Efficacy and Acceptance of Cognitive Behavioral Therapy in Adults with Chronic Fatigue Syndrome: A Meta-analysis, 2024, Maas genannt Bermpohl et al.

SNT Gatchaman

SNT Gatchaman

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Efficacy and Acceptance of Cognitive Behavioral Therapy in Adults with Chronic Fatigue Syndrome: A Meta-analysis
Maas genannt Bermpohl, Frederic; Kucharczyk-Bodenburg, Ann-Cathrin; Martin, Alexandra

Background
The systematic aggregation of research on cognitive behavioral therapy (CBT) in chronic fatigue syndrome (CFS) needs an update. Although meta-analyses evaluating interventions typically focus on symptom reduction, they should also consider indicators of treatment acceptability, e.g., drop-out rates.

Methods
Randomized controlled trials (RCTs) investigating CBT in adults with CFS compared to inactive and non-specific control groups were included. First, efficacy was examined, considering fatigue, depression, anxiety, and perceived health. Secondly, drop-out rates through different trial stages were analyzed: Non-completion of all mandatory sessions, drop-out (primary study definition), treatment refusal (non-starters), and average of sessions completed.

Results
We included 15 RCTs with 2015 participants. CBT was more effective than controls in fatigue (g = -0.52, 95%CI -0.69 to -0.35), perceived health, depression, and anxiety at post-treatment. At long-term follow-up the effects were maintained for fatigue and anxiety. Rates of non-completion (22%, 95%CI 3–71), drop-out (15%, 95%CI 9–25), and treatment refusal (7%, 95%CI 3–15) were relatively low, with a high average proportion of sessions completed. Total time of therapy moderated the effect on fatigue, while the number of sessions moderated the effect on perceived health. Fatigue severity influenced adherence.

Conclusions
The results indicate that CBT for CFS is effective in reducing fatigue, fatigue related impairment, and severity of depression and anxiety. Conclusions on efficacy at follow-ups are still limited. However, adherence is high in CBT. The results may help to inform clinical practice. Future research should focus on examining the maintenance of effects, while also emphasizing the importance of treatment acceptance.

Link | PDF (International Journal of Behavioral Medicine)
 
Chronic fatigue syndrome (CFS) is a debilitating disorder characterized by medically evaluated, unexplained, persistent or recurrent persistent fatigue that is not the result of current stress, not relieved by rest, results in significant activity limitations, and for which there is no clear organic explanation. However, there is a broad array of possible diagnostic criteria that can be used for CFS. Hence, CFS according to the presented definition needs to be differentiated from newer classification approaches for myalgic encephalomyelitis/CFS.
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While the etiology of CFS remains unclear, evidence suggests that not only biological but also psychosocial factors play an important role in the development and maintenance of the condition. Cognitive behavioral therapy (CBT) derives from corresponding disorder models that assume interactions among biological/ physical, psychological, and social factors.
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CBT has been shown to be one of the most effective psychological treatments for CFS. In CFS, CBT is based on assumptions about the interaction of cognitive processes and behaviors, which contribute to the perpetuation of the ailments. It usually involves identifying the patient's negative thoughts, beliefs, and behaviors believed to contribute to the physical symptoms, most importantly, patients’ focus on perceived symptoms of fatigue is decreased. The therapist helps the patient develop altered and more realistic views on their illness, and coping skills to manage their symptoms. Thus, patients experience reversibility of symptoms, which results in enhanced self-efficacy.
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They also seem to be not looking under the lid at what the CBT involves. Is it PACE style persuading people they aren't really sick and encouraging exercise, or is it supportive to help cope with illness and to help managing life changes to enable pacing? These are diametrically opposites, yet all masquerade under the same umbrella, to mix my metaphors further.
 
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The paper said:
The systematic aggregation of research on cognitive behavioral therapy (CBT) in chronic fatigue syndrome (CFS) needs an update
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For sure, it has been at least several days since the last one.
Randomized controlled trials (RCTs) investigating CBT
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Uh, no. There are no controlled trials of CBT because it cannot be properly controlled. Usually they simply don't expand the acronym and allude to controlled when they mean clinical, but this just shows how meaningless words are in EBM.
while also emphasizing the importance of treatment acceptance
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The beatings will continue until morale questionnaires are properly filled in.

Decades of this nonsense, and they're still at the exact same point where they started. They haven't changed a damn thing, are still repeating the same old stuff, and it doesn't matter that none of this works. What absurd nonsense so-called evidence-based medicine is. You could not design a more worthless process if you tried your best.
 
Yep, I was going to comment about this being yet another zombie-hydra.

The results of this meta-analysis provide important insights into the efficacy and acceptance of CBT in the treatment of CFS in adults. Our findings confirm that CBT is an effective intervention for CFS. [...] All in all, these results are in line with previous research
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That previous research being meta-analyses of the same papers (or at least the subset published at that time).
 
Consistently awful.
I really don't see the point of meta analyses of multlple trials that take outcomes of trials at face value. They really only add value to the record if the reviewers dig deeper into the quality of the data they are collating. Not only the obvious things of blinding if outcomes are subjective, but secondary outcomes, what outcomes are clinically significant, long term follow up, what patient organisations say their members report about treatments, etc.
 
Trial By Error: Yet Another Meta-Analysis Purporting to Prove that CBT Is Effective for “Chronic Fatigue Syndrome”

I just wrote about how PACE was favorably cited in an article in Nature Reviews Cardiology. Last month, that piece of crap was also included as part of yet another meta-analysis that mushed together the findings from a load of bad papers and concluded that, collectively, they prove something or other. This new paper—“Efficacy and Acceptance of Cognitive Behavioral Therapy in Adults with Chronic Fatigue Syndrome: A Meta‐analysis”–was published by the International Journal of Behavioral Medicine and written by investigators from the clinical psychology department at the University of Wuppertal in Wuppertal, Germany.

