Cognitive Behavioural Therapy for chronic fatigue and CFS: outcomes from a specialist clinic in the UK (2020) Adamson, Wessely, Chalder

wigglethemouse said:
See table 4 in paper for reasons
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I've only just realised the tables were at the end of the paper - I stopped reading once I'd got to the references and assumed the table were going to be inserted in the published text. What an idiot. I wondered where some of the info people were mentioning had come from!

Nine hundred and ninety five participants were included in the analysis.
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And for self-rated CGI they had data from 365 patients?
 
Yep wow.
* 995 participants but only 365 had full data.
* Cohort wise the clinic received everyone whose GP thought they had fatigue but only 52% of those met the CDC criteria for CFS.
* No one questionnaire had more than 52% participants coverage from start to 3 month follow-up after treatment
* All subjective data. No objective data.
 
dave30th said:
This is such crap--the "growing evidence from previous RCTs." What growing evidence? Each study shows the opposite of what they claim it shows.
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Playing to their own beguiled audience who lap up whatever crap (pardon the gory thought) these folk emit. Truth, science, integrity, etc. have nothing to do with it. Sophistry pure and simple. The prime objective seems to be winning/succeeding, other human values being relegated way below that.
 
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Thanks @Dr Carrot for describing your experience.

Given the long waiting time for treatment, the idea that those that met the NICE criteria but not the Oxford criteria might have been ill for between 4 and 6 months makes no sense.
All participants were treated for CFS at the National Persistent Physical Symptoms Research and Treatment Unit. All met NICE criteria for CFS 7 . According to self-reported accounts of their symptoms, 754 (76%) participants met Oxford criteria for CFS and 518 (52%) met CDC criteria for CFS.
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So perhaps those who didn't meet Oxford criteria weren't fatigued enough, ie scored less than 4 on CFQ at the start?
Deterioration was assessed by number deteriorated, i.e. how many became a fatigue case (score >4) that were not a case at the start of treatment and how many people showed a worsening of fatigue (2 point increase out of 33).
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Or perhaps Oxford would have excluded them because their primary cause of fatigue was depression and/or anxiety.
In the tables at the end, it shows HADS-A caseness of 65% at the start of treatment, and HADS-D caseness of 55% at the start. So more than half of patients had either clinical anxiety or clinical depression or both at the start.
So maybe they weren't treating many people with ME/CFS at all - most had other forms of CF, many of them anxiety and/or depression.

I apologise for posting so frequently on this thread. This is a paper that just keeps on giving, in terms of stupidity.

Note also there is no mention, let alone measuring and reporting, of harm. Shame on them.
 
Trying to understand the drop-outs in this paper because, as Trish has pointed out, that seems to be the main issue in how the results are represented.

They say they had data from 995 patients and a drop-out rate of 31% so you would think the main outcomes in this paper had around 687 patients who underwent CBT and filled in questionnaires. But if we look at the tables, the data for the main outcomes shows that there were far fewer patients who filled in the questionnaires.

For example, the self-imported improvement scores had data from only 365 patients. It would be good if the paper explained why the other 630 patients didn't fill in this questionnaire at follow-up. Was it for example because they only started handing out the questionnaire in a particular year and not before that?

A similar problem exists for the symptom questionnaires. For fatigue, for example, only 503 filled in the questionnaire at discharge while 977 filled it in at the start of the treatment. So why did 40% not fill in the questionnaire at discharge? At first, I thought it was because these patients might still be in treatment but the Method section says that patients were excluded "if they were still in active treatment".

So I think the most likely explanation is that the authors considered someone a drop-out only if they failed haven't filled in any of the questionnaires. So some of the 40% who didn't fill in the fatigue questionnaire at follow-up might have filled in another questionnaire and so they aren't counted as having dropped out.

That might be reasonable, it's just weird that so many people have filled in one of the questionnaires but not others. I would think the main difficulty in ensuring follow-up is getting in contact with the patient and make him/her fill in information. I suppose that if you manage to contact the patient and fill in one short questionnaire, it wouldn't be a big deal to let them fill in another short questionnaire - one like the Chalder Fatigue Scale that the patient filled in at the start of treatment. So it would be good if the paper could explain why this is is the case with their data.

It also makes the data hard to interpret. When they say that "90% were satisfied with their treatment" we don't really know how many patients that represents. 90% of what? How many patients rated treatment satisfaction? The abstract also says that "85% of patients self-reported that they felt an improvement in their fatigue at follow-up" without clarifying that only a third of the patients filled in this questionnaire at follow-up, about the same proportion of patients, dropped out and might have a different opinion.

It's rather misleading to state in the abstract that "data was available for 995 patients" and then highlight figures that only apply to a minority of those 995 patients.
 
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I would imagine that the easiest way to get a 90% satisfaction result would be to start at 100% and deduct those who specifically, on the correct form, filled out perfectly, in black fountain pen, not blue biro, stated that they were dissatisfied/unhappy.

