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Comparative epidemiology of chronic fatigue syndrome in Brazilian and British primary care: prevalence and recognition

  • Hyong Jin Cho (a1), Paulo Rossi Menezes (a2), Matthew Hotopf (a3), Dinesh Bhugra (a4) and Simon Wessely (a3)...
Abstract
Background

Although fatigue is a ubiquitous symptom across countries, clinical descriptions of chronic fatigue syndrome have arisen from a limited number of high-income countries. This might reflect differences in true prevalence or clinical recognition influenced by sociocultural factors.

Aims

To compare the prevalence, physician recognition and diagnosis of chronic fatigue syndrome in London and São Paulo.

Method

Primary care patients in London (n=2459) and São Paulo (n=3914) were surveyed for the prevalence of chronic fatigue syndrome. Medical records were reviewed for the physician recognition and diagnosis.

Results

The prevalence of chronic fatigue syndrome according to Centers for Disease Control 1994 criteria was comparable in Britain and Brazil: 2.1% v. 1.6% (P=0.20). Medical records review identified 11 diagnosed cases of chronic fatigue syndrome in Britain, but none in Brazil (P<0.001).

Conclusions

The primary care prevalence of chronic fatigue syndrome was similar in two culturally and economically distinct nations. However, doctors are unlikely to recognise and label chronic fatigue syndrome as a discrete disorder in Brazil. The recognition of this illness rather than the illness itself may be culturally induced.

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Copyright
Corresponding author
H. J. Cho, Department of Psychiatry, Federal University of São Paulo, Rua Botucatu 740, CEP 04023-900, São Paulo, Brazil. Email: h.cho@iop.kcl.ac.uk
Footnotes
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Declaration of interest

None.

Funding detailed in Acknowledgements.

Footnotes
References
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Comparative epidemiology of chronic fatigue syndrome in Brazilian and British primary care: prevalence and recognition

  • Hyong Jin Cho (a1), Paulo Rossi Menezes (a2), Matthew Hotopf (a3), Dinesh Bhugra (a4) and Simon Wessely (a3)...
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eLetters

Re: Diagnosing CFS: Cross cultural studies are necessary to avoid category fallacy

Hyong Jin Cho, Research fellow
15 July 2009

We thank Dr Paralikar and colleagues for their interests in our recent article. The assertion that chronic fatigue syndrome (CFS) is a culture-bound syndrome of the high-income Western countries may be largelybased on the observation that “clinical descriptions of chronic fatigue syndrome, also known in some countries as myalgic encephalomyelitis, have arisen from a limited number of high-income countries in Northern Europe, North America and Oceania” (quote from Cho et al, 2009[1]). We aimed to examine the reasons for this particular observation while proving or disproving the above assertion was beyond the scope of our study. Without any pre-assumptions regarding the local validity of the construct of CFS, we used this ‘etic’ construct originated from the high-income Western countries in Brazil in order to examine whether this foreign concept defines a similar proportion of individuals as cases. We found that, usingthe current CDC case definition of CFS, similar proportions of primary care attenders were defined as CFS cases in Sao Paulo and London. However,Brazilian doctors were unlikely to recognise and/or label such patients asCFS cases.

In a way, we actually used Kleinman’s formulation of the category fallacy as a research method in our study. That is, by imposing an alien diagnostic concept where its local validity is untested and unknown, we examined which component of this alien construct is not sanctioned by the local cultural context: the occurrence itself or the recognition/labelling. In Brazil, although unexplained fatigue as formulated by the Western medical community indeed does occur, “it is not sanctioned as a medical condition worthy of medical treatment, sick leave or sickness benefit, and it may be more likely to be considered as part ofeveryday adversity and less likely to be recognised as a medical disorder”(quote from Cho et al, 2009[1]).

