CBT – Page 12 – American ME and CFS Society

Cost-effectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome

Abstract:

BACKGROUND: There is some evidence that cognitive behaviour therapy (CBT) is efficacious in chronic fatigue syndrome (CFS), but little data on its cost-effectiveness.

DESIGN: Prospective economic analysis alongside a randomized clinical trial.

METHODS: CFS patients were randomly assigned to CBT, guided support groups (SG), or the ‘natural course’ (NC, no protocol-based interventions). Patients were treated for 8 months and followed-up for another 6 months. Costs per patient showing clinically significant improvement, based on the CIS fatigue scale, and costs per quality-adjusted life year, were determined for a time period of 14 months.

RESULTS: Data were available for 171 patients at 8 months and for 128 at 14 months. At 8 and 14 months, the percentages of improved patients were 31% and 27% for CBT, 9% and 11% for SG, and 12% and 20% for NC. Mean QALYs gained at 14 months were, for CBT, SG and NC, respectively, 0.0737, -0.0018 and 0.0458. CBT and SG mean treatment costs were euro1490 and euro424. Other medical costs for CBT, SG, and NC, respectively, were euro324, euro623 and euro412 for the first period, and euro232, euro561 and euro378 for the second period. Non-medical costs for these periods for CBT, SG and NC were euro262, euro550, euro427 and euro226, euro439, euro287, respectively. Productivity costs were considerable, but not significantly different between groups.

DISCUSSION: CBT was less costly and more effective than SG. Compared to NC, the baseline incremental cost-effectiveness of CBT was euro20 516 per CFS patient showing clinically significant improvement, and euro21 375 per QALY. The bootstrap ratios showed considerable uncertainty regarding the results. Future research should focus on productivity costs, and follow patients prospectively over a longer period.

Comment in:

Cost-effectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome. [QJM. 2004]

Source: Severens JL, Prins JB, van der Wilt GJ, van der Meer JW, Bleijenberg G. Cost-effectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome. QJM. 2004 Mar;97(3):153-61. http://qjmed.oxfordjournals.org/content/97/3/153.long (Full article)

Is graded exercise better than cognitive behaviour therapy for fatigue? A UK randomized trial in primary care

Abstract:

BACKGROUND: Patients frequently present with unexplained fatigue in primary care, but there have been few treatment trials in this context. We aimed to test cognitive behaviour therapy (CBT) and graded exercise therapy (GET) for patients presenting to their family doctor with fatigue. Secondly, we described the outcome for a cohort of patients who presented to the same doctors with fatigue, who received standard care, plus a booklet.

METHOD: This was a randomized trial, followed by a prospective cohort study. Twenty-two practices in SE England referred 144 patients aged 16 to 75 years with over 3 months of unexplained fatigue. Self-rated fatigue score, the hospital anxiety and depression rating scale, functional impairment, physical step-test performance and causal attributions were measured. In the trial six sessions of CBT or GET were randomly allocated.

RESULTS: In the therapy groups the mean fatigue score decreased by 10 points (95% confidence interval (CI) = -25 to -15), with no significant difference between groups (mean difference = -1.3; CI = -3.9 to 1.3). Fewer patients attended for GET. At outcome one-half of patients had clinically important fatigue in both randomized groups, but patients in the group offered CBT were less anxious. Twenty-seven per cent of the patients met criteria for CFS at baseline. Only 25% of this subgroup recovered, compared to 60% of the subgroup that did not meet criteria for CFS.

CONCLUSIONS: Short courses of GET were not superior to CBT for patients consulting with fatigue of over 3 months in primary care. CBT was easier ‘to sell’. Low recovery in the CFS subgroup suggests that brief treatment is too short.

