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Chronic Fatigue Syndrome: Can Psychotherapy And Exercise Help?

[Recently] in The New York Times, David Tuller [wrote] about a study published in The Lancet that shows that psychotherapy is an effective treatment for chronic fatigue syndrome. In his article “Psychotherapy Eases Chronic Fatigue, Study Shows,” Tuller writes:

The new study, conducted at clinics in Britain and financed by that country’s government, is expected to lend ammunition to those who think the disease is primarily psychological or related to stress.

The authors note that the goal of cognitive behavioral therapy, the type of psychotherapy tested in the study, is to change the psychological factors “assumed to be responsible for perpetuation of the participant’s symptoms and disability.”

In the long-awaited study, patients who were randomly assigned to receive cognitive behavioral therapy or exercise therapy, in combination with specialized medical care, reported reduced fatigue levels and greater improvement in physical functioning than those receiving the medical care alone — or getting the medical care along with training in how to recognize the onset of fatigue and to adjust their activities accordingly.

Interesting. Generally I like to stay away from the “it’s all in your head” debates. I’ll let the commenters do the talking here.

*This blog post was originally published at Shrink Rap*

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One Response to “Chronic Fatigue Syndrome: Can Psychotherapy And Exercise Help?”

  1. KAL says:

    A number of issues are raised here. CFS aside, the first is that this trial was not as successful as hyped.

    If you dig deeper and actually read both the registered protocols and the final study you will notice that the authors changed their endpoints to make their study appear more successful than it would have been if they had kept the original endpoints – and even by doing that, by the strictest standards, it was only mildly successful.

    The protocol originally registered showed that ‘recovery,’ required an SF-36 PF score of 85 or over, however the final endpoints published were measured as: ‘back to normal’ – which only needed a SF-36 PF score of 60. Inclusion criteria for the trial required that patients have “severe and disabling fatigue” – this included SF-36 PF scores of up to 65.

    Thus a more accurate statement of this finding would be: An additional 15% of patients in the CBT and GET conditions achieved normal functioning in comparison to standard medical care. The critical standard of clinical significance is that a therapy results in restoration of normal function and according to the study authors own data, many patients may have already been at or above the revised cutoff when they entered the trial.

    So large doesn’t automatically equal impressive in this case.

    Secondly, the authors defined their patient cohort using a definition that only they use (and one they created and funded) and it does not include the cardinal symptom of post exertional malaise lasting more than 24-hours unrelieved by rest.

    The international standard used by the vast majority of researchers, and the one used by researchers who study adaptive pacing and exercise induced abnormalities in CFS patients, is the original 1994 criteria.

    So just saying you are studying fruit because apples and oranges are both round is disingenuous.

    You don’t have to be a rocket scientist to understand that extrapolation of, let’s face it, a only mildly effective treatment to patients who are far far more ill than the cohort studied is highly problematic.

    So should cognitive behavioral therapy and GET be used at all? Maybe. We know from other diseases besides CFS that CBT helps people cope with the very real psychosocial overlays that attend any severe disease on an individual basis. However, there is not scientific evidence that CBT reverses so much as the common cold much less “cures” disease. Does exercise “cure” exercise intolerance? This trial provided no objective scientific evidence that this is the case either because they did not study patients with what is medically known as exercise intolerance.

    Of course if your cohort has people who have affective disorders only who got mixed in to the data set because very few variables were actually controlled for and the criteria for “fatigue” was deliberately vague then CBT and GET may be very appropriate for such people. Possibly, misdiagnosing MDD when a patient actually has a neuroimmune disease raises a number of ethical issues beyond ineffective and potentially harmful treatment.

    If you don’t use clean data sets RCTs are no more effective at generalization than smaller studies.

    So why did they do this? Besides fitting with their ideology, many of the authors had financial conflicts of interest as well. Many of them consult for litigators who represent companies fighting disability claims and disability insurers who make money by not paying out. If these authors acting as paid consultants can say this person can be “cured” by CBT and GET then the company has a basis to deny the claim.

    Or if the disability insurer can claim that CFS is a mental disorder they only pay two years of disability vs a lifetime for an organic disorder.

    So yeah, just sayin’ conflicts of interest are important to mention just as they are in drug trials.

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