Treatment for Chronic Fatigue Syndrome

  • In exclusive interviews with Pro Health’s editor, the following respected physicians discussed their approaches to treating CFS and FM with both traditional and alternative methods, including expert advice from their standard protocols and other recommendations for important issues patients deal with including pain, fatigue, sleep, depression, brain fog, diet, exercise, and nutritional supplementation.
  • Natural Therapies

Conventional Treatments for Chronic Fatigue Syndrome

Patient Management of Chronic Fatigue Syndrome
Physicians advise patients with Chronic Fatigue Syndrome to pace themselves carefully and to avoid unusual emotional or physical stress. Follow a regular and manageable daily routine and take modest regular exercise under the supervision of a physician or physical therapist. In some instances, acupuncture, aquatic therapy, chiropractic, massage, self-hypnosis, stretching, tai chi, therapeutic touch, and yoga have proven helpful in managing Chronic Fatigue Syndrome. Certain psychotherapies such as family therapy have shown promise in the development of coping skills that are necessary to counter the adverse effects of chronic illness on the family or patient’s caregiver.

Prescription Medications
There are currently no FDA-approved prescription medications for use in treating Chronic Fatigue Syndrome. There are, however, a number of medications that are used to treat the various symptoms of Chronic Fatigue Syndrome. Many are recommended for effects that may be unrelated to their primary use. These may include antidepressants, antifungals, antihistamines, antivirals, CNS depressants (or stimulants), immunoglobulins, cardiac medications, anti-inflammatories, anticonvulsants, corticoids, and expectorants.

Understanding and Treating Chronic Fatigue Syndrome and Fibromyalgia

This article provides an overview of Fibromyalgia and Chronic Fatigue Syndrome, including information about symptoms and homeostasis (self-healing).

“The most commonly accepted definition is that the person affected needs to show a history of widespread pain (pain is considered widespread when all of the following are present: pain in the left side of the body, pain in the right side of the body, pain above the waist and pain below the waist. In addition there should be pain in the spine or the neck or front of the chest, or thoracic spine or lower back) and pain in 11 of 18 tender point sites on finger pressure.”

“Both Chronic Fatigue Syndrome and Fibromyalgia often seem to begin after an infection or a severe shock (physical or emotional), and the symptoms are very similar. The only obvious difference seems to be that for some people the fatigue element is the most dominant while for others the muscular pain symptoms are greatest. In other words for many people the diagnosis Chronic Fatigue Syndrome and Fibromyalgia are interchangeable terms, although there are certain symptoms (fever, swollen glands for example) which are found in a higher percentage of Chronic Fatigue Syndrome patients than those with Fibromyalgia, which sometimes make such a comparison less precise.”

Charles Lapp, M.D., on the Effective Treatment of Chronic Fatigue Syndrome and Fibromyalgia

Charles Lapp, M.D., is nationally recognized and sought after as a medical consultant regarding CFS and FM. He is Co-Chairman of the Clinical Affairs Committee for the American Association for CFS, medical advisor to the CFIDS Association of America, and a board member of the American FM Syndrome Association. Dr. Lapp is currently Director of the Hunter-Hopkins Center, P.A., Medical Consultations, in Charlotte, North Carolina, where he is a practicing physician, and is also Assistant Consulting Professor at Duke University Medical Center in Durham, North Carolina.

Here you will find Dr. Lapp’s definition of Fibromyalgia and Chronic Fatigue Syndrome, as well as his recommendations for treatment of sleep disorders, pain, low energy, depression, and brain fog associated with Fibromyalgia. Also includes information on his standardized treatment protocol, the “Stepwise Approach.”