Source: Ridsdale L, Darbishire L, Seed PT. Is graded exercise better than cognitive behaviour therapy for fatigue? A UK randomized trial in primary care. Psychol Med. 2004 Jan;34(1):37-49. http://www.ncbi.nlm.nih.gov/pubmed/14971625

Review: cognitive behavioural interventions may be effective for chronic fatigue syndrome and chronic back pain

Comment on: Systematic review of mental health interventions for patients with common somatic symptoms: can research evidence from secondary care be extrapolated to primary care? [BMJ. 2002]

Psychological disorders have a high financial burden with many indirect costs. Behavioural strategies and cognitive behavioural interventions may be effective for a range of mental disorders, including some of the most chronic, severe and costly mental health problems.1 Very few medical professionals are adequately trained to deliver such treatments, however. This article is both timely and important because it emphasises the need to disseminate cognitive behaviour therapies more widely.

Raine et al conducted a thorough review of the efficacy of psychological treatments for common somatic symptoms: chronic fatigue syndrome, irritable bowel syndrome and chronic back pain. The results were consistent with the findings by the American Psychological Association’s Task Force on Promotion and Dissemination of Psychological Procedures:2 cognitive behaviour interventions and behaviour therapy are effective for treating chronic back pain and chronic fatigue syndrome. Raine et al found that treatment effects were stronger in secondary care compared with primary care settings. Furthermore, antidepressants were effective in both settings for treating irritable bowel syndrome.

The review has some limitations. First, as in all secondary analyses, the review is based only on published studies (that are more likely to report positive outcomes). There may also be problems with how interventions were defined and implemented. The majority of studies did not follow a treatment manual and did not measure adherence to the therapy protocol. The distinction between “behaviour therapy” and “cognitive-behaviour therapy” therefore remains elusive. This leaves important questions unanswered about how and why these treatments work (ie the mechanisms and mediators of change).3

You can read the rest of this comment here: http://ebmh.bmj.com/content/6/2/55.long

Source: Hofmann SG. Review: cognitive behavioural interventions may be effective for chronic fatigue syndrome and chronic back pain. Evid Based Ment Health. 2003 May;6(2):55. http://ebmh.bmj.com/content/6/2/55.long (Full article)

Does graded activity increase activity? A case study of chronic fatigue syndrome

Abstract:

The reliance on self-report outcome measures in clinical trials of graded activity-oriented cognitive-behavior therapy in chronic fatigue syndrome (CFS) makes it difficult to draw definitive conclusions about actual behavioral change.

The participant in this case study was a 52-year-old married male with CFS who was working full-time. Outcome measures included a step counter to objectively measure physical activity as well as a daily diary measure of exercise activity and in vivo ratings of perceived energy, fatigue, and affect. The following psychometric instruments were also used: the CFS Symptom Inventory, the SF-36, the Beck Depression Inventory, and the Beck Anxiety Inventory. The 26-session graded activity intervention involved gradual increases in physical activity.

From baseline to treatment termination, the patient’s self-reported increase in walk time from 0 to 155 min a week contrasted with a surprising 10.6% decrease in mean weekly step counts. The final follow-up assessment revealed a “much improved” global rating, substantial increases in patient-recorded walk time and weight lifting intensity, yet a relatively modest increment in weekly step counts. It appeared that improvement was associated with mood-enhancing, stress-reducing activities that were substituted for stress-exacerbating activities.

Source: Friedberg F. Does graded activity increase activity? A case study of chronic fatigue syndrome. J Behav Ther Exp Psychiatry. 2002 Sep-Dec;33(3-4):203-15. http://www.ncbi.nlm.nih.gov/pubmed/12628637

Systematic review of mental health interventions for patients with common somatic symptoms: can research evidence from secondary care be extrapolated to primary care?

Abstract:

OBJECTIVES: To determine the strength of evidence for the effectiveness of mental health interventions for patients with three common somatic conditions (chronic fatigue syndrome, irritable bowel syndrome, and chronic back pain). To assess whether results obtained in secondary care can be extrapolated to primary care and suggest how future trials should be designed to provide more rigorous evidence.

DESIGN: Systematic review.

DATA SOURCES: Five electronic databases, key texts, references in the articles identified, and citations from expert clinicians.

STUDY SELECTION: Randomised controlled trials including participants with one of the three conditions for which no physical cause could be found. Two reviewers screened sources and independently extracted data and assessed quality.

