Neurasthenia spectrum disorders : clinical cultural epidemiology in Pune, India

Background: Persistent and unexplained fatigue and weakness constitute disorders, such as Chronic Fatigue Syndrome (CFS) in USA, fibromyalgia in Europe, and Neurasthenia (NT) in East Asia. Their overlapping diagnostic criteria include essential clinical and additional culture-specific features. They are best regarded as Neurasthenia Spectrum Disorders (NSDs) focusing on essential clinical criteria. Because clinical understanding is limited, public health challenges are more difficult. Psychiatric comorbidity is frequent, e.g. fatigue with depression. NSDs are rarely diagnosed or researched in India. Therefore, we aimed to study clinical cultural epidemiology of NSDs in urban general hospital in Pune, India.
Methods: We did a set of cross-sectional studies. Prevalence was estimated by survey of 1,874 consecutive outpatients in clinics of Psychiatry, Medicine, Dermatology, and Ayurved by a brief semi-structured interview. In phase 2, using the same tool, 352 patients were studied in the same clinics with informed consent. A small case-control design compared biomedical markers with controls. SCID-I was used for psychiatric diagnoses. Hamilton scales and SCL-90+ measured dimensional psychopathology. Diagnostic interviews for CFS and NTs (3 definitions: ICD-10, DSM-IV draft, CCMD-2) measured their agreement and sensitivity across the four clinics. EMIC interviews assessed and compared quantitative and qualitative aspects of illness experience (PD), meaning (PC), and help seeking (HS). Appropriate statistical methods were used to compare frequencies, means, and mean prominence; and to test concordance of CFS and NTs.
Results: Prevalence of NSD was 5% across four clinics, but higher in Dermatology and Ayurved clinics, and among women (63.8%). Haemoglobin and BMI were similar in patients and controls, but Corrected Arm Muscle Area was lower in patients. Non-specific anxiety and somatoform disorders outnumbered depression (mostly in Psychiatry clinic). Hamilton and SCL scores were highest in Psychiatry and lowest in Ayurved. Pairwise and four-way concordance among four NSDs was very poor (kappa=0.02). EMIC interviews showed weakness more than fatigue, ‘tensions’, future worries, need for support, and diverse and clinic-specific explanatory models with normative stresses. Biological explanatory models were prominent in Medicine, psychological ones in Psychiatry, cultural ones in Dermatology, and multiple ones in Ayurved clinics. Social models and poor health habits, weakness, and sexual-reproductive PCs were common across clinics. Dissatisfied patients sought help from many medical and non-medical sources.
Conclusions: High burden and emotional distress, sarcopenia, anxiety and somatization more than depression and ‘weakness with anxiety’ are salient features. NSDs may be explained physiologically and psychologically. Diversity with prominent psychological models is notable. Women’s narratives showed role multiplicity and poor supports. Men’s concerns were the overwork, inadequacy and sexual PCs. Rapid urban development, frustration and demoralization are important cultural contexts. Cultural studies are necessary for clinical and public health purposes.