Neurasthenia: Prevalence, Disability and Health Care Characteristics In

BRITISH JOURNAL OF PSYCHIATRY (2002), 181, 56^61

Neurasthenia: prevalence, disability and health care feelings of fatigue after minor physical effort;effort; characteristics in the Australian community (b)(b)accompaniedaccompanied by one or more of the following symptoms: muscular aches or pains; dizziness; tension headache; IAN HICKIE, TRACEY DAVENPORT, CATHY ISSAKIDIS and GAVIN ANDREWS sleep disturbance; inability to relax; and irritability; (c)(c)inabilityinability to recover through rest, relaxa- tion or enjoyment; (d)(d)durationduration exceeds 3 months; (e)(e)doesdoes not occur in the presence of organic Background Neurasthenia imposes a Neurasthenia as a diagnostic entity has a mental disorders, affective disorders or panic or generalised anxiety disorder. high burden on primary medical health long and chequered history in psychiatry (Wessely, 1990; Hickie et aletal, 1998). Despite Although the WHO thought neurasthenia care systemssystemsin in allallsocieties. societies. changes in diagnostic fashion, aetiological sufficiently different to other ‘Neurotic, Aims TodetermineTo determine the prevalence of theorising and modes of treatment, people stress-related and somatoform disorders’ who essentially report mental and physical to justify its own category, research groups ICD^10 neurasthenia and associated fatigue, a range of other neuropsycho- have tended to be more conservative. Tradi- comorbidity,disability and health care logical and mood symptoms (e.g. impaired tionally, most psychiatric epidemiologists utilisation.utilisation. concentration and short-term memory, irri- highlight the comorbidity with depressive table mood, non-restorative sleep) as well and anxiety disorders (Wessely, 1990) and MethodMethod Utilisation of a national sample as other non-specific physical symptoms have rejected the utility of differentiating of Australian households previously (e.g. muscle aches and pains, headache, the concept until social covariates, course surveyed using the Composite general malaise) continue to impose a high or response to treatment distinguish it from burden on primary medical health care (say) dysthymia(Goldberg & Bridges, International Diagnostic Interview and systems in all societies (U(Ustun¨ stu¨ n & Sartorius, 1991). Such disorders have not been other measures. 1995; Hickie et aletal, 2001,2001aa).). included in the major North American epidemiological studies of the past decade ResultsResults Prolonged and excessive (Kessler(Kessler et aletal, 1994). A more proactive Classification of neurasthenia fatigue wasreported by1465 people view, however, has argued for evidence (13.29% oftheof the sample).Ofthese,sample).Of these, one in Although the diagnostic concept fell into of independence from depression and nine people meet current ICD ^10 criteria disrepute in the English-speaking world in anxiety at the levels of multivariate the 20th century (being seen more simply for neurasthenia.Comorbidity was modelling of symptom data (Gillespie etet as a variant of depression or anxiety), it alal, 1999), genetic vulnerabilities (Hickie associated with affective, anxiety and persisted in most non-English speaking et aletal, 1999,1999aa), longitudinal course (Hickie physical disorders.Peopledisorders. People with countries. Consequently, the ICD–10 et aletal, 1999,1999bb) and treatment response. neurasthenia alone (550.5% of the (World Health Organization (WHO), Although such studies link neurasthenia 1992) contains a clear definition of the con- population) were less disabled and used more closely with other somatoform dis- cept and the World Psychiatric Association orders, there is evidence that the category less services thanthose with comorbid (WPA) has promoted a renewed diagnostic can be distinguished from entities such as disorders.disorders. and research effort (WPA, 1999). In doing fibromyalgia, irritable