Was the situation really calling out for yet another major review of trials of psycho-behavioral treatments for what the investigators insist on calling CFS? According to this crew, yes.

https://virology.ws/2024/01/30/tria...is-purporting-to-prove-that-cbt-is-effective/
 
I noticed that in some of the trials they included, only a minority of patients met CFS criteria. I only read the review once but could not find any mention of this, which is rather misleading.

Here are for example, some quotes from the trials:

Huibers et al. 2004
“At baseline, 66 patients (44%) met research criteria for chronic fatigue syndrome”

"Inclusion criteria were severe fatigue (a score of 35 or more on the fatigue sub-scale of the Dutch Checklist Individual Strength (CIS; Vercoulen et al, 1999; Beurskens et al, 2000) for 4 months or more as one of the main health problems, and complete absenteeism from work for 6–26 weeks. Patients were excluded from participation if they had medical conditions that explained fatigue (e.g. cancer); were receiving another intervention for fatigue (e.g. treatment for burnout); had a previously classified psychiatric disorder; or were receiving current psycho[1]logical treatment"

Friedberg et al. 2013
“Thirty-nine percent of the sample met symptom criteria for CFS and the remaining 61% who did not meet full CFS criteria were classified as UCF”

"Primary care patients eligible for the study met these criteria: (1) age between18–65, not pregnant, and ability to fully participate in the study; (2) at least six months of persistent fatigue with participant-reported impairment in physical, social, and/or role domains; (3) no medical or psychiatric exclusions, as determined by the patient's primary care physician and a psychiatric nurse"

Prins et al. 2001
"Patients were eligible for the study if they met the US Centers for Disease Control and Prevention criteria for CFS, with the exception of the criterion requiring four of eight additional symptoms to be present."

O’Dowd et al. 2020
Adults were eligible for this study if they were aged over 18; reported fatigue for at least 1 month but less than 4 months; had known causes of fatigue, e.g. cancer had been excluded; had normal results for the screening blood tests recommended in National Institute for Clinical Excellence guidance for CFS; and scored ≥ 4 on the Chalder Fatigue Scale.
 
Here's their risk of bias assessment of fatigue, post-treatment taken from the supplementary material:

upload_2024-1-31_14-10-51.png
I don't understand why some trials received a 'low' score for Bias due to measurement of the outcome because these were all subjective outcomes used in unblinded trials. There doesn't seem to be a justification or explanation for this score in the supplementary material.

Nonetheless it is clear that pretty much all trials were high risk of bias but there is no mention of this in the abstract. What is the point of doing a review I wonder if you don't incorporate the reliability of studies and the quality of evidence? Selecting studies and summarising results can probably be done by an automated script if that is the goal.

In the discussion section the authors write the following about risk of bias:

Since the overall RoB was rated at least some concerns, but mostly high for the included studies, this should be taken into account when interpreting the results. Nonetheless, the high rating can partly be explained by the nature of conventional psychotherapeutic trial designs used for these studies. This does not imply that these designs are without flaw, however, these ratings do not render the results irrelevant. For example, one major criticism of psychotherapy trials in CFS is a lack of blinding [56]. However, this overemphasizes the assumed effect of blinding in trials, which is not reflected in clinical data
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So the same arguments again: because the high risk of bias is due "to the nature of conventional psychotherapeutic trial designs" it should somehow be less important? And reference [56] is again the MetaBlind study. Although it could not find an effect of blinding the reviewers misrepresent its findings because it clearly stated that "blinding should remain a methodological safeguard in trials."
 
The review also ignored objective outcomes and long-term results of for example the PACE trials which all found no effect.

Also frustrating that they interpret drop-out rates as an indicator of acceptance of CBT. I know of many patients who feel forced to undergo these 'rehabilitative' interventions because of the pressure of insurance doctors: if they quit they would get into trouble with applying for disability benefits. The Dutch Health Council of the Netherlands had to explicitly state that refusal of CBT should not be interpreted as a refusal to try to recover because there were so many issues with this.

Then there is section at the end of the paper where they go on to explain why patients dislike CBT:

"One reason why some people with CFS are reluctant to undergo psychological therapy could be the lack of willingness to engage in psychological therapy among people with CFS. This may stem from a mismatch between their personal beliefs about their condition and the foundational principles of therapies like CBT"
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It is frustrating that this prejudice still gets repeated. Why not ask patients themselves? There are multiple surveys, patient organisations who advocate against this therapy but the authors seem to have preferred to have a guess themselves.
 
Then there is the issue that they lumped everything together, regardless of the content of the CBT. One is mindfullness based cognitive therapy, another is pretty much relationship-therapy, some forms of CBT are focused on stress reduction while others (most of them) try to cure patients by addressing deconditioning and unhelpful illness beliefs.
 
All authors are from the Department of Clinical Psychology and Psychotherapy, University of Wuppertal, and also produced these two reviews last year,

Evidence base of digital psychotherapy for somatic symptom disorder, functional somatic syndromes and bodily distress in adults: A systematic review and meta-analysis, paywall, https://www.sciencedirect.com/science/article/abs/pii/S002239992300140X

Efficacy of mindfulness- and acceptance-based cognitive-behavioral therapies for bodily distress in adults: a meta-analysis 2023 Bermpohl et al - forum thread

Ultimately I don't think we should be surprised why they are happy to view CBT so positively.
 
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