“Most doctors who study both Chronic Fatigue Syndrome and Fibromyalgia find the two disorders so similar that we consider them “identical” for all intents and purposes. There are some subtle differences, however. Chronic Fatigue Syndrome is most likely triggered by an infectious or flu-like illness, whereas a number of Fibromyalgia cases are triggered by minor injury or trauma. Chronic Fatigue Syndrome is characterized biochemically by elevated levels of RNaseL (an anti-viral enzyme), whereas Fibromyalgia is unique in having excess Substance P (which triggers pain in nerves) in the bodily fluids. Profound exertional fatigue, post-exertional malaise, deep myalgias, sleep disruption, cognitive dysfunction, and autonomic abnormalities are common to both. Fibromyalgia tends to be a more persistent ailment, whereas studies have shown more spontaneous improvement in PWCs (Persons with Chronic Fatigue Syndrome). Persons with “pure Fibromyalgia” (that is, minimal cognitive dysfunction) tend to improve with low level, slowly progressive exercise, whereas persons with Chronic Fatigue Syndrome are more likely to flare or relapse with even minimal activity.”

“Low energy (combating fatigue): Start with high dose (injectible) B12 and NADH. Next step, consider Wellbutrin (a dopamine agonist) or a non-sedating Selective Serotonin Reuptake Inhibitor (SSRI, like Prozac, Zoloft, Celexa, Effexor). But the best therapy is to use low doses of CNS stimulants like methylphenidate (Ritalin), dexamphetamine (Dexedrine or Adderall), and modafinil (Provigil). The latter has an excellent safety profile, minimal effect on the cardiovascular system, and little abuse or habituation potential. Provigil not only improves fatigue (alertness), but also somnolence, mental clarity, attention deficits, and depression.”

Kent Holtorf, M.D., on Effective Treatment of Chronic Fatigue Syndrome and Fibromyalgia

Kent Holtorf, M.D., established the Hormone and Longevity Center in Torrance, California to concentrate of the treatment of hormone deficiencies. Eighty percent of Dr. Holtorf’s practice involves patients complaining of fatigue, with CFS and FM comprising the largest area of his practice. His medical practice focuses on these conditions as well as hypothyroidism, natural hormone replacement and optimization. He was recently selected to be the medical director of the Fibromyalgia and Fatigue Centers, and is currently writing a book on the topic.

This article outlines possible causes, diagnosis, and treatment of Chronic Fatigue Syndrome and Fibromyalgia.

“Current research suggests that many triggers can initiate a cascade of events, causing the hypothalamic, pituitary, immune and coagulation dysfunction. The most common initiating cause is a viral infection, which is very commonly Epstein-Barr Virus, Cytomegalovirus or HHV6. These are found in 80% of Chronic Fatigue Syndrome and Fibromyalgia patients. Many people with these syndromes can pinpoint the onset of the disease(s) to a viral infection that never got better. Also, stress seems to be a contributing factor. Effective treatment, with 80 to 90 percent of individuals achieving significant clinical benefits, can be achieved by simultaneously treating the above problems that an individual is found to have.”

“The mix of treatments needed varies from patient to patient. There are some abnormalities that are common. For instance, close to 100% of individuals with these syndromes have low thyroid. This is, however, usually not picked up on the standard blood tests because the TSH is not elevated in these individuals due to pituitary dysfunction. Many of these individuals will also have high levels of the anti-thyroid reverse T3, which is usually not measured on standard blood tests. In addition, the majority of individuals can also have a thyroid receptor resistance that is not detected on the blood tests. Consequently, thyroid treatment, especially with timed release T3, is effective for many patients. T4 preparations (inactive thyroid) such as Synthroid and Levoxyl do not work well for these conditions.”

Derek Enlander, M.D., on the Treatment of Chronic Fatigue Syndrome and Fibromyalgia

Derek Enlander, M.D., is originally from Belfast, Ireland, and is Physician-in-Waiting to the British Royal Family and to several members of the British government during their visits to New York. He is presently in private practice in New York where he sees CFS and FM patients, is on the faculty of Mt. Sinai Medical Center in New York City and serves as President of the Israel Medical Research Foundation.

Included in this article is Dr. Enlander’s advice on treating common Fibromyalgia related syndromes such as fatigue, pain, and brain fog, as well as information about a formula he has developed to help treat Fibromyalgia symptoms.

