The evidence is not there to recommend CBT and GET to improve employment outcomes in CFS
For over a decade now, some individual patients with Chronic Fatigue Syndrome (CFS)* in Great Britain and Ireland (and probably elsewhere) have been pressurised by insurance companies and occupational health professionals into undertaking graded exercise therapy (GET) and the form of cognitive behaviour therapy (CBT) that is based on scheduling increases in activity. This seems to have been largely due to hype around the efficacy of GET and CBT and extrapolations from subjective measures, as the evidence that such interventions are efficacious in restoring the ability to work is week.
Based on the information in Tables 1, 3 and the qualitative results from this paper, CBT and GET have again been recommended to occupational professionals in these workshops.
A lot of the evidence regarding CBT and GET and their effect on occupational outcomes in CFS has been summarised in a review (1). For some reason this is quoted sometimes as justifying claims it is evidence-based to say that GET and CBT have been shown to restore the ability to work in CFS. However the data is far less impressive. It is summarised in table 6 of that paper. The accompanying text says: "Among the 14 interventional trials with work or impairment results after intervention, there were too few of any single intervention with any specific impairment domain to allow any assessment of association."
The PACE Trial is by far the biggest trial of these therapies in the field. It shows neither CBT nor GET led to an improved rate of days of lost employment [Means (sds): APT: 148.6 (109.2); CBT: 151.0 (108.2); GET: 144.5 (109.4); SMC (alone): 141.7 (107.5)] (Table 2) (2). Neither CBT nor GET led to improvements in numbers receiving welfare benefits or other financial payments (Table 4). These results are in contrast to the self-reported improvements in fatigue, physical functioning and some other measures (3).
A major audit of Belgian CFS rehabilitation (CBT & GET) centres also gives real-world data on the issue (4). The sample size was large, with over 600 patients with a confirmed diagnosis of CFS (using the Fukuda et al. criteria
(5)) taking part. It "comprised on average per patient 41 to 62 hours of rehabilitation" It found that "physical capacity did not change; employment status decreased at the end of the therapy." Again improvements were found in some self-reported measures.
It should be noted that a large assortment of abnormalities have been found in terms of the exercise response in CFS, with high rates of adverse reactions have been reported in patient surveys from CBT and GET, particularly with the latter, again putting in to question any recommendations of CBT and GET for CFS (6,7).
All in all, I question suggestions that occupational health professionals should be recommending CBT and GET to individuals with CFS.
* I'll use the term for consistency.
References:
(1) Ross SD, Estok RP, Frame D, Stone LR, Ludensky V, Levine CB. Disability and chronic fatigue syndrome: a focus on function. Arch Intern Med. 2004 May 24;164(10):1098-107.
http://archinte.ama-assn.org/cgi/content/full/164/10/1098 or
http://archinte.ama-assn.org/cgi/reprint/164/10/1098
(2) McCrone P, Sharpe M, Chalder T, Knapp M, Johnson AL, et al. (2012) Adaptive Pacing, Cognitive Behaviour Therapy, Graded Exercise, and Specialist Medical Care for Chronic Fatigue Syndrome: A Cost-Effectiveness Analysis. PLoS ONE 7(8): e40808. doi:10.1371/journal.pone.0040808
(3) White PD, Goldsmith KA, Johnson AL, Potts L, Walwyn R, et al. (2011) Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome
(PACE): a randomised trial. Lancet 377: 823-836.
(4) [Fatigue Syndrome: diagnosis, treatment and organisation of care] KCE Reports 88. (with summary in English). Accessed: 6th August, 2012.
https://kce.fgov.be/publication/report/fatigue-syndrome-diagnosis-treatment-and-organisation-of-care
(5) Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A. The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group. Ann Intern Med. 1994 Dec 15;121(12):953-9.
(6) Twisk FN, Maes M. A review on cognitive behavorial therapy (CBT) and graded exercise therapy (GET) in myalgic encephalomyelitis (ME) / chronic fatigue syndrome (CFS): CBT/GET is not only ineffective and not evidence-based, but also potentially harmful for many patients with ME/CFS. Neuro Endocrinol Lett. 2009;30(3):284-99. Review.
(7) Kindlon T. Reporting of Harms Associated with Graded Exercise Therapy and Cognitive Behavioural Therapy in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Bulletin of the IACFS/ME. 2011;19(2):59-111.
http://www.iacfsme.org/BULLETINFALL2011/Fall2011KindlonHarmsPaperABSTRACT/tabid/501/Default.aspx
