Implementing cognitive behavior therapy for chronic fatigue syndrome in mental health care: a costs and outcomes analysis

Abstract:

BACKGROUND: This study investigated the costs and outcomes of implementing cognitive behavior therapy (CBT) for chronic fatigue syndrome (CFS) in a mental health center (MHC). CBT is an evidence-based treatment for CFS that was scarcely available until now. To investigate the possibilities for wider implementation, a pilot implementation project was set up.

METHOD: Costs and effects were evaluated in a non-controlled before- and after study with an eight months time-horizon. Both the costs of performing the treatments and the costs of implementing the treatment program were included in the analysis. The implementation interventions included: informing general practitioners (GPs) and CFS patients, training therapists, and instructing the MHC employees. Given the non-controlled design, cost outcome ratios (CORs) and their acceptability curves were analyzed. Analyses were done from a health care perspective and from a societal perspective. Bootstrap analyses were performed to estimate the uncertainty around the cost and outcome results.

RESULTS: 125 CFS patients were included in the study. After treatment 37% had recovered from CFS and the mean gained QALY was 0.03. Costs of patients’ health care and productivity losses had decreased significantly. From the societal perspective the implementation led to cost savings and to higher health states for patients, indicating dominancy. From the health care perspective the implementation revealed overall costs of 5.320 euros per recovered patient, with an acceptability curve showing a 100% probability for a positive COR at a willingness to pay threshold of 6.500 euros per recovered patient.

CONCLUSION: Implementing CBT for CFS in a MHC appeared to have a favorable cost outcome ratio (COR) from a societal perspective. From a health care perspective the COR depended on how much a recovered CFS patient is being valued. The strength of the evidence was limited by the non-controlled design. The outcomes of this study might facilitate health care providers when confronted with the decision whether or not to adopt CBT for CFS in their institution.

 

Source: Scheeres K, Wensing M, Bleijenberg G, Severens JL. Implementing cognitive behavior therapy for chronic fatigue syndrome in mental health care: a costs and outcomes analysis. BMC Health Serv Res. 2008 Aug 13;8:175. doi: 10.1186/1472-6963-8-175. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2536664/ (Full article)

 

Treating Chronic Fatigue states as a disease of the regulation of energy metabolism

Abstract:

Chronic Fatigue Syndrome is a physiological state in which the patient feels high levels of fatigue without an obvious organic cause, which affects around 1 in 400 people in the developed world. A wide range of causes have been suggested, including immune or hormonal dysfunction, viral or bacterial infection, and psychological somatization. It is likely that several causes are needed to trigger the disease, and that the triggers are different from the mechanisms that maintain fatigue over months or years. Many treatments have been tested for CFS, with very limited success – a programme of combined CBT and graded exercise shows the most effect.

I suggest that patients with CFS have a reduced ability to increase mitochondrial energy production when exertion requires it, with fewer mitochondria that are each more efficient, and hence nearer to their maximum energy output, than normal. A range of indirect evidence suggests that the renin-angiotensin system stimulates mitochondrial responsiveness and reduces mitochondrial efficiency: chronic under-stimulation of this system could contribute to CFS aetiology.

If correct, this means that CFS can be successfully treated with RAS agonists (eg angiotensin mimetics), or adrenergic agonists. It also suggests that there will be a positive link between the use of adrenergic- and RAS-blocking drugs and CFS incidence, and a negative link between adrenergic agonist use and CFS.

 

Source: Bains W. Treating Chronic Fatigue states as a disease of the regulation of energy metabolism. Med Hypotheses. 2008 Oct;71(4):481-8. doi: 10.1016/j.mehy.2008.02.022. Epub 2008 Aug 5. https://www.ncbi.nlm.nih.gov/pubmed/18684570

 

Increased oxidative stress suggested by low serum vitamin E concentrations in patients with chronic fatigue syndrome

Abstract:

Serum alpha-tocopherol concentrations were determined in 50 patients with chronic fatigue syndrome (CFS) and 40 control subjects (Control). Prevalence of each or any coronary risk factor was not significantly different between CFS and Control.

CFS had significantly lower alpha-tocopherol concentrations than Control. The concentrations were significantly lower in the subjects with any coronary risk factors than those without in CFS as well as Control. Even among the subjects with any coronary risk factors and also among those without, CFS had significantly lower alpha-tocopherol concentrations than Control.

In conclusion, CFS had significantly lower alpha-tocopherol concentrations irrespective of coronary risk factors than Control, suggesting the presence of increased oxidative stress in CFS.