bowel, somatic so, the WPA sought to broaden the concept depression and somatic anxiety (Kirmayer Conclusions Fatigue is frequent in the to include cognitive, emotional, somatic, & Robbins, 1991). Australian community andandis is commonin energy and sleep variables that could give Although the nosological debate is people attending generalpractice.general practice. the syndrome specific attributes that are complex, studies in primary care indicate Neurasthenia is disabling and demanding clearly different to the symptoms of depres- that prolonged fatigue syndromes are sive and anxiety disorders (WPA, 1999). of serviceslargely because of its common. Prevalence rates for prolonged The ICD–10 diagnostic criteria for fatigue (typically greater than 1 month) comorbidity with other mental and research (WHO, 1993) are included in the vary from 18 to 37% (Pawlikowska et aletal,, physical disorders.Until a remedy for chapter on ‘Neurotic, stress-related and 1994; Hickie et aletal, 1996, 2001aa), whereas),whereas persistentfatigue is provided, doctors somatoform disorders’ in a subsidiary the WHO Primary Care Study (Sartorius section entitled ‘Other neurotic disorders’, should take an active psychological et aletal, 1993) found that an average of implying a disorder of uncertain lineage. 5.3% of general practice patients met approachto treatment. The diagnostic criteria for neurasthenia criteria for neurasthenia (range 1.1– can be summarised as follows: Declaration of interest None. 10.5%). All studies have emphasised that the syndrome is associated with disability, (a)(a)either,either, persistent and distressing feel- chronicity, comorbidity and high service ings of exhaustion after minor mental utilisation. The Australian National Survey effort or persistent and distressing of Mental Health and Wellbeing (Andrews(Andrews

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et aletal, 2001) is the first national Data analysis neurasthenia is not a common mental community based psychiatric survey to Routine data analysis procedures were used disorder.disorder. include a module specifically designed to but, as a result of the complex sample identify people who met criteria for design and weighting, specific software Prevalence ICD–10 neurasthenia. This paper is an was required to estimate standard errors Data on the weighted prevalence of neur- account of the key findings, emphasising (s.e.). The s.e. of prevalence estimates and asthenia are displayed in Table 1, by age not only prevalence rates but also patterns confidence intervals around odds ratios and gender, for people meeting criteria in of comorbidity, disability and health care (ORs) derived from logistic regression the past month (1.2%) and sometimes in utilisation.utilisation. models were estimated using delete-1 the past year (1.5%). Only 20% of people jackknife repeated replication in 30 who met criteria during the year were not design-based subsamples (Kish & Frankel, current cases. The disorder is chronic. The METHOD 1974). These calculations used the female to male ratio was small (1.4 and Sample SUDAAN software package (Shah et aletal,, 1.2) in contrast to what is often believed, 1997).1997). The national survey was conducted by the and different from the pattern seen in Australian Bureau of Statistics under the health care facilities. On further examin- terms of their Act that guarantees the RESULTSRESULTS ation of the numbers of people in the popu- privacy of respondents. A multi-stage lation who reported fatigue (13.2%), sample of private dwellings in rural and DiagnosisDiagnosis significantly more females than males said urban Australia was drawn. Each state The criteria for neurasthenia are listed ‘yes’ (14.9% v.v. 11.3%;11.3%; PP550.05). In0.05).In and territory was stratified and each dwell- above. Criterion A, prolonged and addition, when respondents were asked ing within a stratum had an equal and excessive fatigue, was