Tag: comment

Cognitive behaviour therapy for adolescents with chronic fatigue syndrome: data are insufficient and conclusion inappropriate

Comment on: Cognitive behaviour therapy for adolescents with chronic fatigue syndrome: randomised controlled trial. [BMJ. 2005]

 

Editor—I have concerns about the design and interpretation of the study reported by Stulemeijer et al on cognitive behaviour therapy for adolescents with chronic fatigue syndrome.1 The trial arms were not matched for the number of contacts with healthcare professionals. Experience from larger and more carefully controlled randomised interventional trials of patients with chronic fatigue syndrome has clearly shown that short term improvement in symptoms is related directly to the maintenance of regular contacts with healthcare professionals rather than the therapeutic effect of the intervention itself and consequently, the improvement is not sustained once the contact is lost.2

The authors did not offer patients in their waiting list the opportunity to meet therapists regularly for five months but without having cognitive behaviour therapy. Few follow up data on patients in the intervention arm show that the specific treatment benefit was carried forward without regular contacts with the therapists. A cautious approach is essential in inferring direct benefit from cognitive behaviour therapy in the intervention arm (as opposed to short term benefit from close contact with therapists). The level of activity in some of their participants whom the authors considered to be passive remained unclear.

You can read the rest of this comment here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC555921/

 

Source: Chaudhuri A. Cognitive behaviour therapy for adolescents with chronic fatigue syndrome: data are insufficient and conclusion inappropriate. BMJ. 2005 Apr 2;330(7494):789-90; author reply 790. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC555921/ (Full article)

 

Patients with chronic fatigue syndrome are being ignored

Comment on: What causes chronic fatigue syndrome? [BMJ. 2004]

 

Editor—Earlier this year more than 28, 000 people signed a petition calling for urgent government funded research into the physical causes of myalgic encephalomyelitis and chronic fatigue syndrome. Such is the frustration of people who do not believe that their views are being listened to by the medical establishment.

So White’s editorial reviewing the possible causes of myalgic encephalomyelitis and chronic fatigue syndrome should be welcome news.1 But is it?

Many doctors support the idea of a disease model with predisposing, precipitating, and perpetuating factors. However, White does not offer any innovative suggestions as to how this could be used to better understand an illness that now covers a wide variety of clinical presentations and an equally diverse range of patho-physiological findings. Having created this mess, the medical profession must now accept that this heterogeneous group of patients is unlikely to have the same pathoaetiology and respond to the same form of treatment, be it pharmacological or behavioural.

What is needed is thought provoking research that dispenses with the oversimplistic view that myalgic encephalomyelitis and chronic fatigue syndrome entail little more than a vicious circle of abnormal illness beliefs and behaviour, inactivity, and deconditioning. The World Health Organization now classifies both myalgic encephalomyelitis and chronic fatigue syndrome as neurological disorders in section G93.3 of ICD-10. The time has come to look at the neurology of central fatigue—instead of pouring yet more money into the bottomless pit of psychological research.

You can read the rest of this article here:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC535506/

 

Source: Shepherd C. Patients with chronic fatigue syndrome are being ignored. BMJ. 2004 Dec 11;329(7479):1405. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC535506/ (Full article)

 

What causes chronic fatigue syndrome?

Comment in: Patients with chronic fatigue syndrome are being ignored. [BMJ. 2004]

Comment on: Childhood predictors of self reported chronic fatigue syndrome/myalgic encephalomyelitis in adults: national birth cohort study. [BMJ. 2004]

 

Chronic fatigue syndrome, also known as myalgic encephalomyelitis, is an illness of unknown nature and cause, but most medical authorities now accept its existence.1-3 Research about its cause has been hampered by the absence of a biological marker, the heterogeneous nature of the illness, and difficulties in differentiating cause from effect.2,3 Yet, some progress has been made, particularly when causes are divided into predisposing, triggering, and maintaining factors.

