Chronic Fatigue Syndrome
Cognitive Behavioral Therapy and Graded Exercise
Cognitive behavioral therapy and graded exercise therapy are generally agreed to have the highest level of evidence for success in treating CFS (Jones 2011; Moss-Morris 2013). Cognitive behavioral therapy involves systematically adjusting behavior and may encompass improved exercise, dietary, and sleep habits; relaxation; and getting support from others (Cox 2004). Graded exercise therapy involves initiating a low-intensity exercise program and slowly increasing the intensity over time (CDC 2013). Adaptive pacing therapy, which also may be useful in treating CFS, involves carefully controlling the amount of activity and exercise in accordance with tolerance (Cox 2004).
Although exercise can be quite helpful for individuals with CFS, exercise regimens must begin at a low level (such as walking a few blocks or bicycling a few miles) and gradually build up to longer and more intense exercise. Many people with CFS may experience worsened fatigue if they initially try to exercise or work at intensive levels without gradually building up stamina over time (Nijs 2008). One study randomly assigned 29 CFS subjects to a program of graded aerobic exercise and 30 CFS subjects to flexibility and relaxation exercises. The exercise group started with 5-15 minutes of slow walking with gradual increases in speed and duration; light swimming or bicycling were encouraged as alternative options to walking. The other group performed flexibility and relaxation exercises for 10 minutes a day, gradually increasing to 30 minutes. After 12 weeks of treatment, improvement occurred in both groups, though twice as many subjects in the exercise group (55%) rated themselves as “very much” or “much” better compared to the flexibility group (27%) (Fulcher 1997).
Stimulant drugs such as methylphenidate (Ritalin, Concerta) or amphetamine/dextroamphetamine (Adderall) have been used to treat CFS. In a randomized controlled trial on 60 CFS subjects, treatment with 10 mg methylphenidate twice daily resulted in significantly less fatigue and better concentration compared to placebo (Blockmans 2006). A study of 10 CFS subjects reported that fatigue was significantly reduced in 90% of subjects treated with 5 or 10 mg of Adderall twice daily for four weeks compared to 40% who improved in the placebo group (Olson 2003). Another study treated CFS subjects who had deficits in cognitive function with either lisdexamfetamine dimesylate (Vyvanse, 30-70 mg daily), an amphetamine stimulant that has been used to treat ADHD in children and adults (Hutson 2014), or placebo. After six weeks of treatment, the Vyvanse-treated subjects had significantly better emotional control and working memory as well as significantly less fatigue and generalized pain compared to subjects who received placebo (Young 2013). A study to evaluate the effects of daily low dose (5-10 mg) methylphenidate coupled with either a multifaceted nutritional supplement (containing vitamins, amino acids, and mitochondrial nutrients such as magnesium, coenzyme Q10 [CoQ10], and L-carnitine) or placebo is underway as of the time of this writing (Montoya 2014).
Stimulant drugs have a number of common adverse side effects including insomnia, loss of appetite, potential heart problems, as well as the potential for addiction and misuse (Chavez 2009; Reddy 2013). There is some evidence that such medications may alter normal brain function, including neurotransmission, and only limited information is available on the long-term effects of stimulant medication (Hyman 1996; Wang 2013; Vitiello 2001; Berman 2009).
About 33-50% of CFS patients also experience depression (Morelli 2011). Selective serotonin reuptake inhibitor (SSRI) anti-depressant medications (such as fluoxetine [Prozac], sertraline [Zoloft], paroxetine [Paxil], and citalopram [Celexa]) are frequently prescribed to people with CFS. Some published studies have reported that antidepressant medications are of some help, although the topic has been the subject of little rigorous research. A double-blind study on 96 adults with CFS reported that six months of treatment with 20 mg fluoxetine was associated with significantly less depression but not significantly less fatigue compared with placebo (Wearden 1998). A small study of 16 CFS subjects reported that 10-20 mg of citalopram daily was associated with significantly less fatigue and depression after 12 weeks (Amsterdam 2008).