“Fatigue” describes an extreme state of tiredness or exhaustion. When it is ongoing and not explained by exertion, it can become problematic. Fatigue is relatively common in the general population with around one in three teens reporting that they are lethargic and more worn out than normal (Collin et al., 2016). In addition, many teens who are depressed report significant fatigue; 73.3% of the sample of over 400 11-17 year olds seen in CAMHS who met the DSM-IV diagnostic criteria for Major Depressive Disorder reported experiencing significant fatigue (Goodyer et al., 2016). Fatigue could impact on motivation, participation in activities, concentration and attention and indeed, engagement in therapy. This means that fatigue could contribute to problem maintenance in several ways. Yet, in CAMHS practice, we rarely ask about fatigue, or seek to address it directly (Higson-Sweeney, Loades, Hiller, & Read, 2019).
Successful treatments have been developed for fatigue across a range of physical conditions (Hulme et al., 2018). However, these treatments have not explicitly been tested within the context of adolescent depression, and fatigue has not tended to be an outcome of interest in existing treatments. Therefore, we don’t know what works for fatigue in this population.
A cognitive and/or behavioural approach to tackling fatigue has proved useful in other populations of adolescents with fatigue such as Chronic Fatigue Syndrome (Lloyd, Chalder, & Rimes, 2012; Nijhof, Bleijenberg, Uiterwaal, Kimpen, & van de Putte, 2012). Treatment includes a focus on sleep, establishing a regular wake-up time. By working backwards from the wake-up time to work out the bedtime needed to have the required number of hours of sleep, bedtime can allow for the optimum sleep opportunity. Having naps during the day is discouraged due to the negative effect these have on night-time sleep quality. These elements of treatment are the same as those used in Cognitive Behaviour Therapy (CBT) for Insomnia, which has been tested in adolescents and shown to have positive effects on mood (Conroy et al., 2019). In addition, fatigue treatment focuses on stabilising and then gradually increasing activity levels. Teens affected by fatigue tend to have fallen into one of two activity patterns:
- excessive rest (which may work well for short-term fatigue, but is not helpful for more chronic fatigue)
- ‘boom and bust’ cycles, which are typified by doing lots (overdoing it) and then very little.
Neither pattern is helpful in overcoming fatigue. Instead, establishing a baseline level of activity that is manageable every single day, and then gradually increasing this (by 10-20% every 1 to 2 weeks), can address fatigue. Where unhelpful thoughts are interfering with making behavioural changes, these can be explored and addressed using cognitive strategies such as thought challenging or through gaining some distance from the thoughts using mindfulness or defusion techniques.
With teens who are depressed, this approach to fatigue can complement National Institute for Health and Care Excellence (NICE) recommendations for treatment (NICE, 2005, 2015). Indeed, NICE recommend addressing sleep problems. Although in CAMHS, we often ask about sleep at initial assessment, following through by intervening, including using psychoeducation and motivational interviewing as necessary is important (Higson-Sweeney et al., 2019). Furthermore, we often aim to increase the amount of enjoyable activities that an individual with depression is doing as part of behavioural activation. By doing this gradually, and by attending to how much a person is doing each day, as well as trying to ensure that this is relatively consistent, we can concurrently manage and begin to address fatigue. It is also important to consider how fatigue might impact on how we work within the session with an individual; we may need to keep sessions shorter, to chunk information, to repeat information, and to write things down more.
More research is needed to establish how best to address fatigue in adolescents who are depressed. But for now, it seems reasonable to conclude that it is an important symptom to ask about, given how common it is in this population. Once we have identified it as a problem, we can work collaboratively with a teenager to think about how it might be contributing to problem maintenance and what we might need to do to overcome it.
Collin, S. M., Norris, T., Nuevo, R., Tilling, K., Joinson, C., Sterne, J. A. C., & Crawley, E. (2016). Chronic Fatigue Syndrome at Age 16 Years. Pediatrics, 137(2). doi:10.1542/peds.2015-3434
Conroy, D. A., Czopp, A. M., Dore-Stites, D. M., Dopp, R. R., Armitage, R., Hoban, T. F., & Arnedt, J. T. (2019). Modified cognitive behavioral therapy for insomnia in depressed adolescents: a pilot study. Behav Sleep Med, 17(2), 99-111.
Goodyer, I., Reynolds, S., Barrett, B., Byford, S., Dubicka, B., Hill, J., . . . Fonagy, P. (2016). Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled superiority trial. The Lancet Psychiatry. doi:10.1016/s2215-0366(16)30378-9
Higson-Sweeney, N., Loades, M. E., Hiller, R. M., & Read, R. (2019). Addressing sleep problems and fatigue within child and adolescent mental health services: A qualitative study Clinical Child Psychology & Psychiatry.
Hulme, K., Safari, R., Thomas, S., Mercer, T., White, C., Van der Linden, M., & Moss-Morris, R. (2018). Fatigue interventions in long term, physical health conditions: A scoping review of systematic reviews. PLoS One, 13(10), e0203367. doi:10.1371/journal.pone.0203367
Lloyd, S., Chalder, T., & Rimes, K. A. (2012). Family-focused cognitive behaviour therapy versus psycho-education for adolescents with chronic fatigue syndrome: long-term follow-up of an RCT. Behav Res Ther, 50(11), 719-725. doi:10.1016/j.brat.2012.08.005
NICE. (2005). Depression in children and young people: Identification and management in primary, community and secondary care.
NICE. (2015). Depression in children and young people: Psychological interventions for mild depression and pharmacological interventions for moderate to severe depression (update)
Nijhof, S. L., Bleijenberg, G., Uiterwaal, C. S., Kimpen, J. L., & van de Putte, E. M. (2012). Effectiveness of internet-based cognitive behavioural treatment for adolescents with chronic fatigue syndrome (FITNET): a randomised controlled trial. The Lancet, 379(9824), 1412-1418.
Dr. Loades is funded by the National Institute for Health Research (Doctoral Research Fellowship, DRF-2016-09-021). The views expressed in this publication are those of the authors(s) and not necessarily those of the NHS, The National Institute for Health Research or the Department of Health and Social Care or ACAMH.
Department of Psychology, University of Bath
Bristol Medical School, University of Bristol