The role of insomnia in the treatment of chronic fatigue

Combining Double-Dose and High-Dose Pulsed Dapsone Combination Therapy for Chronic Lyme Disease/Post-Treatment Lyme Disease Syndrome and Co-Infections, Including Bartonella: A Report of 3 Cases and a Literature Review

Three patients with relapsing and remitting borreliosis, babesiosis, and bartonellosis, despite extended anti-infective therapy, were prescribed double-dose dapsone combination therapy (DDDCT) for 8 weeks, followed by one or several two-week courses of pulsed high-dose dapsone combination therapy (HDDCT). We discuss these patients' cases to illustrate three important variables required for long-term remission. First, diagnosing and treating active co-infections, including Babesia and Bartonella were important. Babesia required rotations of multiple anti-malarial drug combinations and herbal therapies, and Bartonella required one or several 6-day HDDCT pulses to achieve clinical remission. Second, all prior oral, intramuscular (IM), and/or intravenous (IV) antibiotics used for chronic Lyme disease (CLD)/post-treatment Lyme disease syndrome (PTLDS), irrespective of the length of administration, were inferior in efficacy to short-term pulsed biofilm/persister drug combination therapy i.e., dapsone, rifampin, methylene blue, and pyrazinamide, which improved resistant fatigue, pain, headaches, insomnia, and neuropsychiatric symptoms. Lastly, addressing multiple factors on the 16-point multiple systemic infectious disease syndrome (MSIDS) model was important in achieving remission. In conclusion, DDDCT with one or several 6-7-day pulses of HDDCT, while addressing abnormalities on the 16-point MSIDS map, could represent a novel effective clinical and anti-infective strategy in CLD/PTLDS and associated co-infections including Bartonella.

Digital cognitive behaviour therapy for insomnia in individuals with self-reported insomnia and chronic fatigue: A secondary analysis of a large scale randomized controlled trial

Insomnia is associated with fatigue, but it is unclear whether response to cognitive behaviour therapy for insomnia is altered in individuals with co-occurring symptoms of insomnia and chronic fatigue. This is a secondary analysis using data from 1717 participants with self-reported insomnia in a community-based randomized controlled trial of digital cognitive behaviour therapy for insomnia compared with patient education. We employed baseline ratings of the Chalder Fatigue Questionnaire to identify participants with more or fewer symptoms of self-reported chronic fatigue (chronic fatigue, n = 592; no chronic fatigue, n = 1125). We used linear mixed models with Insomnia Severity Index, Short Form-12 mental health, Short Form-12 physical health, and the Hospital Anxiety and Depression Scale separately as outcome variables. The main covariates were main effects and interactions for time (baseline versus 9-week follow-up), intervention, and chronic fatigue. Participants with chronic fatigue reported significantly greater improvements following digital cognitive behaviour therapy for insomnia compared with patient education on the Insomnia Severity Index (Cohen's d = 1.36, p < 0.001), Short Form-12 mental health (Cohen's d = 0.19, p = 0.029), and Hospital Anxiety and Depression Scale (Cohen's d = 0.18, p = 0.010). There were no significant differences in the effectiveness of digital cognitive behaviour therapy for insomnia between chronic fatigue and no chronic fatigue participants on any outcome. We conclude that in a large community-based sample of adults with insomnia, co-occurring chronic fatigue did not moderate the effectiveness of digital cognitive behaviour therapy for insomnia on any of the tested outcomes. This may further establish digital cognitive behaviour therapy for insomnia as an adjunctive intervention in individuals with physical and mental disorders.

Comparison of Acceptance and Commitment Therapy (ACT) and Cognitive Behavior Therapy (CBT) for Chronic Insomnia: A Pilot Randomized Controlled Trial

Purpose

Acceptance and Commitment Therapy (ACT) is part of the third wave of cognitive behavior therapy, and has six core components: acceptance, cognitive defusion, self as context, being present, values, and committed behavior. This study aimed to examine the efficacy of ACT for insomnia compared with cognitive behavior therapy for insomnia (CBT-I) in patients with chronic primary insomnia.

Methods

The study recruited patients with chronic primary insomnia from a university hospital between August 2020 and July 2021. Thirty patients were enrolled and randomly assigned to receive either ACT (n = 15) or CBT-I (n = 15). Interventions were performed over four weeks, with four sessions of face-to-face therapy and four sessions of online therapy. The outcomes were measured using a sleep diary and a questionnaire.

