Source: The Primary Care Companion to the
Journal of Clinical Psychiatry
Vol. 10, #2, pp. 120-128
Date: March 2008
URL:
http://psychiatrist.com/pcc/
http://psychiatrist.com/pcc/abstracts/abstracts.asp?abstract=pcc100206.htm
A systematic review of Chronic Fatigue Syndrome: Don't assume it's
depression
-----------------------------------------------------------------------------
James P. Griffith, M.D., F.A.C.P., and Fahd A. Zarrouf, M.D.
- From the Internal Medicine/Psychiatry Residency Program, West Virginia
University, Charleston.
- Corresponding author and reprints: Fahd A. Zarrouf, M.D., Medicine/
Psychiatry Residency Program, West Virginia University, 501 Morris St.,
4 West, Charleston, WV 25326 (e-mail: fahdzarrouf@hotmail.com).
- The authors report no financial relationship with any company whose
products are mentioned in this article or with manufacturers of competing
products.
Received July 20, 2007; accepted Sept. 14, 2007.
FIGURE CAPTION
Figure 1. Algorithm for Evaluating Chronic Fatigue Syndrome (CFS)
TABLES
Table 1. Chronic Fatigue Syndrome Criteria^a
--------------------------------------------------------------------------------
1. Unexplained, persistent fatigue that is not due to ongoing exertion, is not
substantially relieved by rest, is of new onset (not lifelong), and results
in a significant reduction in previous levels of activity
AND
2. Four or more of the following symptoms are present for 6 months or more:
Impaired memory or concentration
Postexertional malaise (extreme, prolonged exhaustion and exacerbation of
symptoms following physical or mental exertion)
Unrefreshing sleep
Muscle pain
Multijoint pain without swelling or redness
Headaches of a new type or severity
Sore throat that's frequent or recurring
Tender cervical or axillary lymph nodes
--------------------------------------------------------------------------------
^a From the Centers for Disease Control and Prevention.1
Table 2. Comparison Between Chronic Fatigue Syndrome (CFS) and Depression Across
Different Studies
-------------------------------------------------------------------------------------------------------------
Domain CFS Depression
-------------------------------------------------------------------------------------------------------------
History
Postexertional malaise56 Feeling better after
exercise/activities
Unrefreshing sleep/excessive sleep56 Insomnia or excessive
sleep
Fatigue is associated with intense frustration Fatigue is associated
with apathy and anhedonia
at not functioning well57
Patients are less likely to interpret symptoms Patients are more
likely to interpret symptoms
in terms of negative emotional states58 in terms of
negative emotional states
Patients attribute their illness to external or Patients may
attribute their illness to
somatic experiences59,60 psychological
factors
More likely to cope with their illness by More likely to cope
with their illness by
limiting stress and activity levels59 increasing their
activity levels
Difficulties in the doctor-patient relationship Less likely to
develop difficulties in the doctor-
related to frustration of no diagnosis61 patient
relationship, and most likely related
to treatment or
comorbid disorders
Physical and mental status examinations
Patients are weaker and they have more pain Patients are stronger
and they have fewer pain
complaints62 complaints
Sore throat that is frequent or recurring1 NA
Tender cervical or axillary lymph nodes1 NA
CFS patients generally performed worse on MDD patients
generally performed worse on
cognitive tests than healthy controls, but cognitive tests
than healthy controls, and
better than patients with MDD63 worse than
patients with CFS
Diagnostic tests^a
Low DHEA level64 Low DHEA sulfate
derivative level
Sleep studies showed more non-REM sleep Sleep studies showed
more REM sleep disturbances
disturbances56
More resting T (CD3+/CD25-) cells. Fewer resting T
(CD3+/CD25-) cells.
Fewer CD20+/CD5+ B cells20 More CD20+/CD5+ B
cells
-------------------------------------------------------------------------------------------------------------
^a There is no definite diagnostic test.
Abbreviations: DHEA=dehydroepiandrosterone, MDD=major depressive disorder,
NA=not applicable, REM=rapid eye
movement.
