensions of fatigue. It is concluded that fatigue related to low quality of external stimulation can be distinguished from fatigue related to a high quantity of external stimulation. This distinction is useful when considering theoretical issues and treatment of fatigue.

Complaints of fatigue: related to too much as well as too little external stimulation?

Fatigue has been acknowledged as a widespread problem associated with a variety of factors. In the present paper, we attempt to explain fatigue complaints on the basis of Pennebaker's (1982) "competition of cues" notion. Competition of cues suggests that both extremely low and extremely high levels of external stimulation in daily life may be related to relatively higher frequencies of complaint. The dimensional structure of external stimulation is first explored and then the shape of the relation between external stimulation (i.e., stimuli perceived in daily life) and fatigue was studied in a sample of 777 general-practice patients. Other risk factors for fatigue and moderating factors are also taken into consideration. Results show that quantity and quality of external stimulation can be distinguished. Both high quantity (high "experienced overload") and low quality (low "attractiveness of external stimulation") are related to higher fatigue frequencies. "Experienced overload" is a particularly strong predictor, in addition to "perceived health" of fatigue complaints. It is concluded that the "quality-quantity model for understanding fatigue" proposed here highlights psychological factors important for any theoretical framework of fatigue.

Gender differences in fatigue: biopsychosocial factors relating to fatigue in men and women

BACKGROUND

Fatigue is a common problem, which is found more frequently among women than men. To date, neither the etiology of fatigue nor the factors that explain the gender difference in its incidence are still fully understood.

METHODS

In a sample of men (n = 4,681) and women (n = 4,698) (age range, 15-64 years) in the Dutch National Survey of Morbidity and Interventions in General Practice, the gender differences in the underlying biological, psychological, and social factors of fatigue were analyzed.

RESULTS

Both general and gender-specific factors were recognized. Men and women who experience complaints of fatigue appeared to be younger and more highly educated. They had more acute health complaints and more psychosocial problems and also showed a lower level of perceived health. Among women, only gender-specific biological complaints and psychosocial problems were related to fatigue. In addition, relevant sociodemographic variables included taking care of young children and being employed. Among men, fatigue was particularly related to having handicaps and severe chronic complaints. Taking care of young children did not make a difference in the male sample.

CONCLUSIONS

Fatigue can only be adequately understood in a multicausal model with biomedical and psychosocial factors. Complaints of fatigue are too often ignored in general practice. By adopting a patient-centered style of communication, physicians can acquire a more complete picture of the patients' fatigue.

Anxiety but not depression is associated with elevated blood pressure in a community group of French elderly

OBJECTIVE

This study examined whether anxiety and depression were independently associated with elevated blood pressure in elderly persons.

METHOD

The study group consisted of 1389 subjects aged 59 to 71 years recruited from the electoral rolls of the city of Nantes (France). Subjects completed the Center for Epidemiologic Studies-Depression scale (CES-D) and the Spielberger Inventory scales to assess depressive symptoms and anxiety symptoms, respectively. Data were collected on sociodemographic characteristics, smoking and drinking habits, medical history, and drug use. Two measures of systolic and diastolic blood pressure were taken after a 10-minute rest. Body mass index was computed from weight and height measurements. Subjects taking antihypertensive drugs (N = 281) were excluded from the present analysis.

RESULTS

Depression and anxiety scores were significantly correlated (r = .61 in men; r = .65 in women; p<.001). In univariate analyses, anxiety scores were correlated with systolic and diastolic blood pressure in men, but not in women; blood pressure was not associated with depressive symptoms in either sex. Multivariate logistic regressions, controlling for possible confounders, showed that in both men and women, the risk of high blood pressure increased with increasing anxiety scores; odds ratios for high blood pressure were less than 1 in subjects with depressive symptomatology.

CONCLUSIONS

This study suggested that anxiety but not depression was independently associated with an increased risk for high blood pressure.

Differential diagnosis of fatigue in women

The incidence of fatigue among women has been reported to be higher than among men. Life events such as childbirth, menopause, and socially imposed roles may confer unique vulnerability. Effective treatment of fatigue is dependent on accurate diagnosis. The mechanisms of fatigue are not well understood, but physiologically based fatigue can be differentiated from psychogenic fatigue. Such differentiation helps to direct and enhance the effectiveness of interventions.

Fatigue and radiotherapy: (B) experience in patients 9 months following treatment

Little is known regarding the prevalence and course of fatigue in cancer patients after treatment has ended and no recurrence found. The present study examines fatigue in disease-free cancer patients after being treated with radiotherapy (n = 154). The following questions are addressed. First, how do patients describe their fatigue 9 months after radiotherapy and is this different from fatigue in a nonselective sample from the general population (n = 139)? Secondly, to what degree is fatigue in patients associated with sociodemographic, medical, physical and psychological factors? Finally, is it possible to predict which patients will suffer from fatigue 9 months after radiotherapy? Results indicated that fatigue in disease-free cancer patients did not differ significantly from fatigue in the general population. However, for 34% of the patients, fatigue following treatment was worse than anticipated, 39% listed fatigue as one of the three symptoms causing them most distress, 26% of patients worried about their fatigue and patients' overall quality of life was negatively related to fatigue (r = -0.46). Fatigue in disease-free patients was significantly associated with: gender, physical distress, pain rating, sleep quality, functional disability, psychological distress and depression, but not with medical (diagnosis, prognosis, co-morbidity) or treatment-related (target area, total radiation dose, fractionation) variables. The degree of fatigue, functional disability and pain before radiotherapy were the best predictors of fatigue at 9-month follow-up, explaining 30%, 3% and 4% of the variance respectively. These findings are in line with the associations found with fatigue during treatment as reported in the preceding paper in this issue. The significant associations between fatigue and both psychological and physical variables demonstrate the complex aetiology of this symptom in patients and point out the necessity of a multidisciplinary approach for its treatment.

A naturalistic study of the chronic fatigue syndrome among women in primary care

Chronic fatigue syndrome (CFS), a controversial illness without clear etiology, causes profound debilitation in its sufferers. This study explored subjects' perceptions of the variables that mediated the course of their illness and identified coping strategies in 15 women with CFS referred from the practice of a primary care physician. Exploratory semistructured interviews were adapted from Kleinman's Illness Narratives. Four instruments were used: the Beck Depression Inventory, the Sickness Impact Profile, a modified Karnofsky scale, and the Defense Mechanism Rating Scale. Of the 15 women, 60% reported improvement and/or recovery at the time of the interview. Improvement was associated with social support and lower levels of depressive symptoms. Health status was influenced by how subjects perceived their illness, their future, and the doctor's prognosis; and by the physician's early diagnosis, validation of the CFS, and intensive medical follow-up. Obsessional and healthy neurotic defense levels predominated, which differs from historical comparison groups with dysthymia and panic disorder. Psychological adaptation to CFS is similar to adaptive coping in other chronic illnesses: subjective perceptions of health status can predict functional status. Physician validation is particularly important given the controversial status of CFS. Maintaining relationships with others--doctor, work, family, and group/spiritual activities reflected healthy coping strategies that promoted hope and attitudinal shifts. The finding of a mixture of neurotic and healthy defenses and a low proportion of defenses associated with personality disorders has not been previously reported in the CFS literature and warrants further investigation.