Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Review: Cognitive behavior therapy is effective for the chronic fatigue syndrome

ACP J Club. 1999 Mar-April;130:40. doi:10.7326/ACPJC-1999-130-2-040


Source Citation

Price JR, Couper J. Cognitive behaviour therapy for adults with chronic fatigue syndrome. Cochrane Review, latest version 24 Aug 1998. In: The Cochrane Library. Oxford: Update Software.


Abstract

Question

Does cognitive behavior therapy (CBT) reduce symptoms, improve function and quality of life, and use fewer health services in adults with the chronic fatigue syndrome (CFS)?

Data sources

Studies were identified using MEDLINE (1966 to June 1998), EMBASE/Excerpta Medica (1980 to May 1998), PsycLIT (1974 to September 1997), Biological Abstracts, SIGLE (System for Information on Grey Literature in Europe) (1980 to December 1997), and Index to Scientific and Technical Proceedings (1992 to 1998). The trials register of the Depression, Anxiety and Neurosis Cochrane Review Group was searched; bibliographies of relevant studies were scanned; and experts were contacted.

Study selection

Randomized controlled trials were selected if adults with CFS reported fatigue as the principal symptom; the fatigue was medically unexplained, of sufficient severity to cause disability or distress, and had lasted ≥ 6 months; psychological treatment included both attempted modification of thoughts and beliefs and behavioral responses about symptoms and illness; and control interventions were orthodox medical care or other non-CBT interventions. Studies that evaluated drug treatments and self-help groups were excluded.

Data extraction

Data were extracted on study quality, patient and intervention characteristics, and outcomes (physical function, symptoms, quality of life, compliance, and acceptability of treatment).

Main results

13 trials were identified, and 3 met the inclusion criteria (210 adults). CBT was compared with relaxation in 1 study and orthodox medical care in 2 studies. The study that compared CBT with relaxation found improvements in function (2 measures) (Table), fatigue (2 measures), global assessment, satisfaction, quality of life, and proportion of patients who continued to meet the criteria for CFS. 1 study that compared CBT with orthodox medical care showed improvements in function (1 of 3 measures) (Table), global assessment, pain disability, and depression. The third study did not find a benefit.

Conclusion

Cognitive behavior therapy improves function and reduces fatigue in adults with the chronic fatigue syndrome.

Sources of funding: Wellcome Trust; Medical Research Council; Oxford and Anglia NHS Research and Development Directorate.

For correspondence: Dr. J. Price, MRC/NHS R&D Fellow in Health Services Research, Department of Psychiatry, University of Oxford, The Warneford Hospital, Headington, Oxford UK OX3 7JX. FAX 44-1865-793101.


Table. Improved physical function at 6 to 7 months after cognitive behavior therapy (CBT) for the chronic fatigue syndrome*

Comparison CBT Experimental therapy RBI (95% CI) NNT (CI)
Relaxation 66.7% 20.0% 233% (66 to 625) 3 (2 to 4)
Medical care 73.3% 26.7% 175% (54 to 432) 3 (2 to 5)

*Abbreviations defined in Glossary; RBI, NNT, and CI calculated from data in article.


Commentary

Medically unexplained syndromes, such as CFS and fibromyalgia, continue to baffle physicians, especially in the area of treatment decisions. No specific causes have been verified for these syndromes, although many are claimed. Thus, treatments aimed at putative causal factors, whether viral, neurologic, or psychiatric, have not found favor outside of anecdotal observations (1).

On the other hand, considerable interest centers on the possibilities of rehabilitation, based on the idea that what starts these conditions is both obscure and unchangeable, but what keeps them going is more amenable to management. CBT is one form of rehabilitation. It is based on looking at the way conscious thoughts and beliefs about symptoms and illness influence both mood and behavior. CBT is linked with modification of these behavioral responses, involving some alteration in rest, exercise, sleep, and activity.

This systematic review concludes that CBT is indeed helpful in management and can deliver important clinical improvement. Should physicians start using CBT in the management of CFS? Yes, but will they? Probably not, for a number of reasons. First, CBT is a skilled therapy that requires experience, training, and supervision. Such skills are in short supply. Second, the review shows that CBT can be time-consuming—better results came from 12 sessions than 6. Third, the most disabled patients, those confined to bed or a wheelchair, were excluded from these studies, although uncontrolled studies are very promising (2). Finally, although CBT was acceptable to the patients in these trials, this acceptance probably only resulted from paying meticulous attention to engagement and establishing a therapeutic alliance. In the real world, suggesting CBT can often be interpreted as suggesting that the patient's symptoms are "all in the mind." Such an interpretation is erroneous but will continue to be the biggest barrier to implementation.

Simon Wessely, MD
Guy's, King's and St. Thomas' School of MedicineLondon, England, United Kingdom


References

1. Wessely S, Hotopf M, Sharpe M. Chronic Fatigue and Its Syndromes. Oxford: Oxford Univ Pr; 1998.

2. Chalder T, Butler S, Wessely S. In patient treatment of chronic fatigue syndrome. Behavioural Psychotherapy. 1996;24:351-65.