Results

Post-intervention, the ACT and CBT-I groups had significantly improved sleep quality, insomnia severity, depression, beliefs about sleep, sleep onset latency (SOL), and sleep efficacy (SE) (p < 0.05). However, anxiety was significantly reduced in the ACT group (p = 0.015), but not in the CBT-I group.

Conclusion

ACT had a significant effect on primary insomnia and secondary symptoms, especially anxiety related to insomnia. These findings suggest that ACT could be a potential intervention for individuals who do not respond to CBT-I, who have high anxiety regarding sleep problems.

[Asthenia, mental fatigue and cognitive dysfunction]

Conditions associated with asthenia are usually characterized by increased fatigue, impaired activities of daily living and decreased productivity. In clinical practice it is important to distinguish between idiopathic chronic fatigue (primary or functional asthenia) and chronic fatigue syndrome (CFS). Fatigue can also be classified by neuromuscular and/or cognitive and mental fatigue. The article discusses the neuroanatomical basis and focuses on the neurocognitive theory of pathological fatigue. In addition the relationship between mental stress, fatigue and cognitive impairments such as subjective cognitive impairment (SCI) and mild cognitive impairment (MCI) are also discussed. We discuss the rationale that for treatment of asthenic conditions accompanied by cognitive dysfunction it is justified to use combination therapy - fonturacetam and a preparation containing nicotinoyl-GABA and Ginkgo Biloba.

Insomnia Symptoms and Daytime Fatigue Co-Occurrence in Adolescent and Young Adult Childhood Cancer Patients in Follow-Up after Treatment: Prevalence and Associated Risk Factors

Insomnia symptoms and daytime fatigue commonly occur in pediatric oncology, which significantly impact physical and psychosocial health. This study evaluated the prevalence of insomnia only, daytime fatigue only, the co-occurrence of insomnia−daytime fatigue symptoms, and associated risk factors. Childhood cancer patients (n = 565, 12−26 years old, ≥6 months after treatment) participated in a national, cross-sectional questionnaire study, measuring insomnia symptoms (ISI; Insomnia Severity Index) and daytime fatigue (single item). Prevalence rates of insomnia and/or daytime fatigue subgroups and ISI severity ranges were calculated. Multinomial regression models were applied to assess risk factors. Most patients reported no insomnia symptoms or daytime fatigue (61.8%). In the 38.2% of patients who had symptoms, 48.1% reported insomnia and daytime fatigue, 34.7% insomnia only, and 17.1% daytime fatigue only. Insomnia scores were higher in patients with insomnia−daytime fatigue compared to insomnia only (p < 0.001). Risk factors that emerged were: female sex and co-morbidities (all), shorter time after treatment and bedtime gaming (insomnia only), young adulthood (insomnia−fatigue/fatigue only), needing someone else to fall asleep and inconsistent wake times (both insomnia groups), lower educational level and consistent bedtimes (insomnia−fatigue). Insomnia symptoms and daytime fatigue are common and often co-occur. While current fatigue guidelines do not include insomnia symptoms, healthcare providers should inquire about insomnia as this potentially provides additional options for treatment and prevention.

Mechanisms connecting insomnia to hopelessness among Chinese older adults: Serial mediating roles of fatigue and social support

BACKGROUND

Hopelessness and insomnia remain growing mental health issues worldwide, their relationship has been neglected by international development policies, especially in the countries with rapidly aging population like China. However, there is little conclusive evidence on the mechanisms through which insomnia severity influences hopelessness. Based on previous research regarding the significant associations among fatigue, social support, insomnia and hopelessness, this study aims to investigate the relationship between insomnia and hopelessness as well as how insomnia affects hopelessness through fatigue and social support.

METHODS

A population-based data including 946 community-dwelling older adults extracted from "Elderly Care Household Survey in 2019" in Beijing were used. The age of the participants ranged from 66 to 97 years old, and 53.3% of the respondents were female. Intercorrelations among insomnia, fatigue, social support and hopelessness were examined. Serial multiple mediation models were analyzed by the bootstrapping method to assess whether fatigue and social support serially mediate the relationship between insomnia and hopelessness.