Table 3. Chronic Fatigue Syndrome Differential Diagnoses
--------------------------------------------------------------------------------
Psychiatric/neurological disorders
Depressive disorders
Anxiety disorders
Fibromyalgia
Substance abuse/dependence
Sleep disorders
Infectious diseases
Herpesvirus infections
Lyme disease
Parvovirus B19
Borna disease virus
Glandular fever
Human mononucleosis
Q fever
Enterovirus
Nipah virus encephalitis
Endocrine diseases
Hypothyroidism
Severe obesity
Diabetes mellitus
Immunologic disorders
Lupus
Multiple sclerosis
Temporomandibular joint disorder
Others
Medications
Irritable bowel syndrome
Multiple chemical sensitivity
Gulf War syndrome
Interstitial cystitis
--------------------------------------------------------------------------------
REFERENCES
1. Centers for Disease Control and Prevention. Chronic Fatigue Syndrome.
May 26, 2006. Available at:
http://www.cdc.gov/cfs.
Accessed Feb 3, 2007
2. Wessely S. The epidemiology of chronic fatigue syndrome. Epidemiol
Rev 1995;17:139-151
3. Schafer ML. On the history of the concept neurasthenia and its modern
variants chronic fatigue syndrome, fibromyalgia, and multiple chemical
sensitivities [in German]. Fortschr Neurol Psychiatr 2002;70(11):
570-582
4. Holmes GP, Kaplan JE, Gantz NM, et al. Chronic fatigue syndrome:
a working case definition. Ann Intern Med 1988;108:387-389
5. Lloyd AR, Wakefield D, Boughton C, et al. What is myalgic en-
cephalomyelitis? Lancet 1988;1:1286-1287
6. Lloyd AR, Hickie I, Boughton CR, et al. Prevalence of chronic fatigue
syndrome in an Australian population. Med J Aust 1990;153:522-528
7. Sharpe MC, Archard LC, Banatvala JE, et al. A report: chronic fatigue
syndrome: guidelines for research. J R Soc Med 1991;84:118-121
8. Maquet D, Demoulin C, Crielaard JM. Chronic fatigue syndrome:
a systematic review. Ann Readapt Med Phys 2006;49(6):337-347,
418-427
9. Lee S, Yu H, Wing Y, et al. Psychiatric morbidity and illness
experience of primary care patients with chronic fatigue in Hong Kong.
Am J Psychiatry 2000;157:380-384
10. Davis MP, Khoshknabi D, Yue GH. Management of fatigue in cancer
patients. Curr Pain Headache Rep 2006;10(4):260-269
11. Pearce JM. The enigma of chronic fatigue. Eur Neurol 2006;56(1):31-36
12. Pichot P. Neurasthenia, yesterday and today [in French]. Encephale
1994;20 Spec No 3:545-549
13. Rangel L, Garralda ME, Jeffs J, et al. Family health and characteristics
in chronic fatigue syndrome, juvenile rheumatoid arthritis, and emotional
disorders of childhood. J Am Acad Child Adolesc Psychiatry 2005;
44(2):150-158
14. Endicott NA. Chronic fatigue syndrome in private practice psychiatry:
family history of physical and mental health. J Psychosom Res
1999;47(4):343-354
15. Buchwald D, Herrell R, Ashton S, et al. A twin study of chronic
fatigue. Psychosom Med 2001;63(6):936-943
16. Hickie I, Kirk K, Martin N. Unique genetic and environmental
determinants of prolonged fatigue: a twin study. Psychol Med
1999;29(2):259-268
17. Cho HJ, Skowera A, Cleare A, et al. Chronic fatigue syndrome: an update
