Depression

Depression or low mood and the more severe major depressive disorder (clinical depression) are common but potentially serious mood disorders. Depression causes severe symptoms that affect how someone feels, thinks, and handles daily activities, such as sleeping, eating, or working. To be diagnosed with depression, the symptoms must be present for at least two weeks.

Depression as expressed in patients with ME/CFS is generally considered as secondary depression or reactive depression due to the debilitating effects of ME/CFS. Secondary or reactive depression is common in many chronic illnesses as well as cancer, which may be an acute or chronic illness.

Misdiagnosis of ME/CFS

ME/CFS is often misdiagnosed as depression, as many symptoms can overlap. Older case definitions, such as the Fukuda criteria and the Holmes criteria do not differentiate enough between the symptomatic criteria of depression and chronic fatigue syndrome (CFS).

Differences between depression and ME/CFS

Hawk, Jason, and Torres-Harding defined a number of key symptoms that were worse or different in ME/CFS compared to clinical depression without ME/CFS:

• Significant post-exertional malaise (PEM) was found in ME/CFS patients

PEM is now a required diagnostic criteria for ME/CFS in most countries

• fatigue lasts for a greater the percentage of the time in ME/CFS
• unrefreshing sleep severity is higher
• confusion–disorientation severity is higher
• shortness of breath severity is higher
• ME/CFS patients have less self-reproach (as scored on the Beck Depression Inventory)

Using the symptoms above list, Hawk, Jason, and Torres-Harding were able to report 100% correct classification between patients with major depressive disorder versus ME/CFS.

LaFerney, a psychiatric clinical nurse specialist, adds:

• Reason for depression: Individuals with major depressive disorder often cannot provide a reason or identify a loss to explain their depressed mood. ME/CFS patients are more likely to report feeling discouraged and depressed because of the inability to perform tasks, be employed, or engage in social functions due to ME/CFS symptoms.
• No lack of interest in activities: Depressed patients typically report a lack of interest in activities they previously enjoyed. ME/CFS patients say they would engage in favorite activities more if their illness would allow it.
• Post-exertional malaise: Although both depressed and ME/CFS patients report fatigue, only ME/CFS report post-exertional malaise: with physical symptoms typically worsening 12 to 48 hours after an activity and lasting for days to weeks.
• Antidepressants don't help in ME/CFS: In depressed patients, the diminished ability to think or concentrate should improve with antidepressant drugs or therapies. In patients with ME/CFS, antidepressants often do not improve concentration or memory.

Dr. Sarah Myhill adds an additional difference between depression and CFS:

• Response to exercise: Exercise makes CFS patients much worse, but can be positively therapeutic in pure depression

Clinical trials and patient evidence have both shown that:

• Cognitive behavioral therapy aimed at ME/CFS symptoms is ineffective and often harmful, and can harm mental health, but is an effective evidence-based treatment for depression
• most ME/CFS patients do not have depression, although in common with other chronic illness a significant number of patients develop reactive or secondary depression
• Many physically abnormal findings that are not present in depression, but many of these findings are not from the standard diagnostic tests and no single finding can yet act as a diagnostic biomarker for ME/CFS. Physical abnormalities in ME/CFS indicate immune, neurological, energy transportation, and other findings that cannot be explained by depression, somatization, deconditioning, health anxiety, or other psychological or behavioral factors

If I was cured tomorrow...

“	One question that can differentiate the two groups is to ask the patient, "If you were cured tomorrow, what would you do?" Depressed patients typically can not answer the question without forethought. ME/CFS patients typically can list an abundance of activities without prompt.	”
—Michael LaFerney

The Forgotten Plague Facebook page had a "If I was cured tomorrow..." campaign encouraging ME/CFS patients to upload their dreams to highlight this difference from depression.

Fukuda criteria

In 2006, Hawk, Jason, and Torres-Harding found that the CDC's Fukuda ME/CFS criteria, which is now retired from use, only correctly classified 84.4% of patients when comparing patients with major depressive disorder and to patients with ME/CFS.

Prevalence

• Katrina Berne reports a prevalence of 65-90% for depression.

Symptom recognition

• In the 1988 Holmes criteria, depression is an optional criteria for diagnosis, under the section Minor Symptom Criteria - Neuropsychologic Complaints. It is not a diagnosable symptom in the current CDC criteria, the Fukuda criteria, the Canadian Consensus Criteria or the International Consensus Criteria although secondary depression is recognized as a possible symptom and comorbidity of ME/CFS in the International Consensus Criteria.