Women get chronic fatigue syndrome more commonly than men for unknown reasons, although increasing evidence suggests a genetic influence on the illness.1,3 Premorbid mood disorders are replicated risk markers for chronic fatigue syndrome;1,3 the risks may be inflated by shared symptoms or they may be markers for those patients with comorbid mood disorders.1,3-5 Another replicated premorbid risk marker is increased consulting of a doctor for minor illnesses up to 15 years before diagnosis,w1 w2 suggesting a general vulnerability for either ill health or seeking health care, the latter possibly being mediated by comorbid anxiety.4

You can read the rest of this comment here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC524091/

 

Source: White PD. What causes chronic fatigue syndrome? BMJ. 2004 Oct 23;329(7472):928-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC524091/ (Full article)

 

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

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

 

Sir,

I read Severens et al.’s article on the cost-effectiveness of cognitive behaviour therapy for patients with unexplained chronic fatigue1 with interest, although as several subjects met the CDC criteria for ‘idiopathic chronic fatigue’ rather than ‘chronic fatigue syndrome’,2,,3 I prefer to use the term ‘unexplained chronic fatigue’ as defined by Fukuda et al.3 to describe the patient sample under consideration.

To be able to regard the presented cost estimates as a valid reflection of the medical costs of patients with unexplained chronic fatigue, it is imperative to demonstrate that there are no differences between participants who are included in the analysis and participants who are excluded from the analysis.

According to the authors: ‘An extensive comparison between participants in the cost-effectiveness analyse (n = 171) and the remaining clinical study participants (n = 99) did not reveal any statistically significant differences regarding age, duration of CFS complaints, and scores for Sickness Impact Profile, Karnofsky score, physical activity, a self-efficacy scale, a causal attribution list, and functional impairment.’ (pp. 158–9).

Although details are lacking in the article, baseline data of the included and excluded participants are available from a publication of the Health Care Insurance Board of the Netherlands (College voor zorgverzekeringen).4 Comparing baseline variables of the two groups using two-tailed independent sample t-tests yields the results that are presented in Table 1. The table shows that physical activity (measured by a motion-sensing device called the actometer), self-efficacy, and psychological well-being (measured by the symptom checklist 90) are significantly different at the 0.05 level. The p values for physical activity (p = 0.0081) and self-efficacy (p = 0.0046) are particularly small.

You can read the rest of this comment here: http://qjmed.oxfordjournals.org/content/97/6/379.long

 

Source: Stouten B. Cost-effectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome. QJM. 2004 Jun;97(6):379-80. http://qjmed.oxfordjournals.org/content/97/6/379.long (Full article)

 

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

Sir,

In their economic evaluations of treatments for chronic fatigue syndrome (CFS), Severens et al. compared the cost-effectiveness of cognitive behaviour therapy (CBT) with those of other interventions, and found that the percentage of CFS patients who improved with CBT performed for 8 months was 31% vs. 9% and 12% for other treatments. Considering that, in one study, 28% of CFS patients treated with low-dose hydrocortisone over just one month virtually recovered,  Severens et al. also should have compared the cost-effectiveness of CBT with that of low-dose hydrocortisone.

Treatment with low-dose hydrocortisone for CFS, besides being intuitively far less costly than CBT, is also better-founded clinically than any psychological therapy, because hydrocortisone corrects the hypocortisolism that characterizes at least some CFS patients. Given that ‘frank hypocortisolism’, rather surprisingly, was one of the exclusion criteria for enrolment in the trial of Cleare et al., the percentage of CFS patients who can be effectively treated with low-dose hydrocortisone in day-to-day health care is likely to be higher than the 28% found in that trial.

You can read the rest of this comment here: http://qjmed.oxfordjournals.org/content/97/6/378.long

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

 

Source: Baschetti R. Cost-effectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome. QJM. 2004 Jun;97(6):378-9. http://qjmed.oxfordjournals.org/content/97/6/378.long (Full article)

 

Plasma endothelin-1 levels in chronic fatigue syndrome

Comment on: Increased plasma endothelin-1 levels in fibromyalgia syndrome. [Rheumatology (Oxford). 2003]

 

SIR, We read with interest the report by Pache et al. [1] showing increased endothelin-1 (ET-1) levels in patients with a diagnosis of fibromyalgia syndrome (FMS) and their conclusion that elevated ET-1 levels might contribute to some of the apparent vascular disturbances that characterize the syndrome. Pache et al. also point to the overlap between the clinical presentation of FMS and other ‘stress-associated disorders including chronic fatigue syndrome (CFS) and depression’. Whether FMS or CFS is stress-induced is a contentious issue in itself, but of equal concern is the view that FMS should be considered to be part of the spectrum of illness under the generic name ‘chronic fatigue syndrome’. Clearly, the symptoms of FMS and CFS have much in common [2, 3] but it has been said that FMS represents an additional burden of suffering among those with CFS [4], those patients meeting the case definitions for both FMS and CFS having a worse course, worse overall health and greater disease impact [2]. Furthermore, while many FMS patients experience fatigue, it has been estimated that only about one-fifth fulfil the specific criteria required for CFS [5]. Clinical similarities apart, there are biological differences between the two; for example, cerebrospinal fluid levels of substance P are elevated in FMS but not in CFS patients [6], and cardiovascular responses to postural challenge are characteristic of many CFS patients but are not apparent in those with FMS [7].