focusing on phenomenology and pathophysiology. Curr Opin Psychiatry
2006;19(1):67-73
18. Klimas NG, Salvato FR, Morgan R, et al. Immunologic abnormalities in
the chronic fatigue syndrome. J Clin Microbiol 1990;28:1403-1410
19. Landay AL, Jessop C, Lennette ET, et al. Chronic fatigue syndrome:
a clinical condition associated with immune activation. Lancet
1991;338:707-712
20. Robertson MJ, Schacterle RS, Mackin GA, et al. Lymphocyte subset
differences in patients with chronic fatigue syndrome, multiple sclerosis
and major depression. Clin Exp Immunol 2005;141(2):326-332
21. Lloyd A, Hickie I, Brockman A, et al. Cytokine levels in serum and cere-
brospinal fluid in patients with chronic fatigue syndrome and control
subjects. J Infect Dis 1991;164:1023-1024
22. Staines DR. Postulated vasoactive neuropeptide autoimmunity in fatigue-
related conditions: a brief review and hypothesis. Clin Dev Immunol
2006;13(1):25-39
23. Byrne E. The chronic fatigue syndrome: a reappraisal and unifying
hypothesis. Clin Exp Neurol 1991;28:128-138
24. Nakaya T, Kuratsune H, Kitani T, et al. Demonstration on Borna disease
virus in patients with chronic fatigue syndrome [in Japanese]. Nippon
Rinsho 1997;55(11):3064-3071
25. Li YJ, Wang DX, Bai XL, et al. Clinical characteristics of patients with
chronic fatigue syndrome: analysis of 82 cases [in Chinese]. Zhonghua
Yi Xue Za Zhi 2005;85(10):701-704
26. Matano S, Kinoshita H, Tanigawa K, et al. Acute parvovirus B19 infec-
tion mimicking chronic fatigue syndrome. Intern Med 2003;42(9):
903-905
27. Kerr JR. Pathogenesis of parvovirus B19 infection: host gene variability,
and possible means and effects of virus persistence. J Vet Med B Infect
Dis Vet Public Health 2005;52(7-8):335-339
28. White PD, Thomas JM, Amess J, et al. Incidence, risk and prognosis
of acute and chronic fatigue syndromes and psychiatric disorders after
glandular fever. Br J Psychiatry 1998;173:475-481
29. Chia JK. The role of enterovirus in chronic fatigue syndrome.
J Clin Pathol 2005;58(11):1126-1132
30. Kondo K. Human herpesvirus latency and fatigue. Uirusu 2005;55(1):
9-17
31. Komaroff AL. Chronic fatigue syndromes: a preliminary overview.
Can Dis Wkly Rep 1991;17:23-28
32. Ablashi DV. Viral studies of chronic fatigue syndrome. Clin Infect Dis
1994;18(suppl 1):S130-S133
33. White PD, Thomas JM, Sullivan PF, et al. The nosology of sub-acute
and chronic fatigue syndromes that follow infectious mononucleosis.
Psychol Med 2004;34(3):499-507
34. Ng BY, Lim CC, Yeoh A, et al. Neuropsychiatric sequelae of Nipah virus
encephalitis. J Neuropsychiatry Clin Neurosci 2004;16(4):500-504
35. Parker NR, Barralet JH, Bell AM. Q fever. Lancet 2006;367(9511):
679-688
36. Masuda A, Nakayama T, Yamanaka T, et al. The prognosis after multi-
disciplinary treatment for patients with postinfectious chronic fatigue
syndrome and noninfectious chronic fatigue syndrome. J Behav Med
2002;25(5):487-497
37. Wheatland R. Chronic ACTH autoantibodies are a significant pathologi-
cal factor in the disruption of the hypothalamic-pituitary-adrenal axis in
chronic fatigue syndrome, anorexia nervosa and major depression.