“After a full examination, I treat according to each patient’s health needs. However, yes, there is a common thread of treatment. Over 10 years approximately, I developed a formula given by injection weekly to help alleviate symptoms over time. This formula method is NOT a cure, but it does help significantly over time. Many of my patients have been able to resume a significant portion of their lives, including returning to work.”

“The formula works very slowly, often taking 8-12 weeks before the first signs of improvement begin. Other physicians use some of the ingredients I use to help treat Chronic Fatigue Syndrome/Fibromyalgia, but I have found that combining these ingredients into a single injection and consistently using this protocol has given tremendous improvement for most patients. My studies over the years have found a 70-80% improvement rate with use of the formula compared to only about 30% using individual items from the formula list.”

“Low energy (combating fatigue): One of the ingredients in the formula that I use for patients is glutathione. Many patients find this helpful for increasing energy levels. Other drugs I use may also have side benefits of increasing energy. Neurontin is such a drug. This is an anti-seizure medication that currently has uses in sleep issues, pain issues, as well as helping with energy levels. Antidepressants are used for many reasons besides depression, and these may often help elevate energy levels. If a patient does suffer from depression issues, certain antidepressants may help alleviate any fatigue issues related to the depression. Elavil is one older antidepressant drug that is often helpful for low energy, as well as sleeplessness.”

Michael E. Rosenbaum, M.D., on Treating Chronic Fatigue Syndrome and Fibromyalgia

Michael E. Rosenbaum, M.D., is a pioneer in Nutritional Medicine with 25 years experience in alternative healthcare, specializing in the treatment of Chronic Fatigue Syndrome, fibromyalgia, Myofascial Pain, endocrine and metabolic disorders, and allergies. He is currently in private medical practice in Corte Madera, California.

Outlines Dr. Rosenbaum’s treatment protocol for Chronic Fatigue Syndrome and Fibromyalgia.

“I have found that a cocktail of calcium 600 to 800 mg and magnesium 300 to 500 mg taken before bedtime has a relaxant effect that is very useful for sound sleep and to prevent restless legs. Melatonin and serotonin inducers like tryptophan and 5 HTP are also very useful. Too much tryptophan can cause bizarre and unpleasant dreams. GABA which occupies GABA receptors helps allay anxiety and induces sleep. Usual dose are 500 to 1500 mg.”

“A menu of medications, nutrients and herbs help the treatment in each step [in the my treatment protocol]. The following nutrients and alternative approaches have worked best in my practice:

Energy: B Complex vitamins, especially vitamins B1 and B12; NADH – a stabilized form of vitamin B3, Coenzyme Q10. The above vitamins all participate in the formation of ATP energy packets. For muscle energy, creatine, carnitine and branched chain amino acids are often very useful.

Cognition: Raising brain acetyl choline with tyrosine, N-acetyl carnitine and DMAE; stabilizing brain cell membrane functions with phosphatidyl serine.”

Treating Chronic Fatigue Syndrome and Fibromyalgia: Interview with David Moskowitz, M.D.

David Moskowitz, M.D., graduated from Harvard Medical School in 1980 and trained at Barnes Hospital and Washington University Medical School in St. Louis from 1980 to 1987. From 1987 until 1998, Moskowitz was an assistant professor at St. Louis University Medical School, with a lab and practice at the St. Louis VA Medical Center. In 1998, he started his first biotechnology company. Genomed, his second company, is the disease management company with which he is currently affiliated.

This article discusses Fibromyalgia and Chronic Fatigue Syndrome as autoimmune diseases.

“We have encountered two patients with Fibromyalgia initially diagnosed as having Autoimmune Fatigue Syndrome (AIFS). To investigate the relationship between AIFS and Fibromyalgia, the distribution of the tender points in patients with AIFS was assessed according to the ACR criteria for Fibromyalgia. It was revealed that AIFS patients had 5.6 tender points on average. Patients with headaches, digestive problems, or difficulty going to school had more tender points than patients without. Patients with ana titers < 1:160 had more tender points than patients with ana > or = 1:160. Anti-sa negative patients had more tender points than positive patients.”