RESULTS

Higher level of insomnia severity (coefficient = 0.0421, p < 0.001), higher level of fatigue (coefficient = 0.0171, p < 0.001), and lower level of social support (coefficient = -0.0320, p < 0.001) were significantly associated with higher level of hopelessness. Fatigue and social support in serial, mediated the relationship between insomnia and hopelessness (total effect: coefficient = 0.0623, 95% CI [0.0466, 0.0780]; total direct effect: coefficient = 0.0421, 95% CI [0.0262, 0.0581]; total indirect effect: coefficient = 0.0202, 95% CI [0.0147, 0.0272]).

CONCLUSIONS

Improving sleep quality and eliminating fatigue could effectively alleviate the sense of hopelessness among Chinese older adults. In addition, establishing stronger social support brought by social network from family and friends could confer resilience against the negative effects of despair brought by insomnia. Our findings highlighted the mechanism connecting insomnia to hopelessness, which would inspire the future practice.

Risk factors and multidimensional assessment of long COVID fatigue: a nested case-control study

BACKGROUND

Fatigue is the most prevalent and debilitating long COVID symptom, however risk factors and pathophysiology of this condition remain unknown.We assessed risk factors for long COVID fatigue and explored its possible pathophysiology.

METHODS

Nested case-control study in a COVID recovery clinic. Individuals with (cases) and without (controls) significant fatigue were included. We performed a multidimensional assessment evaluating various parameters, including pulmonary function tests and cardiopulmonary exercise testing, and implemented multivariable logistic regression to assess risk factors for significant long COVID fatigue.

RESULTS

Total of 141 individuals were included. Mean age was 47 (SD 13) years; 115 (82%) were recovering from mild COVID-19. Mean time for evaluation was 8 months following COVID-19. Sixty-six (47%) individuals were classified with significant long COVID fatigue. They had significantly higher number of children, lower proportion of hypothyroidism, higher proportion of sore throat during acute illness and long COVID symptoms, and of physical limitation in daily activities.Individuals with fatigue had poorer sleep quality and higher degree of depression. They had significantly lower heart rate [153.52 (22.64) vs 163.52 (18.53), p=0.038] and oxygen consumption per Kg [27.69 (7.52) vs 30.71 (7.52), p=0.036] at peak exercise.The two independent risk factors for fatigue identified in multivariable analysis were peak exercise heart rate (odds ratio [OR] 0.79 per 10 beats/minute, 95% confidence interval [CI] 0.65-0.96, p=0.019); and long COVID memory impairment (OR 3.76, 95% CI 1.57-9.01, p=0.003).

CONCLUSIONS

Long COVID fatigue may be related to autonomic dysfunction, impaired cognition and decreased mood. This may suggest a limbic-vagal pathophysiology. Clinical Trial registration: NCT04851561.

Fatigue, insomnia and daytime sleepiness in multiple sclerosis versus narcolepsy

OBJECTIVES

In multiple sclerosis (MS), fatigue is the most prevalent cause of impaired ability to work. In narcolepsy, daytime sleepiness is the main symptom but some studies indicate fatigue being present. We aimed to assess fatigue and associated features in patients with MS or narcolepsy and healthy controls and to assess whether clinical parameters separate fatigued (MS-F) and non-fatigued MS patients (MS-NoF).

MATERIALS & METHODS

In this non-interventional cross-sectional study, we recruited 34 MS patients, 15 narcolepsy type 1 patients and 17 healthy controls. An interviewer administered the Fatigue Severity Scale (FSS), the Insomnia Severity Index (ISI), the Epworth Sleepiness Scale, the Patient Health Questionnaire-9 and the Saltin-Grimby Physical Activity Level Scale. Information about clinical parameters and current treatments was collected.

RESULTS

In its fatigue profile, MS-F resembled the narcolepsy group rather than MS-NoF, which resembled the healthy control group. ISI alone was significantly associated with FSS, and only in MS-NoF and healthy controls; in MS-F and the narcolepsy group, no variable was associated with FSS. Months since diagnosis was the only clinical variable significantly separating MS-F from MS-NoF. In MS, disease duration correlated with fatigue. No clinical variables correlated with fatigue in the narcolepsy group.