Furthermore, while Paralikar et al suggested our paper lacked the consideration of the cultural context, we actually discussed and interpreted these findings mostly in light of the sociocultural context. For example, based on the previous studies and our own data, we discussed that the sociocultural differences such as the degree of medicalisation ofthe population and awareness of CFS among the population and the medical professionals might have contributed to the current findings.[1-3]

We have not specifically addressed alternative local formulations forthe problems resembling CFS in Brazil. However, our case vignette study using a typical history of CFS according to the CDC definition revealed that the most common diagnoses given by Brazilian doctors were psyhcological disorders,[3] hence providing some information regarding thequestion raised by Paralikar et al. In order to address this and other important questions, we have collected qualitative data through in-depth interviews of chronically fatigued individuals in Brazil and these data are currently being analysed.

We agree with Dr Paralikar and colleagues that the pattern of recognition and labelling observed in Brazil is not a failing since this pattern is probably due to the sociocultural context rather than due to the medical incompetence. Indeed, we never suggested it was a failure.

Finally, the study by de Fatima de Marinho de Souza et al[4] has actually used the same questionnaire as the current study: the Chalder Fatigue Questionnaire. A more inclusive concept of chronic fatigue, as operationalised by this questionnaire, was also used in the current study,namely unexplained chronic fatigue as we additionally performed the screening for medical causes. The prevalence of unexplained chronic fatigue was also similar in the two settings.

1. Cho HJ, Menezes PR, Hotopf M, Bhugra D, Wessely S. Comparative epidemiology of chronic fatigue syndrome in Brazilian and British primary care: prevalence and recognition. Br J Psychiatry 2009;194:117-122.

2. Cho HJ, Bhugra D, Wessely S. 'Physical or psychological?' - A comparative study of causal attribution for chronic fatigue in Brazilian and British primary care patients. Acta Psychiatr Scand 2008; 118: 34-41.

3. Cho HJ, Menezes PR, Bhugra D, Wessely S. The awareness of chronic fatigue syndrome: A comparative study in Brazil and the United Kingdom. J Psychosom Res 2008; 64: 351-355.

4. de Fatima Marinho de Souza M, Messing K, Menezes PR, Cho HJ. Chronic fatigue among bank workers in Brazil. Occup Med (Lond) 2002;52:187-194.
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Conflict of interest: None Declared

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Diagnosing CFS: Cross cultural studies are necessary to avoid category fallacy

Vasudeo P Paralikar, Consultant Psychiatrist
19 March 2009

To the Editor:

In their comparative epidemiological study of CFS in Brazil and London, Cho and colleagues (2009) conclude that cultural differences affect only the recognition, rather than occurrence, of this condition. Although a reasonable interpretation of the epidemiological data, without complementary consideration of the cultural context, the assertion is likely to obscure some of the most salient features and clinical significance of the study. The authors note that “both population and healthcare professionals seem unfamiliar with the construct of the syndrome.” Recognition of the community and professional inattention and low priority for CFS, however, is not necessarily a failing; it may also be regarded as an updated example of Kleinman’s formulation of the category fallacy—the imposition of alien diagnostic concepts where they lack local validity. The assertion of under-recognition is incomplete without consideration of alternative formulations of the problems that in some respects resemble, but are not diagnosed, CFS. Do such conditions, such as neurasthenia in East Asia and dhat syndrome in South Asia, have characteristic patterning of distress or meaning in Brazil?

If one accepts the authors’ tacit premise that the construction of CFS and related UK formulations (Encephalomyelitis and fibromyalgia) are unquestionably valid diagnoses for use everywhere, then the conclusion that CFS is neglected by professionals but no less important in the Brazilian population is valid. Accepting that premise, however, requires that we ignore the fact that CFS is neither in the ICD or DSM, and neurasthenia was rejected after consideration in the draft version of DSM-IV (Paralikar et al., 2007). Standard texts in the field of cultural psychiatry regard CFS as a North American culture-bound syndrome (Griffithet al., 2003). Earlier research by some of the same Brazilian authors alsohighlights the social determinants of essential features of chronic fatigue, rather than the categorical diagnosis of CFS (de Fatima Marinho de Souza et al., 2002).