“These results suggest a relationship between AIFS and Fibromyalgia in terms of the pathophysiologic mechanisms of the numerous tender points. In other words, ana-positive Fibromyalgia patients could be one form of AIFS, as well as ana-positive Chronic Fatigue Syndrome patients. Thus, autoimmunity could explain the controversial disease entities of Fibromyalgia and/or Chronic Fatigue Syndrome.”

Natural Therapies for Chronic Fatigue Syndrome

Ginseng And Echinacea
Essential Fatty Acids
Coenzyme Q10
NADH
L-Carnitine
Magnesium
DHEA
Digestive Enzymes
Glutamine
Whey Protein
Adapton
Folate
Licorice
Tyrosine
MATÉ

A report in the Annual Review of Medicine stated that Chronic Fatigue Syndrome “is an illness characterized by activation of the immune system, various abnormalities of several hypothalamic-pituitary axes, and reactivation of certain infectious agents” (Komaroff et al. 1998). This suggests that an individual with Chronic Fatigue Syndrome should follow a regimen that involves protecting and enhancing the immune system with proper nutritional supplements, proteins, and hormones. Free radicals play a role in causing damage to the immune system.

A comprehensive approach to Chronic Fatigue Syndrome would address several key areas, based on the results of laboratory tests, including:

  • Immune support (antiviral): ginseng, echinacea, essential fatty acids
  • Supplements involved in energy metabolism: CoQ10, NADH, L-carnitine, and magnesium
  • Adrenal support: DHEA, licorice, and sodium
  • Stress: glutamine and Adapton
  • Brain hormones and neurotransmitters: tyrosine
  • Homocysteine metabolism: B6, B12, folic acid, and SAMe
  • Antioxidants: glutathione, N-acetyl-cysteine, and alpha-lipoic acid
  • Fatigue: ginseng and Maté
  • Digestive support: digestive enzymes

Ginseng and Echinacea
Commission E, the group of scientists that advises the German government about herbs, endorses ginseng “as a tonic to combat feelings of lassitude and debility, lack of energy and ability to concentrate, and during convalescence” (Bahrke et al. 2000).

Ginseng is highly prized in China as an herb that increases energy. The higher grades are extremely expensive.

Echinacea has become very popular in the United States as “the herb” to take for colds and flus. It is known for its ability to stimulate the immune system and suppress infection-causing microbes.

Essential Fatty Acids
The use of essential fatty acids in Chronic Fatigue Syndrome is controversial. It has been proposed that essential fatty acids play a role in Chronic Fatigue Syndrome. One possible mechanism is that viruses, as part of their attack strategy, may reduce the ability of the cells to make 6-desaturated essential fatty acids.

The use of essential fatty acids for postviral fatigue syndrome was examined in a double-blind, placebo-controlled study of 63 adults (Behan et al. 1990). The patients had been ill for 1-3 years after an apparent viral infection and had severe fatigue, myalgia, and a variety of psychiatric symptoms. The patients received either placebo or a preparation containing linoleic, gamma-linolenic, eicosapentaenoic, and docosahexaenoic acids (8 500-mg capsules daily) over a 3-month period. Participants were asked to assess their improvement at months 1 and 3. The treatment group showed continual improvement, whereas many in the placebo group reverted toward baseline.

Improvement with Essential Fatty Acid Treatment

Time Treatment Group Placebo
1 month 74% 23%
3 months 85% 17%

 

The essential fatty acid composition of the subjects’ red cell membrane phospholipids was analyzed at the first and last visits. The essential fatty acid levels were abnormal at the baseline and corrected by active treatment. The authors concluded that essential fatty acids provide a rational, safe, and effective treatment for patients with postviral fatigue syndrome.

A follow-up study of 50 patients diagnosed with Chronic Fatigue Syndrome found no significant difference between the placebo group and those treated with Efamol marine, an essential fatty acid formula. In addition, no difference was seen in red cell membrane lipids between the patients and control group. These results sharply contrasted the previous study by Behan et al..

