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Cognitive Behavioral Therapy and Graded Exercise for CFS: A Meta-Analysis (Castell)

Discussion in 'Latest ME/CFS Research' started by Dolphin, Dec 20, 2011.

  1. Dolphin

    Dolphin Senior Member

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    Here's the abstract. I'll put some comments in messages below it.

    (I've given each sentence its own paragraph)
  2. Dolphin

    Dolphin Senior Member

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    On the authors

    The only one of these three names I recognise without any research is Rona E. Moss-Morris.
    She's a fairly hardline CBT School psychologist.

    Bronwyn D. Castell is a PhD student who could perhaps be easily led (?).

    Generally, this review seems reasonable enough but there are a few points where RMM's bias might be in evidence.
    Bob likes this.
  3. Dolphin

    Dolphin Senior Member

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    The main numbers

    Overall effect sizes for CBT: g = 0.33 (95% CI: 0.10-0.56) (i.e. not large)

    Overall effect sizes for GET: g = 0.28 (95% CI: 0.06-0.51) (i.e. not large)

    I don't have that book but the standard figures quotes are:
    d=0.2 (small effect)
    d=0.5 (moderate effect)
    d=0.8 (large effect)
    Longer piece from Wikipedia below:

    They claim:

    I'm not that familiar with the effect sizes. But I think a g=0.26 would more commonly be called of "small" magnitude rather than "small to medium".



    http://en.wikipedia.org/wiki/Effect_size

    Bob and oceanblue like this.
  4. Dolphin

    Dolphin Senior Member

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    Scores ranged 39-75% for GET, 25-75% for CBT. The PACE Trial was the trial that scored 75%.
  5. Sean

    Sean Senior Member

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    Thanks for that, Dolphin.

    Bollocks.

    The results of this review suggest the opposite that after being tested to death for 20 years, often in highly (even unduly) favourable circumstances, CBT and GET have clearly failed to deliver any substantial therapeutic benefit.


    The eyes are not here
    There are no eyes here
    In this valley of dying stars
    In this hollow valley
  6. Snow Leopard

    Snow Leopard Senior Member

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    Also note the meta review neglected any discussion of safety...

    Moss morris in a previous study on MS related fatigue suggested that self report questionnaires are subject to a variety of biases and actigraph data should be used to demonstrate reduction in disability. Yet there was no discussion of that in the meta review.

    My letter-writing fingers are tingling...
  7. oceanblue

    oceanblue Senior Member

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    Do the effect sizes relate to fatigue, physical activity/function or both?

    Either way they are not very big. I've seen different definitions of 'small' and 'medium' - problem is that Cohen's orginal paper only specified one value, e.g. 0.2 is small, not a range (eg small is 0.1-0.3, or whatever).

    Here's one opinion:
    Nb 1.0 is not the maximum effect size, it's just 1 standard deviation. 2 or more is possible.
  8. biophile

    biophile Places I'd rather be.

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    What about long term followup?
  9. Dolphin

    Dolphin Senior Member

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    Some studies have suggested a reduction in efficacy with time. A figure would have been interesting.
    Bob likes this.
  10. Dolphin

    Dolphin Senior Member

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    Fatigue
    Functional Impairment (generally SF36 by which I presume they mean SF-36 PF subscale)
    Depression
    Anxiety

  11. oceanblue

    oceanblue Senior Member

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    Thanks.

    Odd they should give anxiety and depression equal weight with fatigue and impairment since the former are not CFS symptoms. Also, I'm pretty sure that CBT has been shown to give medium/large effects on anxiety and depression - so would the effect size have been smaller if just for fatigue/function? This hints it might have been.
  12. Enid

    Enid Senior Member

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    What the b..... h ... is co-morbid - this lot continues to bark up the wrong tree - every illness brings what may appear to be to the ignorant a co-morbid. Of course one is thoroughly ill.
  13. Dolphin

    Dolphin Senior Member

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    Yes, it is a bit odd. The paper says Malouff et al. (2008) didn't include them so perhaps they were trying to be different/justify having another meta-analysis on virtually the same data:

    Effect sizes:

    CBT:
    Fatigue: 0.36
    Functional Impairment: 0.36
    Depression: 0.32
    Anxiety: 0.15

    GET:
    Fatigue: 0.41
    Functional Impairment: 0.39
    Depression: 0.15 (not significant)
    Anxiety: 0.01 (not significant)
    oceanblue likes this.
  14. oceanblue

    oceanblue Senior Member

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    Oh, so the effect is bigger without anxiety/depression! Thanks for the info.
  15. Dolphin

    Dolphin Senior Member

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    Sentences like the following:
    can give the impression that they did an analysis and those patients who had comorbid anxiety and depressive symptoms had a different overall response.

    Indeed, Knoop
    However, the Castell et al. paper in fact doesn't look at anxiety or depression as moderators. What the sentence is trying to say is if somebody has anxiety or depressive symptoms, there is a good chance those symptoms won't be changed (i.e. scores on scales won't change) by GET.
    ---
    ETA: I've looked at it again, why GET's CI's overlap with 0 (no effect) while CBT's doesn't, there was no statistically significant difference between the two for CBT and GET - which shows of course that the raw numbers still have a value as this hides the numerical differences, etc.
    oceanblue likes this.
  16. Enid

    Enid Senior Member

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    Barking up the wrong tree - like scrabbling around for the real in dust whilst science passes them by.
  17. Camilla

    Camilla

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    Any analysis of the criteria used in the studies included in the review?
  18. Dolphin

    Dolphin Senior Member

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    Yes, effect sizes for studies with different criteria were:
    Australian (n=2): 0.16 (not significant)
    CDC (n=8) 0.36
    Oxford (n=4) 0.53

    There was not a statistically significant difference (although I'd say it's hard to achieve with such small numbers).

    They didn't look at GET as said there were not enough studies. For GET, 3/5 are Oxford, 2/5 are CDC.

    (CDC here means Fukuda rather than the (so-called) empiric criteria)
    Bob likes this.
  19. Dolphin

    Dolphin Senior Member

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    Misc. comments, for what they are worth

    That's it. No mention of other symptoms!!

    --------
    And yet we are expected to have the one treatment approach for this heterogeneous condition.

    --------

    So now, not alone are the treatments being called evidence-based, but the
    weird and wonder theories they present to patients are also!

    ---------

    This looks like stretching by the authors.

    Whether a research situation would be that different from an ordinary CBT or GET program where patients could also be anxious about the treatment, is far from clear.

    All the last sentence is saying is that anxiety might be difficult to treat. But the way it's written, one might think they were connecting it with the interventions.
    Of course, it could be that the interventions are anxiety-provoking perhaps because of fear of relapsing (which cancels out other anxiety-lessening elements of having time with a therapist, etc) - indeed, perhaps the therapy might have induced a relapse or flare-up at some stage during the period of therapy. Another therapy, like pacing, might be less anxiety provoking.

    ------

    There's a bit above this that might make this extract clearer, but I should probably not quote too much.

    I find this argument strange, if I understand it correctly. What they seem to be saying is that there was less variety between the different outcome measures in FINE and that this is important and ties it in with Powell et al and Moss-Morris et al studies which had the biggest effect sizes overall. Out of the 21 studies, FINE came 12th (where 1st is best).
  20. Snow Leopard

    Snow Leopard Senior Member

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    I don't understand that FINE study comment, are they saying the weak results (breadth of confidence interval LOL) are due to the "physical" explanation provided by the nurses? That comment confuses me..

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