Culturally sensitive clinical care will benefit from reconsideration of a cultural interpretations of these study data and from additional cross-cultural research. Are other diagnoses or local clinical and cultural formulations used to manage and treat such patients locally? Are other non-medical sources of help and social interventions given higher priority by patients and communities in Brazil? Findings of Karasz and McKinley (2007) showing the tendency of North Americans to ‘medicalize’, and South Asians to ‘socialize’ similar clinical vignettes recommend consideration of that point. Among patients studied by Cho et al., one might also ask whether higher rates of associated common mental disorders suggest these psychiatric conditions are more likely to be the focus of treatment. The emphasis on under-recognition of CFS is likely to prove less important for community mental health and culturally sensitive care than questions of how such clinical patterns are understood in the population and explained by professionals.

References

Cho HJ, Menezes PR, Hotopf M, Bhugra D, Wessely S. (2009). Comparative epidemiology of chronic fatigue syndrome in Brazilian and British primary care: prevalence and recognition. The British Journal of Psychiatry 194, 117–122. doi: 10.1192/bjp.bp.108.051813

Kleinman, A. (1977). Depression, somatization, and the new cross-cultural psychiatry. Social Science & Medicine, 11, 3-10.

Paralikar V, Sarmukaddam S, Agashe M, Weiss, MG. (2007). Diagnostic concordance of neurasthenia spectrum disorders in Pune, India. Soc Psychiatry Psychiatr Epidemiol, 42, 561-572.

Griffith EE, Gonzalez CA, & Blue HC. (2003). Introduction to Cultural Psychiatry in Textbook of Clinical Psychiatry, Eds Hales, R., & Yudofsky, S. 4th Edition, Vol.2, 1551-1583. American Psychiatric Publishing, Washington DC, London UK.

de Souza M de Fatima Marinho, Messing K, Menezes PR, & Cho HJ. (2002). Chronic fatigue among bank workers in Brazil, Occupational Medicine 52:187-194

Karasz A, & McKinley PS. (2007). Cultural Differences in Conceptual Models of Everyday Fatigue-A vignette study. Journal of HealthPsychology, 12(4), 613-626.
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Conflict of interest: None Declared

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Prevalence estimates have been inflated due to the female predominance in the samples

Tom Kindlon, Information Officer (voluntary position)
25 February 2009

We are not given information on the gender breakdown of Chronic Fatigue Syndrome (CFS) in this study but if it is in-line with other studies in the field, females would be much more likely to have CFS. Given a much larger percentage of the cohorts are female compared to the general population, this would mean that the (adjusted) prevalence rates for each country would be lower.

The total number of CFS cases found in a particular country cohort = Number of women with CFS + Number of men with CFS = P(CFS|F)*N(F)+P(CFS|M)*N(M) where F=Female, M=Male, N(F)=Number of Females, P(CFS|F)=Probability of a female having CFS, etc.

If one takes P(CFS|M)=0.25*P(CFS|F), which would be comparable to an approximate average of previous studies (for example, [1-4]), and assumes the number of men and women are equal in the 18-45 age bracket, the prevalence rates for CFS in the UK and Brazil are 1.65% and 1.21% respectively.

These figures in themselves are an upper bound on the true prevalencerates, given individuals in neither group went through rigorous and thorough individual assessments to exclude other conditions.

References:

[1] Bazelmans E, Vercoulen JH, Swanink CM, Fennis JF, Galama JM, van Weel C, van der Meer JW, Bleijenberg G.Chronic Fatigue Syndrome and Primary Fibromyalgia Syndrome as recognized by GPs. Fam Pract. 1999 Dec;16(6):602-4.

[2] Jason LA, Richman JA, Rademaker AW, Jordan KM, Plioplys AV, Taylor RR, McCready W, Huang CF, Plioplys S.A community-based study of chronic fatigue syndrome.Arch Intern Med. 1999 Oct 11;159(18):2129-37.

[3] Kim CH, Shin HC, Won CW. Prevalence of chronic fatigue and chronic fatigue syndrome in Korea: community-based primary care study. J Korean Med Sci. 2005 Aug;20(4):529-34.

[4] Reyes M, Nisenbaum R, Hoaglin DC, Unger ER, Emmons C, Randall B, Stewart JA, Abbey S, Jones JF, Gantz N, Minden S, Reeves WC. Prevalence and incidence of chronic fatigue syndrome in Wichita, Kansas. Arch Intern Med. 2003 Jul 14;163(13):1530-6.
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Conflict of interest: None Declared

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