Essential fatty acids are termed “essential” because they play a vital role in health. Essential fatty acids are found in healthy oils, such as fish, flax, borage, and perilla. Unfortunately, fatty acids are damaged by heat, and many people are deficient because of the high heats used to process packaged foods.

Coenzyme Q10
Coenzyme Q10 has long been prescribed for Chronic Fatigue Syndrome patients. CoQ10 is a potent antioxidant that aids in metabolic reactions including the process of forming ATP, the molecule the body uses for energy. Virtually every cell in the body contains CoQ10. It is concentrated in the mitochondria, the area of the cells where energy is produced.

Judy presented a study of 20 female patients with Chronic Fatigue Syndrome who required bed rest following mild exercise and 20 healthy controls: 80% of the Chronic Fatigue Syndrome patients were found to be deficient in CoQ10, which further decreased following mild exercise or over the course of normal daytime activity. After 3 months of CoQ10 supplementation (100 mg/day), the exercise tolerance (400 kg-meters of work) of the Chronic Fatigue Syndrome patients more than doubled. All patients had improved: 90% had reduction and/or disappearance of clinical symptoms, and 85% had decreased postexercise fatigue.

NADH
NADH (reduced B-nicotanimide dinucleotide) is a coenzyme molecule formed from vitamin B3 (niacin). NADH (along with CoQ10) is essential for the production of energy (ATP) in a process called oxidative phosphorylation.

A randomized, double-blind, placebo-controlled crossover study examined the use of NADH in Chronic Fatigue Syndrome: 26 eligible patients diagnosed with Chronic Fatigue Syndrome received either 10 mg of NADH or placebo for a 4-week period. Eight of 26 (31%) responded favorably to NADH in contrast to two of 26 (8%) to placebo. Based upon these encouraging results, the authors decided to conduct a larger study to establish the efficacy of NADH in Chronic Fatigue Syndrome.

NADH (5-10 mg/day) is most effective when taken in the morning, 30 minutes before breakfast.

L-Carnitine
Several studies have found deficiencies of the amino acid L-carnitine in patients with Chronic Fatigue Syndrome, although other studies fail to confirm this. L-carnitine is known to boost energy levels. The lack of consistency in the research literature suggests that there may be a number of marginal nutritional deficiencies that have etiologic relevance to Chronic Fatigue Syndrome. These deficiencies may include carnitine along with the B-complex vitamins, essential fatty acids, L-tryptophan, zinc, magnesium, and others.

Studies show that carnitine given as a supplement to Chronic Fatigue Syndrome patients results in better functional capacity and improvement of disease symptoms. Other studies have shown a dose of 1000-2000 mg daily has resulted in improvement in those with low levels of energy.

Magnesium
Magnesium, a mineral utilized by every cell of the body, participates in energy metabolism and protein synthesis. The body vigilantly protects blood magnesium levels, in part because 350 enzymatic processes depend upon magnesium status for activation. Magnesium is stored in tissues and bone, sharing skeletal residency with calcium and phosphorus.

An article in Lancet described a randomized, double-blind, placebo-controlled study of 20 patients with Chronic Fatigue Syndrome. The Chronic Fatigue Syndrome patients were found to have lower red cell magnesium concentrations. In a clinical trial, 32 Chronic Fatigue Syndrome patients received either placebo or intramuscular magnesium sulfate every week for 6 weeks. Patients treated with magnesium reported having improved energy levels, better emotional state, and less pain, as judged by changes in the Nottingham Health Profile. Red cell magnesium returned to normal in all patients on supplemental magnesium, but in only one patient on placebo. The authors concluded that these results demonstrate that magnesium may have a role in Chronic Fatigue Syndrome.

One study, however, found no difference in red blood cell magnesium concentrations in samples from 89 patients with Chronic Fatigue Syndrome when compared to an age- and sex-matched group selected from the normal population. A magnesium-loading test on six patients found no evidence of deficiency.

