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The Spectra of Neurasthenia and Depression: Course, Stability and Transitions View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by RERO DOC Digital Library Eur Arch Psychiatry Clin Neurosci (2007) 257:120–127 DOI 10.1007/s00406-006-0699-6 ORIGINAL PAPER Alex Gamma Æ Jules Angst Æ Vladeta Ajdacic Æ Dominique Eich Æ Wulf Ro¨ssler The spectra of neurasthenia and depression: course, stability and transitions Received: 1 February 2006 / Accepted: 15 September 2006 / Published online: 25 November 2006 j Abstract Background Neurasthenia has had a Introduction chequered history, receiving changing labels such as chronic fatigue or Gulf war syndrome. Neurasthenia is Neurasthenia is operationally defined by ICD-10 [39] recognized by ICD-10, but not by DSM-IV. Its course, as a syndrome of mental fatigue and/or physical longitudinal stability and relationship to depression is exhaustion with a minimum duration of 3 months. Its not well understood. Methods In a stratified com- world-wide significance was definitely established by munity sample (n = 591), representative of 2600 the large prospective transcultural study of the WHO persons of the canton of Zurich, Switzerland, neur- in general health care [25, 32]. In the United States it asthenia and depression were assessed in six struc- is dealt with mainly as the neurological disorder tured interviews between ages 20 and 41. Course, chronic fatigue syndrome (see review by Wessely stability and comorbidity were examined. A severity [37]) and is absent from the psychiatric classification spectrum of neurasthenia and depression from of DSM-IV (discussed by Morey and Kurtz [22]). symptoms to diagnosis was taken into account. Re- The history of neurasthenia has been summarised sults The annual prevalence of a neurasthenia diag- by Steiner [30], Fischer-Homberger [14], Gosling [16], nosis increased from 0.7% to 3.8% from age 22–41, Shorter [29], Wessely [36], Taylor [31] and Scha¨fer while mere symptoms became less prevalent. Intra- [26, 27]. According to Scha¨fer [26], neurasthenia was individual courses improved in 40% and deteriorated an element of melancholia until the 17th century. In in about 30% of symptomatic cases. The most fre- the 18th century it was regarded as an element of quent symptoms overall, besides criterial exhaustion, hypochondriasis, and became an independent neu- were increased need for sleep, over-sensitivity, ner- ropsychiatric syndrome with Beard [8] and Van vousness and difficulty concentrating. Cross-sectional Deusen [33]. Over the past two decades it has con- associations and overlap with depression were strong. tinued to change its labels in a chameleon-like fashion Longitudinal stability of ICD-neurasthenia was low. in order to be socially acceptable and not stigmatis- Conclusions Neurasthenia is intermittent, overlaps ing, overlapping with chronic fatigue syndrome, significantly with depression, and shows improve- myalgic encephalomyelitis [36], Gulf War syndrome ment and deterioration over time to roughly equal [18], burn-out syndrome [15], as well as with atypical measures. depression [6]. Most research has focussed on chronic fatigue, and j Key words neurasthenia Æ depression Æ prevalence its symptoms have been studied internationally [38]. Æ course Æ comorbidity Æ spectrum But it is plausible that a large number of patients also suffer from acute, shorter and impairing fatigue syndromes, as shown by earlier reports from the Zurich Study [1, 7, 21]. Such a dimensional neuras- A. Gamma (&) Æ J. Angst Æ V. Ajdacic Æ D. Eich Æ W. Ro¨ssler thenia spectrum was also proposed early by Sharpe Zurich University Psychiatric Hospital et al. [28] and Pawlikowska et al. [23]. Research Department In the Zurich Study of a community sample the Lenggstr. 31 neurasthenic syndrome was one of 30 psychological 8032 Zurich, Switzerland Tel.: +41-44/384-2621 and functional somatic syndromes assessed in six Fax: +41-44/384-2446 interviews from the ages of 20–41 [3]. The data make EAPCN 699 E-Mail: [email protected] it possible to analyse symptoms of neurasthenia on a 121 continuum from tiredness to severe physical and the interviewers was reliable and consistent. We cannot answer the mental fatigue and exhaustion (neurasthenia spec- question for the neurasthenia section of the interview, but given the results for depression, we have no reason to doubt the reliability of trum), its longitudinal development over 20 years and the assessment of neurasthenic symptoms by our interviewers. its association with depression. j Diagnoses Methods Neurasthenia was defined by ICD-10 criteria [39] as a syndrome of mental fatigue and/or physical exhaustion with at least one of six j Sample criterial symptoms and a minimum duration of 3 months. No exclusion criteria were applied in order to allow us to study the The initial Zurich Study sample consisted of 4547 subjects (2201 associations with other syndromes. In the first interview (1979) 3- men, 2346 women) representative of the canton of Zurich in months neurasthenia was not yet assessed, only 1-month neuras- Switzerland, who