Depression is also a potential symptom of Long COVID in the World Health Organization's definition.

Notable studies

• 2006, Differential diagnosis of chronic fatigue syndrome and major depressive disorder (Full Text)
• 2008, A Systematic Review of Chronic Fatigue Syndrome: Don't Assume It's Depression (Full Text)

Possible causes

Depression in ME/CFS patients may be caused by:

• The impact of living with a poorly understood chronic illness, known as reactive depression or secondary depression
• Someone with ME/CFS may have depression unrelated to their ME/CFS symptoms, known as primary depression
• People with ME/CFS typical lose the natural benefit of exercise, which means a person who previously used exercise to improve their mood is no longer able to do this
• Depression is a potential side effect of some drugs, particularly a class of drugs known as mood stabilizers, which are used for bipolar depression (manic depression) but cause depression or worsen depression in people without bipolar disorder.

Potential treatments

• Antidepressants
• Cognitive behavioral therapy for depression (CBT)
• Mindfulness and Meditation

Learn more

• 2008, A Systematic Review of Chronic Fatigue Syndrome: Don’t Assume It’s Depression
• 2008, Depression or chronic fatigue syndrome? by Michael C. Laferney
• 2014, How to Prove to Your Doctor You’ve Got Chronic Fatigue Syndrome (ME/CFS) And Are Not Just Depressed by Cort Johnson

See also

• Mood swings
• St. John’s Wort
• Anxiety
• Depression in fibromyalgia

See myalgic encephalomyelitis.

See chronic fatigue syndrome.

chronic illness any long-term illness, regardless of the severity. Chronic illnesses are typically incurable, requiring long-term management.

post-exertional malaise (PEM) - A notable exacerbation of symptoms brought on by small physical or cognitive exertions. PEM may be referred to as a "crash" or "collapse" and can last for days or weeks. Symptoms can include cognitive impairments, muscle pain, trouble remaining upright (orthostatic intolerance), sleep abnormalities, and gastro-intestinal impairments, and others.

See post-exertional malaise.

post-exertional malaise (PEM) - A notable exacerbation of symptoms brought on by small physical or cognitive exertions. PEM may be referred to as a "crash" or "collapse" and can last for days or weeks. Symptoms can include cognitive impairments, muscle pain, trouble remaining upright (orthostatic intolerance), sleep abnormalities, and gastro-intestinal impairments, and others.

Centers for Disease Control and Prevention (CDC) - The Centers for Disease Control and Prevention is a U.S. government agency dedicated to epidemiology and public health. It operates under the auspices of the Department of Health and Human Services.

See Centers for Disease Control and Prevention.

See adverse reaction.

adverse reaction Any unintended or unwanted response to a treatment, whether in a clinical trial or licensed treatment. May be minor or serious.

cognitive behavioral therapy (CBT) - A type of psychotherapy geared toward modifying alleged unhealthy thinking, behaviors or illness beliefs. One of the treatment arms used in the controversial PACE trial.

cognitive behavioral therapy (CBT) - A type of psychotherapy geared toward modifying alleged unhealthy thinking, behaviors or illness beliefs. One of the treatment arms used in the controversial PACE trial.

See cognitive behavioral therapy.

myalgic encephalomyelitis (M.E.) - A disease often marked by neurological symptoms, but fatigue is sometimes a symptom as well. Some diagnostic criteria distinguish it from chronic fatigue syndrome, while other diagnostic criteria consider it to be a synonym for chronic fatigue syndrome. A defining characteristic of ME is post-exertional malaise (PEM), or post-exertional neuroimmune exhaustion (PENE), which is a notable exacerbation of symptoms brought on by small exertions. PEM can last for days or weeks. Symptoms can include cognitive impairments, muscle pain (myalgia), trouble remaining upright (orthostatic intolerance), sleep abnormalities, and gastro-intestinal impairments, among others. An estimated 25% of those suffering from ME are housebound or bedbound. The World Health Organization (WHO) classifies ME as a neurological disease.

NICE guidelines Clinical guidelines used in the UK.

World Health Organization (WHO) - "A specialized agency of the United Nations that is concerned with public health. It was established on 7 April 1948, and is headquartered in Geneva, Switzerland. The WHO is a member of the United Nations Development Group. Its predecessor, the Health Organization, was an agency of the League of Nations." The International Statistical Classification of Diseases and Related Health Problems (ICD) is maintained by WHO.

See World Health Organization.