 

Source: Miwa K, Fujita M. Increased oxidative stress suggested by low serum vitamin E concentrations in patients with chronic fatigue syndrome. Int J Cardiol. 2009 Aug 14;136(2):238-9. doi: 10.1016/j.ijcard.2008.04.051. Epub 2008 Aug 6. https://www.ncbi.nlm.nih.gov/pubmed/18684522

 

Prefrontal cortex oxygenation during incremental exercise in chronic fatigue syndrome

Abstract:

This study examined the effects of maximal incremental exercise on cerebral oxygenation in chronic fatigue syndrome (CFS) subjects. Furthermore, we tested the hypothesis that CFS subjects have a reduced oxygen delivery to the brain during exercise.

Six female CFS and eight control (CON) subjects (similar in height, weight, body mass index and physical activity level) performed an incremental cycle ergometer test to exhaustion, while changes in cerebral oxy-haemoglobin (HbO2), deoxy-haemoglobin (HHb), total blood volume (tHb = HbO2 + HHb) and O2 saturation [tissue oxygenation index (TOI), %)] was monitored in the left prefrontal lobe using a near-infrared spectrophotometer. Heart rate (HR) and rating of perceived exertion (RPE) were recorded at each workload throughout the test.

Predicted VO2peak in CFS (1331 +/- 377 ml) subjects was significantly (P < or = 0.05) lower than the CON group (1990 +/- 332 ml), and CFS subjects achieved volitional exhaustion significantly faster (CFS: 351 +/- 224 s; CON: 715 +/- 176 s) at a lower power output (CFS: 100 +/- 39 W; CON: 163 +/- 34 W). CFS subjects also exhibited a significantly lower maximum HR (CFS: 154 +/- 13 bpm; CON: 186 +/- 11 bpm) and consistently reported a higher RPE at the same absolute workload when compared with CON subjects. Prefrontal cortex HbO2, HHb and tHb were significantly lower at maximal exercise in CFS versus CON, as was TOI during exercise and recovery.

The CFS subjects exhibited significant exercise intolerance and reduced prefrontal oxygenation and tHb response when compared with CON subjects. These data suggest that the altered cerebral oxygenation and blood volume may contribute to the reduced exercise load in CFS, and supports the contention that CFS, in part, is mediated centrally.

 

Source: Patrick Neary J, Roberts AD, Leavins N, Harrison MF, Croll JC, Sexsmith JR. Prefrontal cortex oxygenation during incremental exercise in chronic fatigue syndrome. Clin Physiol Funct Imaging. 2008 Nov;28(6):364-72. doi: 10.1111/j.1475-097X.2008.00822.x. Epub 2008 Jul 29. https://www.ncbi.nlm.nih.gov/pubmed/18671793

 

Post-radiation syndrome as a NO/ONOO- cycle, chronic fatigue syndrome-like disease

Abstract:

Post-radiation syndrome is proposed to be chronic fatigue syndrome (CFS) or a chronic fatigue syndrome-like illness, initiated by exposure to ionizing radiation. This view is supported by the nitric oxide/peroxynitrite (NO/ONOO-) cycle mechanism, the putative etiologic mechanism for CFS and related illnesses.

Ionizing radiation may initiate illness by increasing nitric oxide levels via increased activity of the transcription factor NF-kappaB and consequent increased synthesis of the inducible nitric oxide synthase. Two types of components of the nitric oxide/peroxynitrite cycle have been studied in post-radiation syndrome patients and shown to be elevated.

The symptoms and signs of post-radiation syndrome and its chronicity are similar or identical to those of chronic fatigue syndrome and can be explained as being a consequence of nitric oxide/peroxynitrite cycle etiology. While the data available to test this view are limited, it provides for the first time a comprehensive explanation for post-radiation syndrome.

 

Source: Pall ML. Post-radiation syndrome as a NO/ONOO- cycle, chronic fatigue syndrome-like disease. Med Hypotheses. 2008 Oct;71(4):537-41. doi: 10.1016/j.mehy.2008.05.023. Epub 2008 Jul 29. https://www.ncbi.nlm.nih.gov/pubmed/18667279

 

Bayesian biomarker identification based on marker-expression proteomics data

Abstract:

We are studying variable selection in multiple regression models in which molecular markers and/or gene-expression measurements as well as intensity measurements from protein spectra serve as predictors for the outcome variable (i.e., trait or disease state).

Finding genetic biomarkers and searching genetic-epidemiological factors can be formulated as a statistical problem of variable selection, in which, from a large set of candidates, a small number of trait-associated predictors are identified. We illustrate our approach by analyzing the data available for chronic fatigue syndrome (CFS).

