Implementation of stepped care for patients with CFS in community-based mental health care:..., 2019, Knoop et al

Andy

Andy

Retired committee member
Abstract
BACKGROUND:
Cognitive behavioural therapy (CBT) is an evidence-based treatment for chronic fatigue syndrome (CFS). Stepped care for CFS, consisting of a minimal intervention followed by face-to-face CBT, was found efficacious when tested in a CFS specialist centre. Stepped care implemented in a community-based mental health centre (MHC) has not yet been evaluated.

AIMS:
(1) To test the effectiveness of stepped care for CFS implemented in a MHC at post-treatment and at long-term follow-up; and (2) compare post-treatment outcomes of implemented stepped care with treatment outcomes of a CFS specialist centre.

METHOD:
An uncontrolled study was used to test effectiveness of stepped care implemented in a MHC (n = 123). The outcomes of implemented care were compared with the outcomes of specialist care reported in previous studies (n = 583). Data on outcomes from implemented stepped care were gathered at post-treatment and at long-term follow-up. Mixed models were used as method of analysis.

RESULTS:
Fatigue decreased and physical functioning increased significantly following implemented stepped care (both p < .001). The follow-up was completed by 94 patients (78%) within 1-6 years after treatment. Treatment effects were sustained to follow-up. Patients in the MHC showed less improvement directly following stepped care compared with patients in a CFS specialist centre (p < .01).

CONCLUSION:
Implemented stepped care for CFS is effective with sustained treatment gains at long-term follow-up. There is room for improvement when compared with outcomes of a CFS specialist centre. Some suggestions are made on how to improve stepped care.
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Paywalled at https://www.cambridge.org/core/jour...erm-followup/842DB10C681E7D7A8725BE0DB8848B07
 
Intervention
The minimal intervention consisted of a booklet with guided self-instruction based on the CBT for
CFS protocol. All patients had fortnightly contact with a trained psychiatric nurse via e-mail.
Nurses sent a reminder when patients did not respond every 2 weeks. During therapy, patients
change cognitions and behaviours that are assumed to perpetuate fatigue and disability.
Psychiatric nurses introduced the minimal intervention booklet and provided instructions to
the patient to complete the intervention within 6 months. All patients had a face-to-face
evaluation after completion of the second assessment (at 6 months) with the psychiatric nurse
who delivered the therapy.
If patients were still severely fatigued, they were referred to a CBT therapist within the MHC for
additional face-to-face CBT for CFS. This additional face-to-face CBT was the second step of
stepped care. Following the protocol (Knoop and Bleijenberg, 2010), a full therapy would consist
of 12 to 14 sessions over a period of 6 months. However, dependent on the progress made during
the minimal intervention, the therapist decided which elements of the protocol should be
discussed during the face-to-face CBT (Tummers et al., 2010). Detailed information on the
minimal intervention, and the training and supervision of the nurses and the CBT therapists, can
be read in the Supplementary Material.
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Some characteristics of implemented stepped care may have negatively affected outcome. First,
shortly after face-to-face CBT had been implemented in the MHC, stepped care was introduced
(Wiborg et al., 2014). The newly trained therapists had only limited experience in delivering
face-to-face CBT for CFS outside the context of stepped care. It is likely that it is more difficult
to deliver CBT to patients who were already unsuccessfully treated with the minimal intervention.
Future implementation of CBT for CFS should give therapists enough time to first learn to
effectively treat patients with regular CBT for CFS.
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Limitations
The current study has several limitations. Patients were not randomly assigned to the MHC or to
the CFS specialist centre and may therefore differ. The route of referral that patients had followed
differed between centres. In the CFS specialist centre, patients were usually referred via the
department of internal medicine, whereas in the MHC patients were usually referred by the
general practitioner or internal consultant. This may have led to differences in patient characteristics
between both settings.
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Unfortunately, information about the care patients received between post-treatment assessment
and follow-up was lacking. This is a further limitation of our study.
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Conflict of interest. Hans Knoop and Gijs Bleijenberg receive royalties from a published treatment protocol of CBT for CFS.
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http://sci-hub.tw/https://www.cambr...rm-followup/842DB10C681E7D7A8725BE0DB8848B07#

so again, it's the place, the inexperienced CBT therapists, the type of CBT etc etc
 
Their results seem almost demure by comparison to previous studies. And they actually fill in the CoI statement.

I wonder if because we have had success in changing the narrative that some of the people responsible for delivering the product to the clients haven't perhaps been emboldened to complain about their stress in delivering something that doesn't seem to work based on feedback (regardless of what gets officially recorded).

So now it's not the intransigent sick person at fault but a need for better staff education. This will add to cost of delivery then.

I think progress is being made.

We're not done yet of course. If I could I'd see that anyone with MUS is not shuttled off to a course of CBT and then abandoned. Who knows how long it will take neurology and endocrinology areas of study to catch up with adequate knowledge to do justice to much of the MUS people.

Apologies. I'm aware my posts often meander around the topic at hand.
 
Stepped, uh? Because graded was getting old?

Let's consult the thesaurus and play BS bingo for what's coming next:
calibrated, measured, progressive, registered, sequential, tapered
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Stepped is a bit of a stretch, semantically speaking, and not linked in thesaurus so maybe next iterations will make more creative use of language. Maybe a word cloud from goop.com would provide a better source?
 
Cinders66 said:
Given that they talk only of fatigue what criteria was used? Just what we want psychiatric nurses to challenge our beliefs and behaviour.
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Phil Parker's magical hands, perhaps?

He knows when you're sick
He knows when you're lying
He knows you better than you know yourself
He's Phil, the magical healing hands man

(I know this isn't LP but clearly adequate selection criteria are an afterthought to this bunch so I'm taking creative liberties to make this sad joke work)
 
Very confusing article. Hard to know what we are actually looking at. It seems like a simple follow up of the Tummers et al. 2012 paper.
rvallee said:
Stepped
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By stepped care they mean patients first get the shortened self-help version of CBT and only if that doesn't work, do patients gut the full, face to face version of CBT. It is supposed to lower the costs.
 
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