RSS 1.0Chronic Fatigue Syndrome
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Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysisBackground: Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials. Objectives: This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy. Data sources: The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019. Review methods: Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I-2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality. Results: A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I-2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I-2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I-2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions. Limitations: Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them. Conclusion: Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes. Future work: Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality. Study registration: This study is registered as PROSPERO CRD42017078690.
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Meanings of CFS/ME in the lives of couplesMeanings develop within relationships, and this chapter is based on a qualitative study involving seven adults diagnosed with CFS/ME along with a 'significant other'. The first section concerns the couples' narratives of illness, the accounts of CFS/ME as an all-encompassing, unpredictable illness; as a reverser of roles within the home; as a closed world that separated couples from others; and as something that the couple needed to manage together. The second section, on interpretations, concerns the meanings couples established between themselves and also those they negotiated in relation to the outside world prior to, during and following diagnosis. The third section covers questions of personal and relational change. The chapter aims to stay as close as possible to the words and experiences of our participating couples rather than to impose a scheme of interpretation based on either the research literature or our own clinical perspectives.
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The self and others in CFS/ME: Reinterpreting research evidenceChapter 7 provided interpersonal perspectives on CFS/ME without offering any theoretical commentary. This chapter considers how the meanings of CFS/ME are developed between individuals and others. We begin with a critique of the cognitive-behavioural model of illness and suggest how it might better take account of connections between human relationships and illness. Using examples from Chapter 7 and elsewhere we thenr eview research literature in terms of the following propositions: (1) The social implications of CFS/ME are fundamental to its personal meaning; (2) individuals (and also health professionals) interpret illness through a cultural lens; (3) meanings of CFS/ME are established within personal relationships; (4) interpretations of symptoms, severity of illness and family relationships influence one another; (5) 'coping' is a social process, intimately related to meaning-making; and (6) meanings derived from present and past relationships are important vulnerability factors. Each of these gain support from available evidence although our interpretation sometimes requires a shift from a cognitivist to a discursive paradigm. We end with a discussion of gender.
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Cost-effectiveness of supported self-management for CFS/ME patients in primary careBackground: Nurse led self-help treatments for people with chronic fatigue syndrome/myalgic encephalitis (CFS/ME) have been shown to be effective in reducing fatigue but their cost-effectiveness is unknown. Methods: Cost-effectiveness analysis conducted alongside a single blind randomised controlled trial comparing pragmatic rehabilitation (PR) and supportive listening (SL) delivered by primary care nurses, and treatment as usual (TAU) delivered by the general practitioner (GP) in North West England. A within trial analysis was conducted comparing the costs and quality adjusted life years (QALYs) measured within the time frame of the trial. 296 patients aged 18 and over with CFS/ME diagnosed using the Oxford criteria were included in the cost-effectiveness analysis. Results: Treatment as usual is less expensive and leads to better patient outcomes compared with Supportive Listening. Treatment as usual is also less expensive than Pragmatic Rehabilitation. PR was effective at reducing fatigue in the short term, but the impact of the intervention on QALYs was uncertain. However, based on the results of this trial, PR is unlikely to be cost-effective in this patient population. Conclusions: This analysis does not support the introduction of SL. Any benefits generated by PR are unlikely to be of sufficient magnitude to warrant recommending PR for this patient group on cost-effectiveness grounds alone. However, dissatisfaction with current treatment options means simply continuing with 'treatment as usual' in primary care is unlikely to be acceptable to patients and practitioners