You can read the rest of this comment here: http://rheumatology.oxfordjournals.org/content/43/2/252.long

 

Source: Kennedy G, Spence V, Khan F, Belch JJ. Plasma endothelin-1 levels in chronic fatigue syndrome. Rheumatology (Oxford). 2004 Feb;43(2):252-3; author reply 253-4. http://rheumatology.oxfordjournals.org/content/43/2/252.long (Full article)

 

Enteroviruses in chronic fatigue syndrome: “now you see them, now you don’t”

Comment on: Enterovirus related metabolic myopathy: a postviral fatigue syndrome. [J Neurol Neurosurg Psychiatry. 2003]

 

In the paper by Lane et al(see pp 1382– 1386)1 an association was found between abnormal exercise lactate response and enterovirus sequences in the muscle of some patients with chronic fatigue syndrome (CFS). The paper rekindles the old saga of enteroviruses, muscle inflammation, and fatigue.

You can read the rest of this comment here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1757390/pdf/v074p01361.pdf

 

Source: Dalakas MC. Enteroviruses in chronic fatigue syndrome: “now you see them, now you don’t”. J Neurol Neurosurg Psychiatry. 2003 Oct;74(10):1361-2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1757390/  (Full article)

 

Assessing chronic fatigue

Comment on: The head-up tilt test with haemodynamic instability score in diagnosing chronic fatigue syndrome. [QJM. 2003]

 

Naschitz et al.1 studied patients with chronic fatigue syndrome (CFS) in comparison with some controls ‘exhibiting shared clinical features with CFS’, namely, patients with non-CFS chronic fatigue, fibromyalgia, generalized anxiety disorder, and neurally mediated syncope. Considering that those controls were included in the study on the basis of the clinical overlap of their disorders with CFS, it is surprising that Naschitz et al. failed to include also patients with Addison’s disease, which resembles CFS far more closely than does any other medical condition.2

You can read the rest of this comment here: http://qjmed.oxfordjournals.org/content/96/6/454.long

 

Source: Baschetti R. Assessing chronic fatigue. QJM. 2003 Jun;96(6):454. http://qjmed.oxfordjournals.org/content/96/6/454.long (Full article)

 

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)

 

The head-up tilt test for diagnosing chronic fatigue syndrome

Comment on: The head-up tilt test with haemodynamic instability score in diagnosing chronic fatigue syndrome. [QJM. 2003]

 

Sir,

The recent paper by Naschitz et al.  on the use of the head‐up tilt test with haemodynamic instability score (HIS) in the diagnosis of chronic fatigue syndrome (CFS) provides additional insight about the role of dysautonomia in the pathogenesis of CFS. We would like to raise some points regarding the patient group studied.

The enrolment of clinically‐diagnosed CFS patients and the awareness of diagnosis by technicians prior to performing the tilt test, could result in selection bias. Additionally, generalizing the result of the study, whose population was rich in patients with CFS (40/349, or 11%) to the general population (prevalence of CFS 0.07–0.2%) could be misleading. Using their results of a sensitivity of 90.3% and specificity of 84.5% for a cutoff of HIS >−0.98, a positive head‐up tilt test in a patient presenting with fatigue in the general population would have a positive predictive value of only 0.37–1.15. This result, taken with the fact that around one‐fifth of the patients developed a presyncopal or syncopal episode, would make the test less appealing to patients. However, in a patient presenting with fatigue where clinical diagnosis remained unclear despite lengthy evaluation, the head‐up tilt test could be useful for narrowing down the range of diagnoses.

You can read the rest of this comment here: http://qjmed.oxfordjournals.org/content/96/5/379.2.long

 

Source: Ghosh AK, Ghosh K. The head-up tilt test for diagnosing chronic fatigue syndrome. QJM. 2003 May;96(5):379-80. http://qjmed.oxfordjournals.org/content/96/5/379.2.long (Full article)