What are the recommended treatments for chronic fatigue syndrome?

Management of Chronic Fatigue Syndrome (CFS)

Cognitive Behavioral Therapy (CBT) should be considered the first-line treatment for chronic fatigue syndrome, based on strong evidence for improving health function, quality of life, and physical function. 1

Non-Pharmacological Interventions

First-Line Treatments:

1. Cognitive Behavioral Therapy (CBT)

   • Strong evidence supports CBT for improving function and quality of life 1
   • Effective in both clinical trials and naturalistic treatment settings 2
   • Studies show medium to large effect sizes (|d| = 0.45-0.91) with 85% of patients reporting improvement 2
   • Should focus on:
     • Addressing illness-perpetuating factors
     • Developing consistent patterns of activity and rest
     • Challenging catastrophic interpretations of symptoms

2. Mindfulness-Based Therapies

   • Demonstrated small to moderate improvements in quality of life 1
   • Web-based versions increase accessibility for patients with mobility limitations

Second-Line Approaches:

1. Movement-Based Therapies

   • Yoga, tai chi, and manual acupuncture may benefit patients with fibromyalgia-like symptoms 1
   • Caution: Graded exercise therapy is no longer recommended as it may worsen symptoms 1

2. Sleep Management

   • CBT specifically for insomnia can address sleep disturbances 1
   • Establishing consistent sleep patterns is crucial 3

Pharmacological Interventions

For Pain-Predominant Symptoms:

• Serotonin-norepinephrine reuptake inhibitors (SNRIs) and pregabalin may be considered 1
• NSAIDs should be avoided due to lack of efficacy and potential harm 1

For Fatigue:

• Antidepressants may be considered for fatigue even without depression 1
• Psychostimulants (methylphenidate, modafinil) show limited evidence but may be considered after ruling out other causes of fatigue 4

Not Recommended:

• Stimulants, corticosteroids, antivirals, and antibiotics lack evidence of benefit 1
• Long-term opioid use carries risk of dependence 1
• Supplements (including ginseng and vitamin D) have inconsistent evidence 4

Treatment Algorithm

1. Initial Assessment

   • Confirm diagnosis by excluding alternative physical or psychiatric disorders 3
   • Assess for comorbid conditions (depression, anxiety, sleep disorders)
   • Evaluate the patient's understanding of their illness 3

2. First-Line Treatment

   • Begin with CBT and/or mindfulness-based therapies 1
   • Establish consistent patterns of activity, rest, and sleep 3
   • Provide positive explanation of illness factors (predisposing, triggering, perpetuating) 3

3. For Persistent Symptoms

   • Add pharmacological interventions based on predominant symptoms:
     • Pain: Consider SNRIs or pregabalin 1
     • Fatigue without improvement: Consider antidepressants 1
     • Sleep disturbance: Consider CBT for insomnia 1

4. Ongoing Management

   • Regular reassessment of symptoms and treatment response
   • Monitor for new symptoms or comorbidities
   • Adjust treatment plan based on changing symptom patterns 1

Common Pitfalls to Avoid

1. Overreliance on medications

   • Most medications have limited evidence for CFS 5
   • Avoid polypharmacy which may worsen symptoms

2. Pushing excessive exercise

   • Graded exercise therapy is no longer recommended 1
   • Post-exertional malaise is a core symptom that can be worsened by overexertion

3. Dismissing symptoms as purely psychological

   • CFS is a heterogeneous disorder with likely biological components 6
   • Acknowledging the reality of symptoms builds therapeutic alliance

4. Lack of follow-up

   • Regular monitoring is necessary for ongoing care 1
   • Treatment should be adjusted based on response

By implementing this evidence-based approach to CFS management, clinicians can help patients improve their quality of life and functional capacity despite this challenging condition.