CONCLUSIONS

Fatigued MS patients resemble narcolepsy patients more than they resemble non-fatigued MS patients, who resemble healthy controls. Insomnia is the main factor associated with fatigue in MS, while disease duration is the only clinical variable separating fatigued and non-fatigued MS patients. In fatigued patients, variance in fatigue cannot be explained by insomnia, daytime sleepiness, depression or level of exercise.

Cognitive Behavioral Therapy and Acceptance and Commitment Therapy for the Discontinuation of Long-Term Benzodiazepine Use in Insomnia and Anxiety Disorders

Benzodiazepines have proven to be highly effective for treating insomnia and anxiety. Although considered safe when taken for a short period of time, a major risk–benefit dilemma arises in the context of long-term use, relating to addiction, withdrawal symptoms, and potential side effects. For these reasons, benzodiazepines are not recommended for treating chronic sleep disorders, anxiety disorders, nor for people over the age of 65, and withdrawal among long-term users is a public health issue. Indeed, only 5% of patients manage to discontinue using these drugs on their own. Even with the help of a general practitioner, this rate does not exceed 25 to 30% of patients, of which approximately 7% manage to remain drug-free in the long term. Cognitive Behavioral Therapies (CBT) offer a crucial solution to this problem, having been shown to increase abstinence success to 70–80%. This article examines traditional and novel CBT techniques in this regard, such as Acceptance and Commitment Therapy, which address both the underlying condition (insomnia/anxiety) and the substance-related disorder. The theoretical framework and evidence supporting the use of these approaches are reviewed. Finally, current research gaps are discussed, and key research perspectives are proposed.

Cognitive behavioral therapy for insomnia in veterans with gulf war illness: Results from a randomized controlled trial

Aims:

To examine whether cognitive behavioral therapy for insomnia (CBT-I), delivered by telephone, improves sleep and non-sleep symptoms of Gulf War Illness (GWI).

Main methods:

Eighty-five Gulf War veterans (21 women, mean age: 54 years, range 46–72 years) who met the Kansas GWI case definition, the Centers for Disease Control and Prevention (CDC) case definition for Chronic Multisymptom Illness (CMI), and research diagnostic criteria for insomnia disorder were randomly assigned to CBT-I or monitor-only wait list control. Eight weekly sessions of individual CBT-I were administered via telephone by Ph.D. level psychologists to study participants. Outcome measures included pre-, mid-, and post-treatment assessments of GWI and insomnia symptoms, subjective sleep quality, and continuous sleep monitoring with diary. Outcomes were re-assessed 6-months post-treatment in participants randomized to CBT-I.

Key findings:

Compared to wait list, CBT-I produced significant improvements in overall GWI symptom severity, individual measures of fatigue, cognitive dysfunction, depression and anxiety, insomnia severity, subjective sleep quality, and sleep diary outcome measures. The beneficial effects of CBT-I on overall GWI symptom severity and most individual GWI symptom measures were maintained 6-months after treatment.

Significance:

GWI symptoms have historically been difficult to treat. Because CBT-I, which is associated with low stigma and is increasingly readily available to veterans, improved both sleep and non-sleep symptoms of GWI, these results suggest that a comprehensive approach to the treatment of GWI should include behavioral sleep interventions.

The effect of acceptance and commitment therapy on insomnia and sleep quality: A systematic review

Background

Acceptance and Commitment Therapy (ACT), as a type of behavioral therapy, attempts to respond to changes in people’s performance and their relationship to events. ACT can affect sleep quality by providing techniques to enhance the flexibility of patients’ thoughts, yet maintaining mindfullness. Therefore, for the first time, a systematic review on the effects of ACT on sleep quality has been conducted.

Methods

This systematic review was performed to determine the effect of ACT on insomnia and sleep quality. To collect articles, the PubMed, Web of Science (WOS), Cochrane library, Embase, Scopus, Science Direct, ProQuest, Mag Iran, Irandoc, and Google Scholar databases were searched, without a lower time-limit, and until April 2020.

Results

Related articles were derived from 9 research repositories, with no lower time-limit and until April 2020. After assessing 1409 collected studies, 278 repetitive studies were excluded. Moreover, following the primary and secondary evaluations of the remaining articles, 1112 other studies were removed, and finally a total of 19 intervention studies were included in the systematic review process. Within the remaining articles, a sample of 1577 people had been assessed for insomnia and sleep quality.