endorsed by 1465 whether it was clinically significant (601 known probability of selection. In all, people (13.2% of the sample). These said ‘yes’), female rates were still higher 13 624 private dwellings were initially responses were probed to ensure that the but the confidence intervals just overlapped selected in the survey sample, and one adult symptom was clinically significant and (6.3%(6.3% v.v. 4.4%;4.4%; PP440.05). For all other member aged 18 years and over randomly not attributed by the respondent to drugs criteria (B–D) the rates of endorsement selected as the possible respondent. A total or alcohol, physical illness or injury (601 were almost identical for males and of 10 641 people participated, a response persons agreed that this was so). Criterion females. Thus, although more women than rate of 78.1%. The age and gender charac- C requires that the fatigue does not men in the population report fatigue the teristics of the sample were weighted to respond to rest and 318 of the 601 prevalence of neurasthenia is not higher in match the age and gender distribution in participants endorsed this. Criterion D women. The multivariate associations of the national census. requires that the fatigue lasts 3 months demographic variables are shown in or more, and this was so for 186 Table 2 together with those for people participants. Finally we asked about the with any 12-month12-month mental disorder. Both Assessment presence of the Criterion B symptoms, sets of disorders decline with age, both The whole interview was administered 172 of the 186 met this criterion. Thus, are more common among people who from a laptop computer. The Composite although complaints of fatigue are are separated, widowed or divorced, both International Diagnostic Interview (CIDI v common, only one in nine people who are more common among those with less 2.1; WHO, 1997) was used to determine, complain of fatigue meet current ICD–10 education and both are more common using ICD–10 criteria, the presence of seven criteria for neurasthenia. As distinct from among those born in Australia. That is, anxiety disorders, three affective disorders non-specific complaints of fatigue, as the socio-demographic characteristics and four substance use disorders in the 12 months prior to interview. Neurasthenia was identified using an Ta b l e 11Tab Weighted prevalence of12- and1-month ICD^10 neurasthenia by age and gender interview developed by Tacchini et aletal (1995). All results in this paper are with the exclusion criteria not applied for other Age12-month 1-month1-month mental or physical disorders. Personality MalesFemales PersonsPersonsMales Females Persons disorders were identified using a screening questionnaire (Loranger et aletal, 1997).,1997). %(s.e.)%(s.e.) %(s.e.)%(s.e.) %(s.e.)%(s.e.)%(s.e.) %(s.e.)%(s.e.) %(s.e.)%(s.e.) Disability was measured at the begin- ning of the interview by the SF–12 (Ware 18^24 1.0 (1.2)(1.2)1.0 2.4 (0.9)(0.9)2.4 1.7 (0.7)(0.7)1.7 1.0 (1.2)(1.2)1.0 1.6 (0.7) 1.3 (0.7)(0.7)1.3 et aletal, 1996) and by the National Comor- 25^3425^341.1(0.4) 1.1 (0.4) 1.8 1.8(0.4) (0.4)1.5 (0.3)0.7 (0.4)1.5 (0.4) 1.1 (0.3)(0.3)1.1 bidity Survey ‘days out of role’ questions. 35^441.6 (0.3) 1.7 (0.6)(0.6)1.7 1.6 (0.3)(0.3)1.6 1.4 (0.3)1.2 (0.6)1.3 (0.3) Neuroticism was measured using the 12- 45^5445^541.8 (0.5)2.8 (0.7)2.3(0.4) 2.3 (0.4) 1.7 1.7(0.6) (0.6)2.1 (0.5)1.9 (0.4) item version of the Eysenck scale (Eysenck 55^640.8(0.4) 0.8 (0.4) 1.1 1.1(0.5) (0.5)1.0(0.4) 1.0 (0.4) 0.8 0.8(0.4) (0.4)1.1(0.5) 1.1 (0.5) 1.0 1.0(0.4) (0.4) et aletal, 1985). Demographic and service utili- 446565 0.7 (0.4)(0.4)0.7 0.5 (0.2)(0.2)0.5 0.6 (0.2)(0.2)0.6 0.7 (0.4)(0.4)0.7 0.3 (0.2)(0.2)0.3 0.5 (0.2)(0.2)0.5 sation data were also obtained. The method of the survey has been described previously Total 1.2 (0.3)1.7 (0.3) 1.5 (0.2)(0.2)1.5 1.1 (0.3)(0.3)1.1 1.3 (0.2)(0.2)1.3 1.2 (0.2)(0.2)1.2 (Andrews(Andrews et aletal, 2001).,2001).