CFS is a complex disease from several aspects, e.g., it is difficult to diagnose and difficult to quantify. To identify biomarkers we used microarray data and SELDI-TOF-based proteomics data. We also analyzed genetic marker information for a large number of SNPs for an overlapping set of individuals. The objectives of the analyses were to identify markers specific to fatigue that are also possibly exclusive to CFS. The use of such models can be motivated, for example, by the search for new biomarkers for the diagnosis and prognosis of cancer and measures of response to therapy. Generally, for this we use Bayesian hierarchical modeling and Markov Chain Monte Carlo computation.

 

Source: Bhattacharjee M, Botting CH, Sillanpää MJ. Bayesian biomarker identification based on marker-expression proteomics data. Genomics. 2008 Dec;92(6):384-92. doi: 10.1016/j.ygeno.2008.06.006. Epub 2008 Aug 15. http://www.sciencedirect.com/science/article/pii/S0888754308001420 (Full article)

 

Cognitive behaviour therapy for chronic fatigue syndrome in adults

Abstract:

BACKGROUND: Chronic fatigue syndrome (CFS) is a common, debilitating and serious health problem. Cognitive behaviour therapy (CBT) may help to alleviate the symptoms of CFS.

OBJECTIVES: To examine the effectiveness and acceptability of CBT for CFS, alone and in combination with other interventions, compared with usual care and other interventions.

SEARCH STRATEGY: CCDANCTR-Studies and CCDANCTR-References were searched on 28/3/2008. We conducted supplementary searches of other bibliographic databases. We searched reference lists of retrieved articles and contacted trial authors and experts in the field for information on ongoing/completed trials.

SELECTION CRITERIA: Randomised controlled trials involving adults with a primary diagnosis of CFS, assigned to a CBT condition compared with usual care or another intervention, alone or in combination.

DATA COLLECTION AND ANALYSIS: Data on patients, interventions and outcomes were extracted by two review authors independently, and risk of bias was assessed for each study. The primary outcome was reduction in fatigue severity, based on a continuous measure of symptom reduction, using the standardised mean difference (SMD), or a dichotomous measure of clinical response, using odds ratios (OR), with 95% confidence intervals (CI).

MAIN RESULTS: Fifteen studies (1043 CFS participants) were included in the review. When comparing CBT with usual care (six studies, 373 participants), the difference in fatigue mean scores at post-treatment was highly significant in favour of CBT (SMD -0.39, 95% CI -0.60 to -0.19), with 40% of CBT participants (four studies, 371 participants) showing clinical response in contrast with 26% in usual care (OR 0.47, 95% CI 0.29 to 0.76). Findings at follow-up were inconsistent. For CBT versus other psychological therapies, comprising relaxation, counselling and education/support (four studies, 313 participants), the difference in fatigue mean scores at post-treatment favoured CBT (SMD -0.43, 95% CI -0.65 to -0.20). Findings at follow-up were heterogeneous and inconsistent. Only two studies compared CBT against other interventions and one study compared CBT in combination with other interventions against usual care.

AUTHORS’ CONCLUSIONS: CBT is effective in reducing the symptoms of fatigue at post-treatment compared with usual care, and may be more effective in reducing fatigue symptoms compared with other psychological therapies. The evidence base at follow-up is limited to a small group of studies with inconsistent findings. There is a lack of evidence on the comparative effectiveness of CBT alone or in combination with other treatments, and further studies are required to inform the development of effective treatment programmes for people with CFS.

Comment in: Review: CBT reduces fatigue in adults with chronic fatigue syndrome but effects at follow-up unclear. [Evid Based Ment Health. 2009]

Update of:  Cognitive behaviour therapy for adults with chronic fatigue syndrome. [Cochrane Database Syst Rev. 2000]

 

Source: Price JR, Mitchell E, Tidy E, Hunot V. Cognitive behaviour therapy for chronic fatigue syndrome in adults. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD001027. doi: 10.1002/14651858.CD001027.pub2.https://www.ncbi.nlm.nih.gov/pubmed/18646067

 

Small heart syndrome in patients with chronic fatigue syndrome

Abstract:

BACKGROUND: Small heart syndrome has previously been reported as neurocirculatory asthenia, associated with a small heart shadow on a chest roentgenogram. This is characterized as weakness or fatigue even after ordinary exertion, palpitation, dyspnea, and fainting, resembling patients with chronic fatigue syndrome (CFS).

HYPOTHESIS: Small heart syndrome may be prevalent in patients with CFS.

