RETURN TO TABLE OF
JAMA study may be misleading:
Behavioral Therapies No Cure for CFS
A review article in the Sept. 19, 2001
issue of the Journal of the American Medical Association states what most
familiar with the chronic fatigue syndrome (CFS) literature already know:
studies of treatments in CFS involve small numbers of participants, use
inconsistent outcome measures and yield mixed results.
The authors have summarized the results of two government-funded analyses
(one from the U.S. and the other from the U.K.) of the treatment literature,
including published and unpublished reports of pharmacologic, behavioral and
other therapies. Nineteen databases were searched, identifying 350 studies
conducted between 1986 and 2000. Of those, 44 research reports were included in
the review, representing a total of 2,801 patients.
Reviewers selected studies of pharmacologic interventions including
hydrocortisone, fludrocortisone and galanthamine and immunological therapies
such as immunoglobulin, Ampligen and interferon. Trials of supplements such as
essential fatty acids and magnesium were evaluated, as were studies of massage
and osteopathy. Research on two behavioral interventions, graded exercise
therapy (GET) and cognitive behavioral therapy (CBT), accounted for nine of the
Comparison of the studies proved challenging. There were considerable
differences in study design (36 employed randomized controlled trials and eight
used controlled trials), outcome measures (more than 38 different outcomes were
assessed), duration of treatment (ranging from two to 52 weeks) and length of
follow-up (ranging from two weeks to five years).
The authors highlighted CBT and GET as the most promising therapies,
although they acknowledge that these studies also had the highest dropout rates
of the 44. Five of the nine behavioral studies used the less-restrictive Oxford
criteria to select patients, and all, by design, only included patients who were
well enough to frequently travel to clinic.
Positive effects of other therapies received less attention. Of those
studies with relatively high validity scores, independent trials of
immunoglobulin, hydrocortisone, magnesium and essential fatty acids showed
The reviewers conclude that greater standardization of studies is needed.
They suggest that a classification system for illness severity be developed, as
well as guidelines for the duration of intervention and follow-up. Finally, the
authors prioritize agreement upon outcome measures as a necessary step to
improve the comparability of CFS studies.
complete report of the U.S. evidence-based review summarized in the JAMA article
is due from the Agency for Healthcare Research and Quality in late November or
early December. The U.K. literature analysis is available on the Internet at
Before referring a patient for CBT or GET…
Understand and communicate that these therapies do not offer a cure for
Remind the patient that these services can improve coping mechanisms
and functional ability over time, if administered by a skilled rehabilitation
Make sure the provider-therapist is familiar
with CFS, since too much too soon can lead to relapse and/or discontinuation
Review cost and reimbursement for these therapies — they can be expensive
and insurers often handle them differently than medical