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Ta b l e 2 Multivariate associations of socio-demographic correlates for12-month neurasthenia and disorder is significant, as is the association any12-month ICD^10 mental disorder with any self-reported physical disorder. People who meet criteria for neurasthenia report symptoms that suggest they are at Correlates11 ICD^10 mental disorder increased risk for specific mental and any 12-month neurastheniaAny 12-month mental disorder22 physical disorder. Their risk of a substance Odds ratioratioOdds 95% CIOdds ratio 95% CI95%CI misuse disorder is not increased. When comorbidity is endemic it is diffi- Age cult to know whether the attribute being 18^24 1.0 ^1^ 1.0.0^ measured belongs to the target disorder 25^3425^34 1.00.4^2.9 1.0 0.8^1.3 or to the comorbid disorder. In clinical 35^44 1.10.3^4.3 1.0 0.8^1.2 practice, when the patient has more than one disorder, the patient and doctor agree 45^5445^54 1.60.5^4.8 0.8 0.6^1.1 on a priority and usually deal with the 55^64 0.4* 0.2^1.00.2^1.00.4** 0.3^0.6 main problem first. In the survey, after all 446565 0.40.1^1.8 0.2** 0.1^0.2 disorders had been enumerated, we listed ww22 ((PP)1) 17.77.70.003 218.5 550.001 55 the groups of symptoms they had com- Marital status plained of, and asked people who had met Married/de facto 1.0 ^1^ 1.0.0^ criteria for more than one disorder: ‘Which Separated/divorced/widowed 2.4*1.5^3.7 2.0** 1.5^2.5 of these problems troubles you the most?’. Never married 1.20.6^2.3 1.5** 1.3^1.8 We regarded this as the patient’s main 22 ww 22 ((PP)1) 14.44.40.001 48.9 550.001 problem. In 13 people neurasthenia was Education the only disorder present, whereas a further Bachelor degree or higher 1.0 ^1^ 1.0.0^ 36 who did have comorbid disorders, iden- Diploma 0.80.2^4.2 1.2 0.9^1.6 tified neurasthenia as their main problem. Thus, neurasthenia was the main problem Vocational qualification 1.90.6^6.2 1.5* 1.1^2.0 in 49 people (less than 0.5% of the popu- High school only 2.3 0.6^8.10.6^8.11.6** 1.3^1.8 lation). Of the remainder of people with ww22 ((PP)7) 7.9.90.048 36.3 550.001 33 neurasthenia and comorbid disorders, 50 Employment nominated an affective disorder as their Employed (f/t or p/t) ^^^ ^11.0.0^ main problem, 39 an anxiety disorder and Short-term unemployed33 ^^^ ^1.6*1.6*1.1^2.3 31 a physical disorder as their main Long-term unemployed44 ^^^ ^2.6**2.6**1.8^3.8 problem. Three people thought personality Not in the labour force ^^^ ^11.6**.6** 1.3^1.91.3^1.9 or substance misuse disorders were their 22 main problem. ww33 ((PP)^) ^NSNS38.5 550.001 Country of birth In Table 4 we present data on neuroti- Australia1.0 ^1 ^ 1.0.0^ cism, disability measured by the SF–12 and by disability days, and service utilisation in Other English speaking country 0.5 0.2^1.00.2^1.00.9 0.7^1.20.7^1.2 terms of consultations and hospital admis- Other non-English speaking country0.6 0.3^1.1 0.8* 0.6^1.0 sions. People with neurasthenia as a main ww22 ((PP)6) 6.6.6 0.0370.037 6.60.037 22 problem were less likely to be comorbid f/t, full-time; p/t, part-time; NS, non-significant. with a mental or a physical disorder, less **PP550.05, **PP550.001.0.001. disabled and used fewer services than the 1. Gender, urban v. rural residence, employment status and language used at home were not significant in unad- justed models and were therefore not included in the multivariate model. complete group. We then examined all 2. Source: Andrews et al (2001).(2001). people with neurasthenia, divided into 3. Unemployed 5512 months. 