METHODS: The study population consisted of 56 patients (<50 y of age) with CFS, and 38 control subjects. Chest roentgenographic, echocardiographic, and physical examinations were performed.

RESULTS: Small heart syndrome (cardiothoracic ratio <or= 42%) was significantly more prevalent in the CFS group (61%) than in the control group (24%) (p < 0.01). In CFS patients with a small heart (n = 34), narrow chest (88%), orthostatic dizziness (44%), foot coldness (41%), pretibial pitting edema (32%), r-kidney palpability (47%), and mitral valve prolapse (29%), were all significantly more prevalent than in the control group, and also in the CFS patients without small heart syndrome. Echocardiographic examination demonstrated significantly smaller values of both the left ventricular (LV) end-diastolic dimensions and end-systolic, and stroke volume and cardiac indexes in CFS with a small heart, as compared with control subjects with a normal heart size (42% < cardiothoracic ratio < 50%).

CONCLUSIONS: A considerable number of CFS patients have a small heart. Small heart syndrome may contribute to the development of CFS as a constitutional factor predisposing to fatigue, and may be included in the genesis of CFS.

Copyright (c) 2008 Wiley Periodicals, Inc.

 

Source: Miwa K, Fujita M. Small heart syndrome in patients with chronic fatigue syndrome. Clin Cardiol. 2008 Jul;31(7):328-33. doi: 10.1002/clc.20227. http://onlinelibrary.wiley.com/doi/10.1002/clc.20227/epdf (Full article)

 

Observation on therapeutic effect of multiple cupping at back-shu points on chronic fatigue syndrome

Abstract:

OBJECTIVE: To observe therapeutic effect of multiple cupping at back-shu points of zang-and fu-organs on chronic fatigue syndrome.

METHODS: One hundred and ninety-one cases were randomly divided into 2 groups. The multiple cupping group (n = 142) were treated with multiple cupping along both sides of the spinal cord, and the acupuncture group (n = 49) were treated with acupuncture at acupoints selected according to TCM syndrome differentiation. Their therapeutic effects were assessed by clinical symptoms and Fatigue Assessment Indexes (FAI).

RESULTS: The total effective rate was 97.9% in the multiple cupping group and 79.6% in the acupuncture group with a very significant difference between the two groups (P < 0.01), and after treatment, there was a very significant difference between the two groups in FAI score (P < 0.01).

CONCLUSION: Multiple cupping at back-shu points of zang-and fu-organs is an effective method for chronic fatigue syndrome.

 

Source: Chen GL, Xiao GM, Zheng XL. Observation on therapeutic effect of multiple cupping at back-shu points on chronic fatigue syndrome. Zhongguo Zhen Jiu. 2008 Jun;28(6):405-7. [Article in Chinese] https://www.ncbi.nlm.nih.gov/pubmed/18630535

 

Using multiple sources of knowledge to reach clinical understanding of chronic fatigue syndrome

Abstract:

PURPOSE: Chronic fatigue syndrome (CFS), or myalgic encephalitis (ME), is a contentious condition and often a diagnosis of exclusion. Current policy in the United Kingdom recommends management in primary care. We explored how patients with CFS/ME and family physicians understand this condition and how their understanding might affect the primary care consultation.

METHODS: We undertook a qualitative study with patients and family physicians from North West England participating in a primary care-based randomized controlled trial (FINE Trial). Data were collected through purposive sampling and in-depth semistructured interviews with 24 patients and 14 family physicians. We analyzed interview transcripts using constant comparison methods.

RESULTS: Family physicians access social and cultural knowledge to reach a clinical understanding of CFS/ME and its management. Patients recognize the difficulties family physicians encounter in understanding their symptoms and access similar nonclinical sources of information. We suggest that both patients and physicians use biomedical discourse within the consultation: the physician to maintain the position as an expert, the patient to engage the physician.

CONCLUSIONS: Family physicians obtain information about CFS/ME from their nonprofessional world, which they incorporate into their professional realm. Patients and physicians describe the use of the discourse of science within consultations about CFS/ME. This form of shared understanding could lead to a positive collaborative interaction. Family physicians need a biomedical, evidence-based knowledge about CFS/ME. There is potential to use the rich knowledge base that patients can bring to consultations in training initiatives directed at family physicians.

 

Source: Chew-Graham CA, Cahill G, Dowrick C, Wearden A, Peters S. Using multiple sources of knowledge to reach clinical understanding of chronic fatigue syndrome. Ann Fam Med. 2008 Jul-Aug;6(4):340-8. doi: 10.1370/afm.867. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2478494/ (Full article)