That way non of the pesky drop outs are represented and therefore they don't negatively affect the satisfaction score.

Otherwise it seems odd that a fair proportion of those who dropped out were also perfectly satisfied with the 'treatment'.
 
Trish said:
perhaps those who didn't meet Oxford criteria weren't fatigued enough, ie scored less than 4 on CFQ at the start?
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Wessely has made the argument that the Oxford criteria require severe and disabling fatigue that affects both physical and mental functioning. For example in this letter where he responds to a critique of the criteria by Baraniuk.
Unfortunately this is nothing like the actual Oxford Criteria [2]. Fatigue must be ‘severe, disabling and affects physical and mental function’. Mild or moderate fatigue is clearly excluded. It insists that fatigue must be both mental and physical – there must be cognitive symptoms as well as physical symptoms of fatigue. There is also a duration criteria – ‘the symptom of fatigue should have been present for a minimum of six months during which it is present for more than 50% of the time’. Far from ignoring medical conditions, the criteria explicitly exclude any ‘established medical conditions known to produce chronic fatigue’. So it is clear that any known medical cause of fatigue is incompatible with the criteria
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So perhaps that's the reason who some patients met 'NICE criteria' but not the Oxford criteria.

Source: https://www.tandfonline.com/doi/abs/10.1080/21641846.2017.1364148
 
But when it comes to psychiatric conditions:

(ii) Patients with a current diagnosis of schizophrenia, manic depressive illness, substance abuse, eating disorder or proven organic brain disease. Other psychiatric disorders (including depressive illness, anxiety disorders, and hyperventilation syndrome) are not necessarily reasons for exclusion.
 
If you’re dependent on a clinic for providing some support with employers or benefits claims you’re less likely to be filling in questionnaires at the end of your course of treatment saying it has had no effect or made you worse. You might give a neutral score or slightly positive, you might avoid filling the questionnaire in altogether. Similar for follow up.

Has anyone ever compared CFS clinic evaluation to evaluations of services for MS and/or other chronic illness. I imagine not.
 
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Michiel Tack said:
Wessely has made the argument that the Oxford criteria require severe and disabling fatigue that affects both physical and mental functioning. For example in this letter where he responds to a critique of the criteria by Baraniuk.

So perhaps that's the reason who some patients met 'NICE criteria' but not the Oxford criteria.

Source: https://www.tandfonline.com/doi/abs/10.1080/21641846.2017.1364148
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I've not read the paper so perhaps it defines the 'NICE criteria' differently but the current NICE guidelines say:
Healthcare professionals should consider the possibility of CFS/ME if a person has:

  • fatigue with all of the following features:
    • new or had a specific onset (that is, it is not lifelong)

    • persistent and/or recurrent

    • unexplained by other conditions

    • has resulted in a substantial reduction in activity level

    • characterised by post-exertional malaise and/or fatigue (typically delayed, for example by at least 24 hours, with slow recovery over several days)

      and

  • one or more of the following symptoms:
    • difficulty with sleeping, such as insomnia, hypersomnia, unrefreshing sleep, a disturbed sleep–wake cycle

    • muscle and/or joint pain that is multi-site and without evidence of inflammation

    • headaches

    • painful lymph nodes without pathological enlargement

    • sore throat

    • cognitive dysfunction, such as difficulty thinking, inability to concentrate, impairment of short-term memory, and difficulties with word-finding, planning/organising thoughts and information processing

    • physical or mental exertion makes symptoms worse

    • general malaise or 'flu-like' symptoms

    • dizziness and/or nausea

    • palpitations in the absence of identified cardiac pathology.
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and

The diagnosis of CFS/ME should be reconsidered if none of the following key features are present:

  • post-exertional fatigue or malaise

  • cognitive difficulties

  • sleep disturbance

  • chronic pain.
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which, in my opinion, aren't massively different, if at all, from that description of the Oxford criteria - although one person's "substantial reduction in activity level" might, or might not, equate to "severe" and "disabling".
 
I have no idea how many people may come to this thread that are new to the bPs way of doing research so I thought I'd just put a link to the chalder fatigue scale for perusal if anyone's interested:

http://www.goodmedicine.org.uk/files/assessment, chalder fatigue scale.pdf

This scale is discussed here:

https://www.s4me.info/threads/explo...ic-fatigue-syndrome-1998-morriss-et-al.11065/

And these links and further info on various scales can be found here:

https://www.s4me.info/threads/questionnaires-and-scales-used-in-me-or-cfs-research.879/

In our Science Library.

Also, just want to ask all and sundry if you think it would be feasible for us to attempt to create a viable scale. The question first would be what are we measuring since we all know that ME is not just fatigue.

I realise it may be too big a project. But just put it out there.

Moderator note
This post has been copied and following posts moved to a new thread:
Fatigue scales - finding or creating a valid questionnaire for fatigue in ME/CFS
 
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