RESULTS: Sixty one studies were identified; 20 were classified as primary care and 41 as secondary care. For some interventions, such as brief psychodynamic interpersonal therapy, little research was identified. However, results of meta-analyses and of randomised controlled trials suggest that cognitive behaviour therapy and behaviour therapy are effective for chronic back pain and chronic fatigue syndrome and that antidepressants are effective for irritable bowel syndrome. Cognitive behaviour therapy and behaviour therapy were effective in both primary and secondary care in patients with back pain, although the evidence is more consistent and the effect size larger for secondary care. Antidepressants seem effective in irritable bowel syndrome in both settings but ineffective in chronic fatigue syndrome.

CONCLUSIONS: Treatment seems to be more effective in patients in secondary care than in primary care. This may be because secondary care patients have more severe disease, they receive a different treatment regimen, or the intervention is more closely supervised. However, conclusions of effectiveness should be considered in the light of the methodological weaknesses of the studies. Large pragmatic trials are needed of interventions delivered in primary care by appropriately trained primary care staff.

Comment in: Review: cognitive behavioural interventions may be effective for chronic fatigue syndrome and chronic back pain. [Evid Based Ment Health. 2003]

Source: Raine R, Haines A, Sensky T, Hutchings A, Larkin K, Black N. Systematic review of mental health interventions for patients with common somatic symptoms: can research evidence from secondary care be extrapolated to primary care? BMJ. 2002 Nov 9;325(7372):1082. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC131187/ (Full article)

Predictors of response to treatment for chronic fatigue syndrome

Abstract:

BACKGROUND: Controlled trials have shown that psychological interventions designed to encourage graded exercise can facilitate recovery from chronic fatigue syndrome.

AIMS: To identify predictors of response to psychological treatment for chronic fatigue syndrome.

METHOD: Of 114 patients assigned to equally effective treatment conditions in a randomised, controlled trial, 95 completed follow-up assessments. Relationships between variables measured prior to randomisation and changes in physical functioning and subjective handicap at 1 year were evaluated by multiple regression.

RESULTS: Poor outcome was predicted by membership of a self-help group, being in receipt of sickness benefit at the start of treatment, and dysphoria as measured by the Hospital Anxiety and Depression scale. Severity of symptoms and duration of illness were not predictors of response.

CONCLUSIONS: Poor outcome in the psychological treatment of chronic fatigue syndrome is predicted by variables that indicate resistance to accepting the therapeutic rationale, poor motivation to treatment adherence or secondary gains from illness.

Source: Bentall RP, Powell P, Nye FJ, Edwards RH. Predictors of response to treatment for chronic fatigue syndrome. Br J Psychiatry. 2002 Sep;181:248-52. http://bjp.rcpsych.org/content/181/3/248.long (Full article)

Chronic unexplained fatigue

After more than two years’ gestation, an independent working group, set up by the previous Chief Medical Officer for England, published its final report on the subject of chronic fatigue syndrome (CFS) in January of this year.1 This is a topical subject in the English speaking world as two other management reports have been published in the last six months, by the US government and the Australasian Royal College of Physicians.2 3 The Canadians are also close to a final draft of their own report. This has occurred at the same time as the release of two independent systematic reviews of management. Remarkably the two teams from Texas (USA) and York (UK) reached such similar conclusions that they combined their findings into the one paper.4 The York group has just published their own guidance based on their systematic review.5

You can read the rest of this editorial here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1742445/pdf/v078p00445.pdf

CONFLICT OF INTEREST Dr White was one of the clinicians who resigned from the English report on CFS/ME.

Comment in: Chronic unexplained fatigue. [Postgrad Med J. 2002]

Source: White PD. Chronic unexplained fatigue. Postgrad Med J. 2002 Aug;78(922):445-6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1742445/pdf/v078p00445.pdf (Full article)

Review: behavioural interventions show the most promise for chronic fatigue syndrome

Comment on: Interventions for the treatment and management of chronic fatigue syndrome: a systematic review. [JAMA. 2001]

QUESTION: In patients with chronic fatigue syndrome (CFS), what is the effectiveness of evaluated interventions?