Med Hypotheses 2005;65(2):287-295
38. Gottschalk M, Kumpfel T, Flachenecker P, et al. Fatigue and regulation
of the hypothalamo-pituitary-adrenal axis in multiple sclerosis. Arch
Neurol 2005 Feb;62(2):277-280
39. Wessely S. The neuropsychiatry of chronic fatigue syndrome. Ciba
Found Symp 1993;173:212-229; discussion 229-237
40. Gaab J, Engert V, Heitz V, et al. Associations between neuroendocrine
responses to the Insulin Tolerance Test and patient characteristics in
chronic fatigue syndrome. J Psychosom Res 2004;56(4):419-424
41. Bakheit AM, Behan PO, Dinan TG, et al. Possible upregulation of
hypothalamic 5-hydroxytryptamine receptors in patients with postviral
fatigue syndrome. BMJ 1992;304(6833):1010-1012
42. Inder WJ, Prickett TC, Mulder RT. Normal opioid tone and hypothala-
mic-pituitary-adrenal axis function in chronic fatigue syndrome despite
marked functional impairment. Clin Endocrinol (Oxf) 2005;62(3):
343-348
43. Durlach J, Pages N, Bac P, et al. Chronopathological forms of magne-
sium depletion with hypofunction or with hyperfunction of the biological
clock. Magnes Res 2002;15(3-4):263-268
44. Kuratsune H, Yamaguti K, Sawada M, et al. Dehydroepiandrosterone
sulfate deficiency in chronic fatigue syndrome. Int J Mol Med 1998;
1(1):143-146
45. Nijs J, De Meirleir K. Impairments of the 2-5 synthetase/RNase L
pathway in chronic fatigue syndrome. In Vivo 2005;19(6):1013-1021
46. Winkler AS, Blair D, Marsden JT, et al. Autonomic function and serum
erythropoietin levels in chronic fatigue syndrome. J Psychosom Res
2004;56(2):179-183
47. Hatcher S, House A. Life events, difficulties and dilemmas in the onset
of chronic fatigue syndrome: a case-control study. Psychol Med 2003;
33(7):1185-1192
48. Taylor RR, Jason LA. Chronic fatigue, abuse-related traumatization,
and psychiatric disorders in a community-based sample. Soc Sci Med
2002;55(2):247-256
49. Heim C, Wagner D, Maloney E, et al. Early adverse experience and risk
for chronic fatigue syndrome: results from a population-based study.
Arch Gen Psychiatry 2006;63(11):1258-1266
50. Morriss R, Sharpe M, Sharpley AL, et al. Abnormalities of sleep in
patients with the chronic fatigue syndrome. BMJ 1993;306(6886):
1161-1164
51. Morriss RK, Wearden AJ, Battersby L. The relation of sleep difficulties
to fatigue, mood and disability in chronic fatigue syndrome. J Psychosom
Res 1997;42(6):597-605
52. Friedlander AH, Mahler ME, Yagiela JA. Restless legs syndrome:
manifestations, treatment and dental implications. J Am Dent Assoc
2006;137(6):755-761
53. Terman M, Levine SM, Terman JS, et al. Chronic fatigue syndrome and
seasonal affective disorder: comorbidity, diagnostic overlap, and implica-
tions for treatment. Am J Med 1998;105(3A):115S-124S
54. Ghahramani M, Gooriah V. Chronic fatigue syndrome associated with a
psychotic state resulting in multiple murders. Bull Am Acad Psychiatry
Law 1995;23(4):613-616
55. Skapinakis P, Lewis G, Mavreas V. Unexplained fatigue syndromes in a
multinational primary care sample: specificity of definition and preva-
lence and distinctiveness from depression and generalized anxiety.
Am J Psychiatry 2003;160:785-787
56. Hawk C, Jason LA, Torres-Harding S. Differential diagnosis of chronic
fatigue syndrome and major depressive disorder. Int J Behav Med 2006;
13(3):244-251
57. Moldofsky H. Nonrestorative sleep and symptoms after a febrile illness
in patients with fibrositis and chronic fatigue syndromes. J Rheumatol
Suppl 1989;19:150-153
58. Dendy C, Cooper M, Sharpe M. Interpretation of symptoms in chronic
fatigue syndrome. Behav Res Ther 2001;39(11):1369-1380
59. Moss-Morris R, Petrie KJ. Discriminating between chronic fatigue
syndrome and depression: a cognitive analysis. Psychol Med 2001;
31(3):469-479
60. White PD, Pinching AJ, Rakib A, et al. A comparison of patients with
chronic fatigue syndrome attending separate fatigue clinics based in
immunology and psychiatry. J R Soc Med 2002;95(9):440-444
61. David AS. Postviral fatigue syndrome and psychiatry. Br Med Bull
1991;47(4):966-988
62. Fulcher KY, White PD. Strength and physiological response to exercise
in patients with chronic fatigue syndrome. J Neurol Neurosurg Psychiatry
2000;69(3):302-307
63. Lawrie SM, MacHale SM, Cavanagh JT, et al. The difference in patterns
of motor and cognitive function in chronic fatigue syndrome and severe
depressive illness. Psychol Med 2000;30(2):433-442
64. Scott LV, Salahuddin F, Cooney J, et al. Differences in adrenal steroid
profile in chronic fatigue syndrome, in depression and in health.