A study of 93 patients with unexplained chronic fatigue (54% with Chronic Fatigue Syndrome) examined the relationship between magnesium deficiency and oxidative stress. Magnesium-deficient patients (47%) had lower total antioxidant capacity in plasma which was related to serum albumin. Magnesium-deficient patients whose magnesium body stores did not improve after oral supplementation with magnesium (10 mg/kg/day) had persistently lower blood glutathione levels. The authors concluded that magnesium supplementation was followed by an improvement in magnesium body stores, in serum vitamin E, and in its interrelated stage of lipid peroxidation.

Magnesium plays a crucial role in metabolism. It is needed for activating B vitamins, relaxing muscles, and forming ATP, the energy molecule. Fatigue, muscle cramps, and constipation are signs of magnesium deficiency. Taking too much magnesium often leads to diarrhea. The dose is increased until this occurs and then backed off to maintain a normal consistency of stools.

DHEA
DHEA is a hormone secreted from the adrenal glands. It is a precursor of the sex hormones (estrogen and testosterone). DHEA-S has been shown to have beneficial effects on memory, stress, anxiety, sleep, and depression. Therefore, the deficiency of DHEA-S might be related to the symptoms in patients with Chronic Fatigue Syndrome. DHEA has been reported to improve energy levels in chronic fatigue patients.

One study demonstrated the value of DHEA and vitamin C infusion treatment in the control of Chronic Fatigue Syndrome.

A study of 15 subjects with Chronic Fatigue Syndrome, 15 subjects with major depression, and 11 healthy subjects found that DHEA and DHEA-S levels were significantly lower in the Chronic Fatigue Syndrome subjects compared to the healthy group. DHEA-S levels, but not DHEA, were lower in the depressives. The authors concluded that DHEA has a potential role both therapeutically and as a diagnostic tool in Chronic Fatigue Syndrome.

Another study of DHEA levels in 22 Chronic Fatigue Syndrome patients and 14 healthy controls found normal basal DHEA levels, but a blunted serum DHEA response curve to ACTH (adreno-corticotropic hormone) injection. ACTH normally stimulates the adrenal glands to secrete DHEA. The authors concluded that endocrine abnormalities play a role in Chronic Fatigue Syndrome and that a relative glucocorticoid deficiency might contribute to the overall clinical picture in Chronic Fatigue Syndrome.

DHEA is contraindicated in both men and women with hormone-related cancers.

Digestive Enzymes
Enzymes are responsible for every activity of life. There are two primary classes of enzymes responsible for maintaining life functions: digestive and metabolic. The primary digestive enzymes are proteases (to digest protein), amylases (to digest carbohydrate), and lipases (to digest fat). These enzymes function as a biological catalyst to help break down food. Raw foods also provide enzymes that naturally break down food for proper absorption. Metabolic enzymes are responsible for the structuring, repair, and remodeling of every cell, and the body is under a great daily burden to supply sufficient enzymes for optimal health. Metabolic enzymes operate in every cell, every organ, and every tissue, and they need constant replenishment.

The capacity of the living organism to make enzymes diminishes with age. Some scientists believe that humans could live longer and be healthier by guarding against the loss of our much-needed enzymes. Supplementation with digestive enzymes helps the body to better absorb nutrients from food and lessens the need for the secretion of natural enzymes, thereby preserving them to assist in vital cellular metabolic functions.

Glutamine

An article in the British Journal of Sports Medicine described a study of athletes during an intense training period before the 1992 Olympics. The athletes were divided into three groups that differed in training fatigue and were considered separately. Group A (21 track-and-field athletes) had no lasting fatigue; group B (12 judo competitors) reported heavy fatigue at night but recovered overnight to continue training; group C (18 track-and-field athletes and one rower) had chronic fatigue and had been unable to train normally for at least several weeks. Plasma amino acid analysis showed that group A had a normal amino acid pattern, and both groups B and C had decreased plasma glutamine (average 33%) with, especially in group B, decreased histidine, glucogenic, ketogenic, and branched chain amino acids. Ten athletes in group C presented with infection.