Conclusion

The results of this study indicate that ACT has a significant effect on primary and comorbid insomnia and sleep quality, and therefore, it can be used as an appropriate treatment method to control and improve insomnia.

The presence of overlapping quality of life symptoms in primary antibody deficiency (PAD) and chronic fatigue syndrome (CFS)

Background

Fatigue, sleep disturbance and altered mood are frequently reported in patients with primary antibody deficiency syndrome (PADS) on adequate immunoglobulin replacement therapy. This study aimed to determine the frequency of symptoms compatible with chronic fatigue syndrome (CFS) in patients with PADS.

Methods

The study involved the distribution of 682 self-completed postal questionnaires to ascertain the presence and frequency of symptoms compatible with CFS in patients with PADS. The reporting of symptoms for each patient were scored against the CFS diagnostic criteria used within our own South London Chronic Fatigue service.

Results

The frequency of symptoms compatible with CFS were evident in 26 of the 188 patients (16.25%) returning adequately completed questionnaires. We considered a bias in the return of questionnaires amongst PADS patients with fatigue to be likely. As such we estimated the minimum frequency of CFS in patients with PADS to be 4% based on the 682 PAD patients to whom the questionnaire was distributed. This was significantly higher than the 0.5% estimate of the prevalence of CFS in the community in western populations. While the presence of significant fatigue correlated with the presence of anxiety and depression, there was no association with self-reported lung damage. Sleep disturbance affected 60% of the PAD patients returning satisfactory questionnaires and as expected the CFS score was higher in those with greater physical limitation.

Conclusions

We conclude that patients with PADS have a high frequency of fatigue, low mood and anxiety. We suggest routine questioning for the symptoms of fatigue, disturbed sleep and altered mood in patients with PADS. The use of several treatment strategies in CFS may prove beneficial in improving the quality of life of patients with PAD.

Factors associated with fatigue in patients with insomnia

Although fatigue is common in insomnia, the clinical associates of fatigue in patients with insomnia are largely unknown. We aimed to investigate the clinical associates of fatigue in patients with insomnia. Patients visiting the Stanford Sleep Medicine Center completed the Insomnia Severity Index (ISI), Insomnia Symptom Questionnaire (ISQ), the Fatigue Severity Scale (FSS), the Epworth Sleepiness Scale (ESS), and the Patient Health Questionnaire (PHQ-9). Among 6367 patients, 2024 were diagnosed with insomnia (age 43.06 ± 15.19 years; 1110 women and 914 men) according to the ISI and the ISQ. Insomnia patients with severe fatigue (n = 1306) showed higher insomnia symptoms, daytime sleepiness, depression and longer habitual sleep duration than those without severe fatigue (n = 718). Higher insomnia symptoms, daytime sleepiness and depressive symptoms, and longer habitual sleep duration, independently predicted higher fatigue scores. Among insomnia patients with daytime sleepiness (ESS≥10), only habitual sleep duration and depression predicted fatigue scores. The interaction between insomnia severity and daytime sleepiness significantly predicted the severity of fatigue. Depression was a significant mediator between insomnia and fatigue. For 598 insomnia patients undergoing overnight polysomnography (PSG), no significant correlations were found between fatigue and any PSG parameters. The current study suggests that managing insomnia or depression may reduce the fatigue of insomnia patients, whereas arbitrary efforts to prolong sleep duration may worsen their fatigue.

Prevalence and factors associated with fatigue in the Lausanne middle-aged population: a population-based, cross-sectional survey

OBJECTIVE

To assess the prevalence and factors associated with fatigue in the general population.

DESIGN

Population-based, cross-sectional survey performed between May 2014 and April 2017.

SETTING

General population of the city of Lausanne, Switzerland.

PARTICIPANTS

2848 participants (53.2% women, age range 45-86 years).

PRIMARY OUTCOME MEASURE

Prevalence of fatigue the previous week, defined as a score of ≥4 using the Fatigue Severity Scale.