J Affect Disord 1999;54(1�2):129-137
65. Sharpe M, Chalder T, Palmer I, et al. Chronic fatigue syndrome: a
practical guide to assessment and management. Gen Hosp Psychiatry
1997;19(3):185-199
66. Glass JM. Cognitive dysfunction in fibromyalgia and chronic fatigue
syndrome: new trends and future directions. Curr Rheumatol Rep
2006;8(6):425-429
67. Geisser ME, Gracely RH, Giesecke T, et al. The association between
experimental and clinical pain measures among persons with fibromyal-
gia and chronic fatigue syndrome. Eur J Pain 2007;11(2):202-207
68. Yunus MB. Fibromyalgia and overlapping disorders: the unifying
concept of central sensitivity syndromes. Semin Arthritis Rheum
2007;36(6):339-356
69. Brown MM, Jason LA. Functioning in individuals with chronic fatigue
syndrome: increased impairment with co-occurring multiple chemical
sensitivity and fibromyalgia. Dyn Med 2007;6:9
70. Cook DB, Nagelkirk PR, Poluri A, et al. The influence of aerobic fitness
and fibromyalgia on cardiorespiratory and perceptual responses to exer-
cise in patients with chronic fatigue syndrome. Arthritis Rheum
2006;54(10):3351-3362
71. Matsumoto Y. Fibromyalgia syndrome. Nippon Rinsho 1999;57(2):
364-369
72. Naschitz JE, Rosner I, Rozenbaum M, et al .The head-up tilt test with
haemodynamic instability score in diagnosing chronic fatigue syndrome.
QJM 2003;96(2):133-142
73. Gallagher AM, Coldrick AR, Hedge B, et al. Is the chronic fatigue syn-
drome an exercise phobia? a case control study. J Psychosom Res
2005;58(4):367-373
74. Marshall GS, Gesser RM, Yamanishi K, et al. Chronic fatigue in chil-
dren: clinical features, Epstein-Barr virus and human herpesvirus 6
serology and long term follow-up. Pediatr Infect Dis J 1991;10(4):
287-290
75. Buchwald D, Wener MH, Pearlman T, et al. Markers of inflammation
and immune activation in chronic fatigue and chronic fatigue syndrome.
J Rheumatol 1997;24(2):372-376
76. Swanink CM, Vercoulen JH, Bleijenberg G, et al. Chronic fatigue syn-
drome: a clinical and laboratory study with a well matched control group.
J Intern Med 1995;237(5):499-506
77. Natelson BH, Cohen JM, Brassloff I, et al. A controlled study of brain
magnetic resonance imaging in patients with the chronic fatigue syn-
drome. J Neurol Sci 1993;120(2):213-217
78. Cope H, Pernet A, Kendall B, et al. Cognitive functioning and magnetic
resonance imaging in chronic fatigue. Br J Psychiatry 1995;167(1):86-94
79. Greco A, Tannock C, Brostoff J, et al. Brain MR in chronic fatigue syn-
drome. AJNR Am J Neuroradiol 1997;18(7):1265-1269
80. Lange G, DeLuca J, Maldjian JA, et al. Brain MRI abnormalities exist in
a subset of patients with chronic fatigue syndrome. J Neurol Sci 1999;
171(1):3-7
81. Cook DB, Lange G, DeLuca J, et al. Relationship of brain MRI abnor-
malities and physical functional status in chronic fatigue syndrome.