were screened with the Symptom Checklist 90-R thenia and shorter manifestations. (SCL-90-R; (17)). In order to increase the probability of including No somatic examinations were conducted to ascertain potential individuals at risk for psychiatric syndromes, a stratified subsample somatic causes of neurasthenia. Only attributions of somatic causes of 591 subjects (292 males, 299 females) was selected for interview, by the participants were recorded, which are known not to be a with 66% comprising individuals who scored above the 85th per- reliable guide to the presence of objective somatic causes. Inspec- centile on the SCL-90-R Global Severity Index (‘high-risk group’), tion of the somatic causes reported by the subjects identified and 33% comprising a random sample of those scoring below the roughly three subjects per interview who might qualify for an or- 85th percentile (‘low-risk group’). The 591 subjects are represen- ganic cause for neurasthenic manifestations. None of these causes tative of 2600 persons from the canton of Zurich. The initial belonged to those listed in the ICD’s exclusion criteria. Due to their screening was conducted in 1978, when the subjects were aged 19 small number and to the unreliability of causal attributions we did (men) and 20 (women). Full interviews were conducted in 1979, not exclude these subjects from analysis. 1981, 1986, 1988, 1993, and 1999, by trained clinical psychologists Our neurasthenic spectrum consists of: (1) 3-months neuras- or psychiatrists in the participants’ homes. A broad spectrum of 30 thenia according to ICD-10, (2) 2-weeks neurasthenia [7], (3) psychiatric and somatic syndromes was assessed, including recurrent brief neurasthenia (RBN) [1] and (4) neurasthenic exhaustion/fatigue and depression [3]. The interviewers all had a symptoms. RBN required the presence of a neurasthenic syndrome degree in psychopathology. They were trained in group interviews of short duration (<2 weeks) occurring at least 12 times in the and by learning from experienced interviewers during interviews in previous year. Our spectrum concept arose from the systematically the participants’ homes. collected data in all syndromal sections of the interview; after the stem questions and list of symptoms, the duration (maximum, average) and frequency of neurasthenic episodes were assessed for j Neurasthenia interview the last 12 months as well as the estimated number of days/year with neurasthenic symptoms. Neurasthenia subgroups were formed The stem questions were adapted to current ICD concepts of according to different duration, frequency and severity criteria and neurasthenia and were in 1993/1999: 1) ‘‘in the last 12 months, did the resulting spectrum was validated using clinical indicators such you experience being physically exhausted, washed out, done in, as treatment and suicide attempt rates, comorbidity, work and shattered, even in situations of marginal physical effort?’’, and 2) social impairment [2, 7, 21]. ‘‘in the last 12 months, did you sometimes experience a pro- Major depressive episodes (MDE) were defined according to nounced mental exhaustion and fatigue, even in situations of DSM-III R and dysthymia according to DSM-IV, without the marginal mental effort?’’ If one of the questions was answered with application of any exclusion criteria. Our definition of minor yes, 20 symptoms were checked and an open question asked for depression was strict, i.e. requiring not two but three to four of the possible other symptoms; the symptoms are listed in Table 2 of the nine criterial symptoms of depression and a duration of at least results section. 2 weeks. Recurrent brief depression was defined by about monthly or more frequent episodes of depression lasting <2 weeks, by the presence of five or more of the nine criterial symptoms, plus work impairment (ICD-10). j Validity and reliability of interview The diagnosis of bipolar I disorder was similar to the original definition of Dunner et al. [12], i.e. the presence of mania requiring While we do not have data on the reliability of the interview section hospitalisation was necessary; bipolar II disorder required the on neurasthenia, we have such data for the section on depression, presence of a major depressive episode (DSM-III R) and episodes of which includes the ‘‘neurasthenic’’ items fatigue, lack of energy and overactivity plus two of seven criterial hypomanic symptoms [4]. A motor slowing. In 1993, at the 5th interview of the Zurich study, an diagnostic group of minor bipolar disorder (MinBP) was included interrater-reliability analysis was conducted in eight raters who in the bipolar spectrum concept, comprising dysthymia, minor and rated 22 participants using the depression section of the SPIKE recurrent brief depression in association with two of seven criterial interview. The percent interrater agreement on the presence/ab- hypomanic symptoms, and the chronic form, cyclothymic disorder sence of symptoms was 95.6%. The corresponding mean value of [4]. Kappa was 0.89, indicating almost perfect agreement [5].
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