RESULTS

The prevalence of fatigue was 21.9% (95% CI 20.4% to 23.4%) in the total sample. On bivariate analysis, participants with fatigue were younger, had a higher body mass index, a lower handgrip strength and lower ferritin levels. Participants with fatigue were more frequently women, had a lower educational level, presented more frequently with clinical insomnia, diabetes, anaemia, depression and low thyroid stimulating hormone (TSH) values, had a higher consumption of antihistamines, antidepressants and hypnotics, and rated more frequently their health as bad or very bad. Multivariable analysis showed that obesity (OR 1.40 (95% CI 1.03 to 1.91)), insomnia categories (p value for trend <0.001), depression (OR 3.26 (95% CI 2.38 to 4.46)), anaemia (OR 1.70 (95% CI 1.00 to 2.89)) and low self-rated health status (p value for trend <0.001) were positively associated with fatigue, while older age (p value for trend 0.002) was negatively associated with fatigue. Conversely, no association was found for diabetes, TSH levels, antihistamines or hypnotics.

CONCLUSION

In a population-based sample aged 45-86, fatigue was present in one out of five subjects. Regarding clinical factors, sleep disturbances such as insomnia and sleep apnoea should be assessed first, followed by depression. Regarding biological factors, anaemia should be ruled out, while screening for hypothyroidism is not recommended as a first step. Sleep complaints and fatigue in older subjects are not due to ageing and should prompt identification of the underlying cause.

The Relationship Between Improvement in Insomnia Severity and Long-Term Outcomes in the Treatment of Chronic Fatigue

Background: The current treatments of choice for patients with chronic fatigue are moderately effective. One way to advance treatments is identifying process variables associated with good treatment outcomes. There is little knowledge regarding a possible association between insomnia and long-term outcomes in the treatment of chronic fatigue.

Aims: Testing whether (1) improvement in insomnia is associated with improvement in levels of fatigue at 1-year follow-up, and (2) if such a relationship remains when controlling for improvement in levels of anxiety and depression, and pain in patients with chronic fatigue.

Methods: Patients having been on sick leave 8 weeks or more due to chronic fatigue were referred to a return-to-work program. They received an intensive 3.5-week inpatient treatment program based on acceptance and commitment therapy (ACT). Before treatment and at 1-year follow-up the patients completed questionnaires assessing levels of insomnia severity, pain, anxiety and depression, and fatigue.

Results: A regression analysis found that changes in insomnia-severity were associated with changes in fatigue-levels at 1-year follow-up. When changes in levels of anxiety and depression were entered in the regression analysis, anxiety and depression was significantly associated with levels of fatigue but insomnia was not. The association between anxiety and depression and fatigue was at a trend level when pain was entered into the model.

Conclusion: Long-term improvement in insomnia severity was significantly associated with long-term improvement in chronic fatigue, but not independently of long-term improvement in anxiety and depression, and pain.

Trial Registration:https://clinicaltrials.gov/, identifier NCT01568970.

Association between Salivary Mitochondrial DNA Copy Number and Chronic Fatigue according to Combined Symptoms in Korean Adults

Background

We examined the association between salivary mitochondrial DNA (mtDNA) copy number and chronic fatigue combined with depression and insomnia.

Methods

This cross-sectional study included 58 healthy adults with moderate to severe fatigue (Brief Fatigue Inventory [BFI] ≥4) for longer than 6 months. Subjects were classified as those without combined symptoms, with either depression (Beck Depression Inventory [BDI] ≥13) or insomnia (Pittsburgh Sleep Quality Index [PSQI] ≥5), or with both depression and insomnia. Salivary mtDNA copy number was measured by real-time quantitative polymerase chain reaction. The association was evaluated using a general linear model.

Results

About 76% of participants had either depression or insomnia as additional symptoms. These subjects were predominately female, drank more alcohol, and exercised less than those without combined symptoms (P<0.05). The group with both depression and insomnia exhibited significantly higher BFI and lower mtDNA copy number than those without combined symptoms (P<0.05). After adjusting for confounding factors, significant negative associations between mtDNA copy number and usual fatigue were found in the group without combined symptoms, whereas the negative associations in the group with combined symptoms were attenuated. BDI and PSQI were not associated with mtDNA copy number.

Conclusion

Chronic fatigue is negatively associated with salivary mtDNA copy number. Salivary mtDNA copy number may be a biological marker of fatigue with or without combined symptoms, indicating that a separate approach is necessary.