4. Unemployed 5512 months. those with neurasthenia as a main problem and those with neurasthenia who identified affective, anxiety or physi- of neurasthenia are similar to other disorder and generalised anxiety disorder cal disorders as their main problem. mental disorders, it is likely that social than could be expected by chance after People with neurasthenia as a main risk factors are shared. Employment is adjustment for the prevalence of the co- problem were less disabled (PP¼0.026)0.026) not significant in neurasthenia, whereas morbid disorder and the average level of and used fewer services (PP¼0.005) than psychological morbidity generally is asso- comorbidity of that disorder. These are did the other three groups. ciated with not being in the labour force. the disorders specified as exclusion criteria Comorbidity is regarded as a hallmark in ICD–10. In Model 2 we calculate the of neurasthenia. In Table 3 we present same information, not for individual dis- DISCUSSION data on the prevalence of comorbid disorders but for disorder groups. Now the orders among people with neurasthenia. significant associations are with affective, Complaints of fatigue are frequent in the In Model 1 we show that there is more anxiety and personality disorders. general population and are particularly comorbidity with major depression, panic Naturally the association with any mental common in people attending general

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Ta b l e 3 Weighted prevalence and odds ratios of comorbid ICD^10 mental disorders and any physical practitioners. Generally, the rates of most disorder among persons withwith12-month 12-month neurasthenia mental disorder in primary care patients are increased over community rates by a factor of 2–3 (Hickie et aletal, 2001,2001bb). In thisthis).In Comorbid disorder11 Prevalence of disorder among persons with 12-month national community survey, 13.2% of the neurasthenia Australian adult population report pro- %(s.e.)OR 11 (95% CI)CI)(95% longed and excessive fatigue as a problem. Previous Australian general practice sur- Model 1: Individual disorders veys indicate prevalence rates of 25–37% Major depression 50.4 (4.6)** 5.2 (3.0^9.0) (Hickie(Hickie et aletal, 1996, 2001aa). This study indi- Dysthymia 14.6 (2.7) 1.5 (0.7^3.2)(0.7^3.2)1.5 cates that the prevalence of the more Panic with or without agoraphobia 27.8 (3.9)* 2.6 (1.4^4.9) chronic and disabling syndrome of neur- Social phobia 19.0 (4.8) 2.2 (0.8^6.3) asthenia is 1.5% in the general population Generalised anxiety disorder 40.4 (4.6)* 2.7 (1.3^5.4) and this is consistent with Australian and international studies in primary care that Obsessive^compulsive disorder 3.1 (1.9) 0.7 (0.2^2.2) report rates of neurasthenia (1.3–5.2%; Post-traumatic stress disorder 27.5 (8.5)(8.5)27.5 2.7 (0.8^9.5) SartoriusSartorius et aletal, 1993; Hickie et aletal, 1996).,1996). Alcohol misuse or dependence 14.0 (3.3) 0.8 (0.4^1.6) There have been a series of community Drug misuse or dependence 10.0 (2.4) 2.0 (0.9^4.6) and primary care-based studies for the Model 2: Disorder groups closely related condition of chronic fatigue Any affective disorder 53.7 (4.4)** 5.2 (3.3^8.1) syndrome (6 months of prolonged and Any anxiety disorder 64.9 (4.3)** 6.6 (4.2^10.6) excessive fatigue without other medical or Any substance use disorder 19.9 (4.1) 1.1 (0.5^2.1) psychiatric cause). Here community esti- Any personality disorder 35.5 (4.7)* 2.0 (1.2^3.5)(1.2^3.5)2.0 mates range from 0.2 to 0.7% (Buchwald Model 3: Any other mental disorders 79.3 (4.8)** 14.4 (7.9^26.5) et aletal, 1995; Lawrie et aletal, 1997; Jason etet Model 4: Any physical disorder22 62.3 (4.4)**2.7 (1.8^4.0) alal, 1999) and primary care estimates from 0.5 to 2.5% (Bates et aletal, 1993; Wessely etet **PP550.05; **PP550.001.0.001. alal, 1997).,1997). 