After 3 weeks of additional protein intake, virtually all of the low glutamine levels increased to above 500 micromole/L. Total amino acids increased, and the amino acid pattern normalized: six of the 10 athletes on this protein intake returned to increased training within the 3 weeks. An analysis of the pattern in group C showed a persistent decrease in plasma amino acids (but mainly glutamine) in those with chronic fatigue and infection. Inadequate protein intake appeared to be a factor. Supplementation with glutamine would benefit chronic fatigue patients by enhancing gut motility, improving plasma glutamine levels, and boosting glutathione.

Whey Protein
In a large proportion of people with Chronic Fatigue Syndrome, abnormalities are often found in both humoral and cellular immunity. The exact cause of this is not fully understood. One fairly consistent finding in people with Chronic Fatigue Syndrome is an impaired lymphocyte (T-cell) response to a challenge. That is, the lymphocyte does not respond appropriately or rapidly when presented with an immune challenge. As early research has shown, the ability of lymphocytes to react to an immune challenge is directly related to glutathione levels. Continued use of glutathione by lymphocytes may lead to cellular glutathione depletion and immune failure. Because whey is the most effective way to deliver precursors for glutathiol as a recognized way to raise glutathione levels in humans and animals, it is theorized that whey may be especially effective for persons with Chronic Fatigue Syndrome.

Adapton
The active ingredients in Adapton (extracts from Garum armoricum, a deep sea fish called the Great Bluefish that is native to Brittany in France) are a class of unique precursors to endorphins and other neurotransmitters that exert a regulatory effect on the nervous system. Adapton is widely used throughout Europe and Japan for the treatment of a wide range of stress-induced disorders (see “A Natural Therapy for Stress, Fatigue and Anxiety” in the February issue of Life Extension Magazine).

A study was conducted on 20 patients who had been ill with various forms of chronic fatigue for 1-3 months. Patients were registered and information was collected in accordance with the protocol of the European Fatigue Study Group, which includes scales to measure anxiety, depression, muscle fatigue, mental fatigue, sleep disorders, and headache. Four placebo capsules were given to these patients daily during the first 2 weeks of the study. Then 4 capsules of garum extract were given daily for the next 2 weeks of the study. After 2 weeks on placebo, fatigue symptoms were reduced by an average of 14%, and overall symptoms of anxiety, depression, and insomnia were reduced by 4%. On the other hand, after 2 weeks of taking garum extract, fatigue symptoms were reduced by 51%, and overall symptoms were reduced by 65%. In 2 weeks after discontinuing garum extract therapy, fatigue symptoms increased 15%, and overall symptoms increased 7%. These results demonstrate the broad-spectrum benefits of garum extract for people with chronic stress and fatigue. It is interesting to note that the beneficial effects of garum extract persisted even after the treatment was stopped.

Other studies involved 40 patients who had also been experiencing various forms of chronic fatigue for 1-3 months. Four capsules of garum extract were prescribed daily for 2 weeks. The results, based on the Fatigue Study Group criteria, showed an average benefit of 50% for the 10 functions that most accurately measure fatigue and depression.

Recognizing the challenge of managing the anxiety and depression, which often appear together and require more than one drug for effective treatment, and also the concerns about typical drug therapy and habituation, Dorman et al. conducted a study to examine the efficacy of Garum armoricum in what was termed “free-floating” anxiety. The study subjects were otherwise healthy college students who experienced significant stress and anxiety from final examinations. The study was controlled and vigilance was maintained to watch for possible side effects. Administration of Garum armoricum resulted in a statistically significant difference in mean anxiety test scores, with the subjects taking Garum armoricum demonstrating lowered anxiety test scores during the second and third weeks. Interestingly, Dorman et al. also reported that Garum armoricum had a lingering anxiolytic (tranquilizing) effect following its use (beyond a week) in subjects who were experiencing anxiety.