Int J Neurosci 2001;107(1-2):1-6
82. Lange G, Holodny AI, DeLuca J, et al. Quantitative assessment of
cerebral ventricular volumes in chronic fatigue syndrome. Appl
Neuropsychol 2001;8(1):23-30
83. de Lange FP, Kalkman JS, Bleijenberg G, et al. Gray matter volume
reduction in the chronic fatigue syndrome. Neuroimage 2005;26(3):
777-781
84. Daugherty SA, Henry BE, Peterson DL, et al. Chronic fatigue syndrome
in northern Nevada. Rev Infect Dis 1991;13(suppl 1):S39-S44
85. Caseras X, Mataix-Cols D, Giampietro V, et al. Probing the working
memory system in chronic fatigue syndrome: a functional magnetic
resonance imaging study using the n-back task. Psychosom Med 2006;
68(6):947-955
86. Tanaka M, Sadato N, Okada T, et al. Reduced responsiveness is an essen-
tial feature of chronic fatigue syndrome: a fMRI study. BMC Neurol
2006;6:9
87. Lange G, Steffener J, Cook DB, et al. Objective evidence of cognitive
complaints in chronic fatigue syndrome: a BOLD fMRI study of verbal
working memory. Neuroimage 2005;26(2):513-524
88. Okada T, Tanaka M, Kuratsune H, et al. Mechanisms underlying fatigue:
a voxel-based morphometric study of chronic fatigue syndrome. BMC
Neurol 2004;4(1):14
89. de Lange FP, Kalkman JS, Bleijenberg G, et al. Neural correlates of the
chronic fatigue syndrome: an fMRI study [published online ahead of
print July 7, 2004]. Brain 2004;127(pt 9):1948-1957.
90. Goldstein J. Chronic Fatigue Syndrome: The Struggle for Health.
Beverly Hills, Calif: Chronic Fatigue Syndrome Institute; 1990
91. Schwartz RB, Garada BM, Komaroff AL, et al. Detection of intracranial
abnormalities in patients with chronic fatigue syndrome: comparison of
MR imaging and SPECT. AJR Am J Roentgenol 1994;162(4):935-941
92. Siessmeier T, Nix WA, Hardt J, et al. Observer independent analysis of
cerebral glucose metabolism in patients with chronic fatigue syndrome.
J Neurol Neurosurg Psychiatry 2003;74(7):922-928
93. Yamamoto S, Ouchi Y, Onoe H, et al. Reduction of serotonin transporters
of patients with chronic fatigue syndrome. Neuroreport 2004;15(17):
2571-2574
94. Puri BK. Proton and 31-phosphorus neurospectroscopy in the study of
membrane phospholipids and fatty acid intervention in schizophrenia,
depression, chronic fatigue syndrome (myalgic encephalomyelitis)
and dyslexia. Int Rev Psychiatry 2006;18(2):145-147
95. Wang Q, Xiong JX. Clinical observation on electroacupuncture for
treatment of chronic fatigue syndrome [in Chinese]. Zhongguo Zhen
Jiu 2005;25(10):691-692
96. Price JR, Couper J. Cognitive behaviour therapy for adults with chronic
fatigue syndrome. Cochrane Database Syst Rev 2000;2:CD001027
97. Akagi H, Klimes I, Bass C. Cognitive behavioral therapy for chronic
fatigue syndrome in a general hospital: feasible and effective. Gen
Hosp Psychiatry 2001;23(5):254-260
98. Deale A, Husain K, Chalder T, et al. Long-term outcome of cognitive
behavior therapy versus relaxation therapy for chronic fatigue syn-
drome: a 5-year follow-up study. Am J Psychiatry 2001;158:2038-2042
99. Deale A, Chalder T, Marks I, et al. Cognitive behavior therapy for
chronic fatigue syndrome: a randomized controlled trial. Am J
Psychiatry 1997;154:408-414
100. Masuda A, Nakayama T, Yamanaka T, et al. Cognitive behavioral
therapy and fasting therapy for a patient with chronic fatigue syndrome.
Intern Med 2001;40(11):1158-1161
101. O'Dowd H, Gladwell P, Rogers CA, et al. Cognitive behavioural
therapy in chronic fatigue syndrome: a randomised controlled trial
of an outpatient group programme. Health Technol Assess 2006;
10(37):iii-iv, ix-x, 1-121
102. Coutts R, Weatherby R, Davie A. The use of a symptom "self-report"
inventory to evaluate the acceptability and efficacy of a walking
program for patients suffering with chronic fatigue syndrome.
J Psychosom Res 2001;51(2):425-429
103. Fulcher KY, White PD. Randomised controlled trial of graded exercise
in patients with the chronic fatigue syndrome. BMJ 1997;314(7095):
1647-1652
104. Friedberg F. Does graded activity increase activity? a case study
of chronic fatigue syndrome. J Behav Ther Exp Psychiatry 2002;
33(3-4):203-215
105. Powell P, Bentall RP, Nye FJ, et al. Patient education to encourage
graded exercise in chronic fatigue syndrome: 2-year follow-up of
randomised controlled trial. Br J Psychiatry 2004;184:142-146
106. Goodnick PJ, Sandoval R. Psychotropic treatment of chronic fatigue
syndrome and related disorders. J Clin Psychiatry 1993;54:13-20
107. Natelson BH, Cheu J, Hill N, et al. Single-blind, placebo phase-in trial
of two escalating doses of selegiline in the chronic fatigue syndrome.
