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Tiredness/fatigue in adults - Management
Basis for recommendation
Treat the cause
- This is a pragmatic recommendation.
Iron supplementation
- There is limited evidence from one randomized, placebo-controlled trial in 144 people, sponsored by industry, that iron supplementation significantly reduces self-reported fatigue in women 18–55 years of age without anaemia presenting to primary care with fatigue [Verdon et al, 2003]. Only women with ferritin concentrations of 50 micrograms/L or less improved with treatment. These findings have not been confirmed in any subsequent trials, and CKS expert reviewers were divided over the appropriateness of recommending iron supplementation in this group of people.
Therapeutic relationship
Explanation
- These recommendations are derived from a qualitative study on the effectiveness of GPs' explanations to provide reassurance (normalization) to 36 people with unexplained symptoms in UK primary care [Dowrick et al, 2004].
- Consultations between 21 GPs and 36 people with unexplained medical symptoms were audio-taped.
- Transcripts were analysed for recurring ways that normalizing statements were presented by GPs and responded to by patients.
- The suggested methods for explanation are based on the findings of this study.
Try to broaden the person's perception of fatigue
Modifiable psychological, social, and general health factors
People meeting the criteria for chronic fatigue syndrome (CFS)/myalgic encephalomyelitis or encephalopathy (ME)
People who do not meet the criteria for CFS/ME
- Balance between activity and rest
- Sleep management
- This recommendation is pragmatic.
- Counselling and cognitive behavioural therapy (CBT)
- There is evidence from a randomized trial that, in people with severe fatigue for 4 months or longer and off work for 6–26 weeks, CBT delivered by a GP after 12 hours' training is no more efficacious than no active intervention [Huibers et al, 2004a].
- CKS found no trials in people with persistent, unexplained fatigue (not diagnosed as CFS/ME) that compared CBT or counselling, delivered by qualified practitioners, with no treatment or placebo treatment. However, there is evidence from a randomized trial that, in people with unexplained fatigue lasting 3–4 months or longer, CBT is equivalent to counselling [Ridsdale et al, 2001].
- Subsequently, it was reported that a better outcome was predicted by being psychologically minded and expressing, acknowledging, and accepting emotional distress [Chalder et al, 2003; Godfrey et al, 2007]. The authors recommended that GPs should assess these factors before referring people for psychological treatments.
- Despite the findings of these studies, CBT is commonly recommended in narrative reviews for people with unexplained, persistent or chronic tiredness/fatigue [Ruffin and Cohen, 1994; Sharpe and Wilks, 2002; Dick and Sundin, 2003].
- Graded exercise
- CKS found no randomized, controlled trials in people with unexplained fatigue that have compared exercise with no treatment or placebo treatment, or compared one form of exercise with another.
- There is evidence from one randomized trial that graded exercise is equivalent to cognitive behavioural therapy in reducing unexplained fatigue that has been present for 3 months or longer [Ridsdale et al, 2004].
- Referral to specialist CFS/ME services
- This recommendation is based on comments from CKS expert reviewers.
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