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Chronic fatigue syndrome/myalgic encephalomyelitis: More heat, some light-directions for research and clinical practiceComments on an article by C. Smith & S. Wessely (see record 2014-03300-022). In the paper by Smith and Wessely, problems are outlined in commissioning services in Scotland that accommodate the acrimonious debate between the views of those who consider myalgic encephalomyelitis (ME) to be a neurological condition versus an evidence-based medicine view that chronic fatigue syndrome/ myalgic encephalomyelitis (CFS/ME) is a condition of uncertain aetiology improved by graded exercise treatment (GET) and cognitive behaviour therapy (CBT). A wide range of diagnostic criteria are used in research and clinical practice that differ in terms of duration of chronic fatigue as a central symptom (3, 4 or 6 months), the requirement or not for postexertional fatigue lasting more than 24 h, additional symptoms or diagnoses of exclusion. Factors such as number of symptoms and postexertional malaise did not predict outcome in recent large randomised controlled trials (RCTs) in primary and secondary care, although depression symptoms and duration may do. In summary, GET and CBT are effective and safe in CFS/ME when given by trained and supervised specialist therapists but research is required into alternative or more intensive treatments for those who do not recover with GET and CBT, or have severe CFS/ME. Such RCTs should not use exercise capacity on a treadmill as a primary outcome measure as improvement in exercise capacity is neither necessary nor sufficient for symptomatic and functional improvement. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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Nurse led, home based self help treatment for patients in primary care with chronic fatigue syndrome: Randomised controlled trialObjective: To evaluate the effectiveness of home delivered pragmatic rehabilitation - a programme of gradually increasing activity designed collaboratively by the patient and the therapist - and supportive listening - an approach based on non-directive counselling - for patients in primary care with chronic fatigue syndrome/ myalgic encephalomyelitis or encephalitis (CFS/ME). Design: Single blind, randomised, controlled trial. Setting: 186 general practices across the north west of England between February 2005 and May 2007. Participants: 296 patients aged 18 or over with CFS/ME (median illness duration seven years) diagnosed using the Oxford criteria. Interventions: Participants were randomly allocated to pragmatic rehabilitation, supportive listening, or general practitioner treatment as usual. Both therapies were delivered at home in 10 sessions over 18 weeks by one of three adult specialty general nurses who had received four months' training, including supervised practice, in each of the interventions. GP treatment as usual was unconstrained except that patients were not to be referred for systematic psychological therapies during the treatment period. Main outcome measures: The primary clinical outcomes were fatigue and physical functioning at the end of treatment (20 weeks) and 70 weeks from recruitment compared with GP treatment as usual. Lower fatigue scores and higher physical functioning scores denote better outcomes. Results: A total of 257 (87%) of the 296 patients who entered the trial were assessed at 70 weeks, the primary outcome point. Analysis was on an intention to treat basis, with robust treatment effects estimated after adjustment for missing data using probability weights. Immediately after treatment (at 20 weeks), patients allocated to pragmatic rehabilitation (n=95) had significantly improved fatigue (effect estimate -1.18, 95% confidence interval -2.18 to -0.18; P=0.021) but not physical functioning (-0.18, 95% CI -5.88 to +5.52; P=0.950) compared with patients allocated to treatment as usual (n=100). At one year after finishing treatment (70 weeks), there were no statistically significant differences in fatigue or physical functioning between patients allocated to pragmatic rehabilitation and those on treatment as usual (-1.00, 95% CI -2.10 to +0.11; P=0.076 and +2.57, 95% CI 3.90 to +9.03; P=0.435). At 20 weeks, patients allocated to supportive listening (n=101) had poorer physical functioning than those allocated to treatment as usual (-7.54, 95% CI -12.76 to -2.33; P=0.005) and no difference in fatigue. At 70 weeks, patients allocated to supportive listening did not differ significantly from those allocated to treatment as usual on either primary outcome. Conclusions: For patients with CFS/ME in primary care, pragmatic rehabilitation delivered by trained nurse therapists improves fatigue in the short term compared with unconstrained GP treatment as usual, but the effect is small and not statistically significant at one year follow-up. Supportive listening delivered by trained nurse therapists is not an effective treatment for CFS/ME. Trial registration: International Standard Randomised Controlled Trial Number IRCTN74156610.
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Authors' replyThis is the authors reply to a letter in relation to the following article: Wearden Alison J, Dowrick Christopher, Chew-Graham Carolyn, Bentall Richard P, Morriss Richard K, Peters Sarah et al. Nurse led, home based self help treatment for patients in primary care with chronic fatigue syndrome: randomised controlled trial BMJ 2010; 340 :c1777