Health care utilization among young Australian women with severe tiredness: Results from the Australian Longitudinal Study on Women's Health (ALSWH)

In this article, we explore the use of health services and self-prescribed treatments among 8088 young Australian women with severe tiredness. Data were obtained from the Australian Longitudinal Study on Women's Health. The prevalence of severe tiredness was 49.2%. The frequency of visits to healthcare practitioners was greater among women who sought help for their severe tiredness, compared to women who did not seek help for their severe tiredness or who did not report severe tiredness. Given the impact of this health problem on Australian women, we call for further research on the optimal treatment for severe tiredness.

Investigating unexplained fatigue in general practice with a particular focus on CFS/ME

Unexplained fatigue is not infrequent in the community. It presents a number of challenges to the primary care physician and particularly if the clinical examination and routine investigations are normal. However, while fatigue is a feature of many common illnesses, it is the main problem in Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME). This is a poorly understood condition that is accompanied by several additional symptoms which suggest a subtle multisystem dysfunction. Not infrequently it is complicated by sleep disturbance and alterations in attention, memory and mood.

Specialised services for the diagnosis and management of CFS/ME are markedly deficient in the UK and indeed in virtually all countries around the world. However, unexplained fatigue and CFS/ME may be confidently diagnosed on the basis of specific clinical criteria combined with the normality of routine blood tests. The latter include those that assess inflammation, autoimmunity, endocrine dysfunction and gluten sensitivity. Early diagnosis and intervention in general practice will do much to reduce patient anxiety, encourage improvement and prevent expensive unnecessary investigations.

There is presently an on-going debate as to the precise criteria that best confirms CFS/ME to the exclusion of other medical and psychiatric/psychological causes of chronic fatigue. There is also some disagreement as to best means of investigating and managing this very challenging condition. Uncertainty here can contribute to patient stress which in some individuals can perpetuate and aggravate symptoms. A simple clinical scoring system and a short list of routine investigations should help discriminate CFS/ME from other causes of continued fatigue.

Metacognitions Are Associated with Subjective Memory Problems in Individuals on Sick Leave due to Chronic Fatigue

Background: Subjective cognitive impairments are frequent, but poorly understood in patients with chronic fatigue. We hypothesized that maladaptive metacognitive beliefs at baseline were associated with baseline subjective cognitive impairments, that they predict subjective cognitive impairments at treatment termination, and that a reduction in maladaptive metacognitive beliefs was associated with less subjective cognitive impairments at treatment termination, independent of changes in fatigue, pain, insomnia, depression, and anxiety.

Methods: In this non-controlled study, patients (n = 137) on sick leave due to chronic fatigue received a 3.5-week inpatient RTW rehabilitation program. Of these patients 69 (50.4%) was referred with a ICPC-2 diagnosis of chronic fatigue. Patients completed questionnaires about metacognitive beliefs, somatic complaints, psychological complaints, and cognitive impairments before and after treatment. To test the hypotheses we performed paired t-tests of change, as well as seven hierarchical linear regressions.

Results: Results showed that baseline maladaptive metacognitive beliefs were significantly associated with subjective cognitive impairments at baseline, controlling for symptoms. Score on baseline metacognitive beliefs did not predict impairments post-treatment. Testing specific maladaptive beliefs, pre-treatment scores on cognitive confidence were associated with subjective cognitive impairments both pre and post-treatment, controlling for symptoms. Post-treatment metacognitive beliefs and post-treatment cognitive confidence were associated with post-treatment subjective cognitive impairments, controlling for pre-treatment impairments and pre-treatment metacognitive beliefs, as well as pre and post-scores on symptom measures.

Conclusion: This study reports associations between maladaptive metacognitive beliefs and subjective cognitive impairments in patients with chronic fatigue. Targeting metacognitive beliefs could prove an effective therapeutic intervention for subjective cognitive impairments in these patients.

Subjective insomnia is associated with low sleep efficiency and fatigue in middle-aged women

OBJECTIVES

Many middle-aged women are affected by sleep disturbance. We investigated how subjective insomnia is associated with objective sleep parameters and other background characteristics.