1. ORs were calculated using parameter estimates from logistic regression models and they represent the odds of hav- ing each comorbid disorder (single or group) for persons with neurasthenia compared to persons without neurasthe- Although neurasthenia is by definition nia.Thenia. The ORs were derived from four different models: Model1Model 1 ^ each single mental disorder controlling for the prolonged (443 months), this study presence of all other single mental disorders; Model 2 ^ each disorder group controlling for the presence of all other disorder groups; Model 3 ^ containing one dichotomous variable (any other mental disorder v. no other mental disor- indicates that it is chronic, with 80% of der); and Model 4 ^ containing one dichotomous variable (any physical disorder v. no physical disorder). people who met criteria in the past 12 2. Any physical disorder was defined as presence of at least one of12 conditions: asthma, chronic bronchitis, anaemia, high blood pressure, heart trouble, arthritis, kidney disease, diabetes, cancer, stomach ulcer, chronic liver trouble or months also being current cases. This is hernia rupture. consistent with our previous longitudinal

Ta b l e 44Tab Chronicity, neuroticism, disability and health service utilisation among all persons with 12-month neurasthenia, those with neurasthenia as their principal complaint and among those with an anxiety, affective or a physical disorder as their principal complaint

12-month neurasthenia11

All 12-month A. Neurasthenia as B. Affective as main C. Anxiety as main D. Physical illness as neurasthenia (nn¼172) main problem (nn¼49) problem (nn¼50)50) problem (nn¼39)39) main problem (nn¼31)

Neuroticism, mean (s.e.) EPQ^N 6.7 (0.3) 5.7 (0.5) 7.4 (0.8) 8.3 (0.9) 5.7 (0.6) Disability, mean (s.e.) SF^12 mental component score36.4 (1.1) 42.5 (1.5)(1.5)42.5 31.4 (2.7)*(2.7)*31.4 34.3 (2.5)*(2.5)*34.3 36.6 (4.5)(4.5)36.6 SF^12 physical component score40.4 (1.0) 44.7 (1.9) 42.3 (2.3) 37.6 (2.3) 33.7 (2.8) Disability days 12.8 (1.1) 7.5 (2.4)(2.4)7.5 16.2 (2.5)(2.5)16.2 15.3 (2.2)(2.2)15.3 13.1 (3.0)(3.0)13.1 Service utilisation, % (s.e.) Any consultation22 95.8 (2.1)(2.1)95.8 87.2 (8.0)(8.0)87.2 100 (^) 97.5 (4.0) 100 (^) Any mental health consultation33 60.5 (4.6)(4.6)60.5 50.9 (11.9)(11.9)50.9 88.4 (4.8)*(4.8)*88.4 61.2 (10.8)(10.8)61.2 38.1 (11.7) Any hospital admission44 23.0 (3.1)(3.1)23.0 9.2 (5.6)(5.6)9.2 27.3 (7.2)(7.2)27.3 17.8 (8.2)(8.2)17.8 46.6 (14.6)*(14.6)*46.6

**PP550.05, for comparison with A. Neurasthenia as main problem. 1. There were three people with personality or substance misuse disorders as their main complaint.Groups A^D were compared on disability and health serviceservice utilisation variables using polytomous logistic regression with a four level dependent variable, coded according to main problem diagnosis (neurasthenia as main problem, v.v. affective disorder as main problem, anxiety disorder as main problem, physical disorder as main problem). 2. Refers to any consultation in the previous12 months with any health professional for any reason. 3. Refers to any consultation in the previous12 months with any health professional for mental health problems. 4. Refers to any hospital admission for any reason in the previous12previous 12 months.