Data sources: Published and unpublished studies in any language were identified by searching 19 databases, including Medline, EMBASE/Excerpta Medica, PsycLIT, ERIC, Current Contents, and the Cochrane Library (to 2000); the internet was searched using a meta-search engine; references of retrieved articles were scanned; and individuals and organisations were contacted through a website dedicated to this review and through members of 2 advisory panels.

Study selection: Studies were selected if they were randomised controlled trials (RCTs) or controlled clinical trials of any intervention used in the treatment or management of CFS in adults or children. Studies in which diagnoses were based on another syndrome with criteria similar to CFS, such as myalgic encephalomyelitis, chronic fatigue immune deficiency syndrome, or chronic Epstein-Barr virus infection, were included, but studies of fibromyalgia were not.

Data extraction: Data were extracted on study validity (randomisation and allocation concealment [RCTs], control group appropriateness and adjustment for confounders [controlled studies], baseline comparability of groups, blinding, follow up, drop outs, objectivity of outcome assessment, analysis, sample size, and cointerventions); intervention; diagnostic criteria; duration of follow up; and outcomes (psychological, physical, quality of life and health status, physiological, and resource use).

Main results: 44 studies (n=2801; age range 11–87 y, 71% women) were included (32 studies of adults, 1 of children, and 2 of adults and children; 9 studies did not give age information). 31 different interventions were grouped by type of intervention (behavioural, immunological, pharmacological, supplements, complementary or alternative, and other interventions). 36 studies were RCTs. 18 trials (41%) showed an overall beneficial effect of the intervention (≥1 clinical outcome improved). The results from the RCTs are shown in the table. Cognitive behavioural therapy (CBT) and graded exercise therapy (GET) had beneficial effects. Overall evidence from the other interventions was inconclusive.

Source: Kinsella P. Review: behavioural interventions show the most promise for chronic fatigue syndrome. Evid Based Nurs. 2002 Apr;5(2):46. http://ebn.bmj.com/content/5/2/46.long (Full article)

Family cognitive behaviour therapy for chronic fatigue syndrome: an uncontrolled study

Abstract:

AIM: To examine the efficacy of family focused cognitive behaviour therapy for 11-18 year olds with chronic fatigue syndrome.

METHODS: Twenty three patients were offered family focused cognitive behaviour therapy. The main outcome was a fatigue score of less than 4 and attendance at school 75% of the time.

RESULTS: Twenty patients completed treatment. Eighteen had completed all measures at six months follow up; 15 of these (83%) improved according to our predetermined criterion. Substantial improvements in social adjustment, depression, and fear were noted.

CONCLUSIONS: Family focused cognitive behaviour therapy was effective in improving functioning and reducing fatigue in 11-18 year olds. Gains were maintained at six months follow up.

Source: Chalder T, Tong J, Deary V. Family cognitive behaviour therapy for chronic fatigue syndrome: an uncontrolled study. Arch Dis Child. 2002 Feb;86(2):95-7. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1761081/ (Full article)

Cognitive behavioral therapy and fasting therapy for a patient with chronic fatigue syndrome

Abstract:

Cognitive behavioral therapy temporarily alleviated symptoms of a chronic fatigue syndrome patient but the anxiety about rehabilitation into work became stronger and his symptoms worsened. This patient was successfully rehabilitated by fasting therapy. Natural killer cell activity and serum acylcarnitine levels recovered after fasting therapy. Though fasting therapy transiently increased physical and mental subjective symptoms, the patient gained self-confidence by overcoming difficulties after fasting therapy. A combination of cognitive behavioral therapy and fasting therapy is promising as a treatment for chronic fatigue syndrome.

Source: Masuda A, Nakayama T, Yamanaka T, Hatsutanmaru K, Tei C. Cognitive behavioral therapy and fasting therapy for a patient with chronic fatigue syndrome. Intern Med. 2001 Nov;40(11):1158-61. https://www.jstage.jst.go.jp/article/internalmedicine1992/40/11/40_11_1158/_article (Full article)