Neuropsychobiology 1998;37(3):150-154
108. Klimas NG, Morgan R, Van Rid F, et al. Observations regarding use
of an antidepressant, fluoxetine, in chronic fatigue syndrome. In:
Goodnick PJ, Klimas NG, eds. Chronic Fatigue and Related Immune
Deficiency Syndromes. Washington, DC: American Psychiatric Press;
1993:95-108
109. Vercoulen JH, Swanink CM, Zitman FG, et al. Randomised, double-
blind, placebo-controlled study of fluoxetine in chronic fatigue syn-
drome. Lancet 1996;347(9005):858-861
110. Wearden AJ, Morriss RK, Mullis R, et al. Randomised, double-blind,
placebo-controlled treatment trial of fluoxetine and graded exercise
for chronic fatigue syndrome. Br J Psychiatry 1998;172:485-490
111. Goodnick PJ, Sandoval R, Brickman A, et al. Bupropion treatment
of fluoxetine-resistant chronic fatigue syndrome. Biol Psychiatry 1992;
32:834-838
112. Schonfeldt-Lecuona C, Connemann BJ, Wolf RC, et al. Bupropion aug-
mentation in the treatment of chronic fatigue syndrome with coexistent
major depression episode [letter]. Pharmacopsychiatry 2006;39(4):
152-154
113. Lecrubien Y. Antidepressant drugs: similar but different? In:
Mendlewicz J, Brunello N, Langer SZ, et al, eds. New Pharmacological
Approaches to the Therapy of Depressive Disorders. Basel, Switzer-
land: Karger; 1993:83-91
114. White PD, Cleary KJ. An open study of the efficacy and adverse effects
of moclobemide in patients with the chronic fatigue syndrome. Int Clin
Psychopharmacol 1997;12(1):47-52
115. Morriss RK, Robson MJ, Deakin JF. Neuropsychological performance
and noradrenaline function in chronic fatigue syndrome under condi-
tions of high arousal. Psychopharmacology (Berl) 2002;163(2):
166-173
116. Cleare AJ, O'Keane V, Miell J. Plasma leptin in chronic fatigue
syndrome and a placebo-controlled study of the effects of low-dose
hydrocortisone on leptin secretion. Clin Endocrinol (Oxf) 2001;55(1):
113-119
117. Puri BK, Holmes J, Hamilton G. Eicosapentaenoic acid�rich essential
fatty acid supplementation in chronic fatigue syndrome associated with
symptom remission and structural brain changes. Int J Clin Pract 2004;
58(3):297-299
118. Laviano A, Meguid MM, Guijarro A, et al. Antimyopathic effects of
carnitine and nicotine. Curr Opin Clin Nutr Metab Care 2006;9(4):
442-448
119. Randall DC, Cafferty FH, Shneerson JM, et al. Chronic treatment with
modafinil may not be beneficial in patients with chronic fatigue syn-
drome. J Psychopharmacol 2005;19(6):647-660
120. McDermott C, Richards SC, Thomas PW, et al. A placebo-controlled,
double-blind, randomized controlled trial of a natural killer cell stimu-
lant (BioBran MGN-3) in chronic fatigue syndrome. QJM 2006;99(7):
461-468
121. Blockmans D, Persoons P, Van Houdenhove B, et al. Combination
therapy with hydrocortisone and fludrocortisone does not improve
symptoms in chronic fatigue syndrome: a randomized, placebo-con-
trolled, double-blind, crossover study. Am J Med 2003;114(9):736-741
122. Williams G, Waterhouse J, Mugarza J, et al. Therapy of circadian
rhythm disorders in chronic fatigue syndrome: no symptomatic
improvement with melatonin or phototherapy. Eur J Clin Invest
2002;32(11):831-837
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