METHODS

This cross-sectional study used baseline data obtained from 95 women aged 40-59 years who participated in another study assessing the effects of a dietary supplement. Participants wore an actigraph unit for 3 days to collect information concerning physical activities and objective sleep parameters and were then evaluated for body composition, cardiovascular parameters, and menopausal symptoms including insomnia and fatigue, and lifestyle factors. Stratifying Athens Insomnia Scale scores as low (0-5 points, control group) and high (≥ 6 points, subjective insomnia group), we sought to identify the parameters that are independently associated with subjective insomnia.

RESULTS

Women with subjective insomnia (n = 30) had lower sleep efficiency than did the controls. They were also older; had more live births, lower height, higher body mass index, lower ankle brachial index, and more severe menopausal symptoms including fatigue; took more naps; smoked more cigarettes; and more of them were full-time workers. Multivariate logistic regression analysis revealed that low sleep efficiency (adjusted odds ratio, 1.44 per 1% decrease in sleep efficiency; 95% confidence interval 1.06-2.05) and fatigue assessed with Brief Fatigue Inventory (BFI) (adjusted odds ratio, 1.57 per 1-point increase in BFI score; 95% confidence interval 1.19-2.13) were independent contributors to subjective insomnia.

CONCLUSIONS

Low sleep efficiency and feeling of fatigue were found to be independently associated with subjective insomnia in middle-aged women.

Unresolved grief and its consequences. A nationwide follow-up of teenage loss of a parent to cancer 6-9 years earlier

PURPOSE

The early loss of a parent is a tragedy and a serious life event. This study investigated grief resolution and morbidity in cancer-bereaved teenagers 6 to 9 years after the loss of a parent to cancer.

METHODS

In a nationwide population-based study of 622 of 851 (73 %) youths who as teenagers 6 to 9 years earlier had lost a parent to cancer, we explored the magnitude of unresolved grief and its association with psychological and physiological morbidity. Participants answered a study-specific anonymous questionnaire including questions about if they had worked through their grief and about their current health.

RESULTS

Six to nine years post-loss 49 % reported unresolved grief (8 % no and 41 % a little grief resolution). They had, in comparison with youths reporting resolved grief, statistically significantly elevated risks, e.g. for insomnia (sons' relative risk (RR) 2.3, 95 % CI 1.3-4.0; daughters' RR 1.7, 95 % CI 1.1-2.7), fatigue (sons' RR 1.8, 95 % CI 1.3-2.5; daughters' RR 1.4, 95 % CI 1.1-1.7) and moderate to severe depression, i.e. score >9, PHQ-9 (sons' RR 3.6, 95 % CI 1.4-8.8; daughters' RR 1.8, 95 % CI 1.1-3.1). Associations remained for insomnia in sons, exhaustion in daughters and fatigue in both sons and daughters when depression, negative intrusive thoughts and avoiding reminders of the parents' disease or death were included in a model.

CONCLUSIONS

Approximately half of cancer-bereaved youth report no or little grief resolution 6 to 9 years post-loss, which is associated with fatigue, sleeping problems and depressive symptoms.

Bidirectional relationship between sleep and optimism with depressive mood as a mediator: A longitudinal study of Chinese working adults

OBJECTIVE

Sleep and optimism are important psycho-biological and personality constructs, respectively. However, very little work has examined the causal relationship between them, and none has examined the potential mechanisms operating in the relationship. This study aimed to understand whether sleep quality was a cause or an effect of optimism, and whether depressive mood could explain the relationship.

METHOD

Internet survey data were collected from 987 Chinese working adults (63.4% female, 92.4% full-time workers, 27.0% married, 90.2% Hong Kong residents, mean age=32.59 at three time-points, spanning about 19 months). Measures included a Chinese attributional style questionnaire, the Pittsburgh Sleep Quality Index, and the Depression Anxiety Stress Scale.

RESULTS

Cross-sectional analyses revealed moderate correlations among sleep quality, depressive mood, and optimism. Cross-lagged analyses showed a bidirectional causality between optimism and sleep. Path analysis demonstrated that depressive mood fully mediated the influence of optimism on sleep quality, and it partially mediated the influence of sleep quality on optimism.

CONCLUSION

Optimism improves sleep. Poor sleep makes a pessimist. The effects of sleep quality on optimism could not be fully explained by depressive mood, highlighting the unique role of sleep on optimism. Understanding the mechanisms of the feedback loop of sleep quality, mood, and optimism may provide insights for clinical interventions for individuals presented with mood-related problems.