5959

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reports in primary care that emphasised early ages of onset and chronic course CLINICAL IMPLICATIONS (Hickie(Hickie et aletal, 1999,1999bb). The multivariate associations between age, gender, marital && While complaints of prolonged and excessive fatigue are common in the status, education and country of birth are community, the syndrome of neurasthenia is uncommon. also similar to those identified for other mental disorders in the wider survey. && Neurasthenia is typically chronic and is associated with high levels of comorbid People who meet criteria for neurasthenia affective and anxiety disorders. do report more symptoms of anxiety, affec- && tive and physical disorders than is expected, More pure forms of neurasthenia are associated with lower levels of neuroticism, even after allowing for the probability of disability and health care utilisation. association and level of comorbidity in the LIMITATIONS other disorders.Both these patterns are consistent with thenotion that neur- && Cross-sectional surveys provide only limited insight into the nature of the asthenia is indeed, typically, a mental association between neurasthenic and affective and anxiety disorders. disorder. The patterns of comorbidity are very similar to patients with neurasthenia && The clinical significance of the disorders identified by such community surveys is seen in clinical settings (Farmer et aletal,, inferred from self-reported disability data. 1995).1995). && Interestingly, neuroticism levels were Self-reported comorbid physical disorders are assumed to reflect clinically not increased in persons with neurasthenia significant medical conditions. as their main problem. This is consistent with other reports (Chubb et aletal, 1999). This could suggest that such people are different not only at a symptom-reporting level (emphasising more overtly physical rather IAN HICKIE, FRANZCP,School of Psychiatry,University of New South Wales, Sydney,Australia; and Chief than psychological symptoms) but also at Executive Officer,‘beyondblue: the national depression initiative’,Melbourne, Australia;TRACEY DAVENPORT, the level of important vulnerability factors. BA (Hons), School of Psychiatry,University of New South Wales at St George Hospital, Sydney,Australia; CATHY ISSAKIDIS,ISSAKIDIS,BA BA (Hons),World Health Organization Collaborating Centre for Evidence for Mental Health Given the evidence from other genetic Policy; and, School of Psychiatry,University of New South Wales at St Vincent’s Hospital, Sydney,Australia; modelling studies, it could be seen as con- GAVIN ANDREWS, FRCPsych,World Health Organization Collaborating Centre for Evidence for Mental sistent with less relevance for traditional Health Policy; and, School of Psychiatry,University of New South Wales at St Vincent’s Hospital, Sydney, psychological risk factors in this patient Australia group (Farmer et aletal, 1999; Hickie et aletal,, 19991999aa).). CorrespCorrespondence:ondence: Professor Ian Hickie, Academic Department of PsychPsychiatry,7iatry,7 Chapel Street,Kogarah, @@ When people with neurasthenia were NSW 2217, Australia.Tel: +612 9350 2035; fax: +612 9350 2098; e-mail: ian.hickie beyondblue.org.au subdivided according to the disorder that (First received 17 January 2002, accepted 21March 2002) they regarded as their main problem, people with neurasthenia as a main problem were less disabled and used fewer services than the others with neurasthenia Such cross-sectional surveys can surrounding prolonged fatigue states will who regarded other disorders as their main provide only limited insights. Other longi- persist until doctors provide a remedy for problem. This suggests that the degree of tudinal work (Hickie et aletal, 1999,1999bb;; persistent idiopathic fatigue. disability and service use typically asso- AddingtonAddington et aletal, 2001) has emphasised that ciated with neurasthenia is more because when fatigue and psychological symptoms ACKNOWLEDGEMENTS of the comorbid symptoms (depression co-occur, persons are at high risk of going and anxiety) than prolonged fatigue. In this on to experience further episodes again This paper was supported by a contract from the survey people with neurasthenia as a main characterised by both prolonged fatigue Australian Department of Health and Aged Services problem did not differ in these respects and psychological disorder. Those experi- to the WHO Collaborating Centre for Evidence in Mental Health Policy, Sydney, to support a survey from the large numbers of people who iden- encing prolonged fatigue only, however, data analysis consortium (G.A.,V.Carr,G.Carter,(G.A.,V.Carr,G. Carter, R. appear to have a more stable pattern of tified, irrespective of neurasthenia, depres- Crino,W.Hall, A.Henderson,A. Henderson, I.H.,C. Hunt,L.Hunt, L. Lampe, sion or anxiety as their main problem (see future fatigue without increased rates of J. McGrath, A. McFarlane, P. Mitchell, L. Peters, M. AndrewsAndrews et aletal, 2001). We argue that neur- later psychological disorder. Along with Teesson and K.Wilhelm).The survey was conducted asthenia is recognised as disabling and other genetic and treatment data, this by the Australian Bureau of Statistics, who do not demanding of services largely because of suggests differing aetiological and illness necessarily endorse the view expressed in this paper. its comorbidity with other affective, course determinants. All such studies imply anxiety and physical disorders. 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