In a study based on the positive results of an earlier study of Garum armoricum in the areas of weakness and fatigue-related depression and anxiety, Le Poncin et al. (2000) conducted a double-blind versus placebo study to examine the effects of Garum armoricum on memory and cognitive disorders. Their results demonstrated statistically significant positive effects, especially in the group of subjects who were 40-50 years of age. Significant improvement was noted in refreshing sleep, motivation, concentration, and memorization skills. Le Poncin et al.reported that the favorable effects on weakness and fatigue-related depression appeared to be factors in improved memory and cognitive function. Le Poncin et al. concluded that Garum armoricum had no harmful side effects, was not addictive, and had proven efficacy in their studies. Any reactions were mild, without the necessity of interrupting the treatment. Therefore, it appears that garum extract is extremely well-tolerated and is without contraindications.

A Japanese researcher reported that when garum extract reduces anxiety, it results in improved learning, including enhanced EEG (electroencephalogram) brain wave activity (Haruyama undated report).

Even though studies demonstrate that Garum armoricum extract relieves depressive symptoms and anxiety that are often associated with chronic stress and fatigue, it may not be effective or appropriate for more complex conditions, such as clinical depression or bipolar manic depression. Use of Adapton for these more complex conditions should be only under the supervision of a physician.

Folate
Folic acid is involved in red blood cell health and proper cell division, as well as other functions in maintaining healthy tissues. Folic acid has been shown to prevent neural tube defects and to function as a methyl donor to lower homocystine. Folic acid has a role in the prevention of heart disease and some cancers.

An article in the journal Neurology described a study in which serum folate levels were measured in 60 patients with Chronic Fatigue Syndrome. Researchers found that 50% had values below 3.0 mcg/L. The authors concluded that some patients with Chronic Fatigue Syndrome are deficient in folic acid.

Licorice
Licorice is highly valued as a medicinal herb by the Chinese and is an ingredient in almost all of the Chinese patent herbal formulas. Licorice has a sweet taste and helps combat fatigue. The active constituent in licorice, glycyrrhizin, stimulates the production of hormones, including cortisone, and stimulates the production of interferon, which boosts immunity. Licorice is an old herbal remedy that has been used medically for Addison’s disease and adrenal insufficiency.

Tyrosine
Tyrosine (and phenylalanine) are amimo acid precursors of the neurotransmitters dopamine, epinephrine, and norepinephrine (which used to be called adrenaline and noradrenaline). Deficiencies in these neurotransmitters are known to cause low levels of energy.

An article in the journal Medical Science of Sports Exercise described a study of the effects of tyrosine on exercise tolerance and brain neurochemistry of mice. Tyrosine injections improved maze performance and prevented increased levels of serotonin (5-HT) in the hypothalamus after exercise. Tyrosine administration significantly improved food consumption, cognitive behavior, and activity performance. The authors concluded that tyrosine may improve exercise tolerance and delay fatigue.

An article in the journal Brain Research Bulletin described a study of the effects of tyrosine on a group of 21 cadets during a demanding military combat training course: 10 subjects received 5 daily doses of a protein-rich drink containing 2 grams of tyrosine, and 11 subjects received a carbohydrate-rich drink with the same amount of calories (255 kcal). The group supplied with the tyrosine-rich drink performed better on a memory and a tracking task than the group supplied with the carbohydrate-rich drink. In addition, the supplementation of tyrosine decreased systolic blood pressure. No effects on mood were found. The authors concluded that these findings suggest that supplementation with tyrosine may, under operational circumstances characterized by psychosocial and physical stress, reduce the effects of stress and fatigue on cognitive task performance.

MATÉ
Commission E approves using 1-2 tsp (2-4 grams) a day of maté (Ilex paraguayensis) leaves in a brewed tea for banishing mental and physical fatigue. Ilex paraguayensis is an evergreen shrub that is found in certain areas of South America. Most of maté’s energy-boosting activity comes from caffeine; however, the effect is quite different from that of coffee. The energy boost takes about 30 minutes to become apparent and lasts several hours. Flavonoids including rutin, isoquercitin, and glycosides are also found in its leaves. Maté tea is reported to be a favorite tea among dancers in Brazil and is traditionally served in a gourd. Homeopathic preparations of maté are also available in tablets, globules, or as a tincture.


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