'Recovery' from chronic fatigue syndrome after treatments given in the PACE trial

[user9876]

CFS/ME: More heat, some light - directions for research and clinical practice: http://jnnp.bmj.com/content/early/2013/02/12/jnnp-2012-304824.short?rss=1

The above editorial was written by Richard Morris and published 13 February 2013 in the journal JNNP and relates to the breakdown in CPPG in Scotland - the argument being that such disputes are unhelpful when considering treatment a la PACE. Here's the full text: http://jnnp.bmj.com/content/early/2013/02/12/jnnp-2012-304824.extract.jpg

It sucks but might help in trying to understand their point about objective measures for exercise not being seen as relevant/useful should anyone be considering a contra argument.

One of the things that Morris claims is that GET has been delivered safely and reliably within the context of a RCT but patient reports suggest the dangers of delivery by untrained people.

However it should be noted that 15% (24 out of 160) people treated in the GET group received in adaquate treatment. Where as Morris concludes that GET should only be delivered by trained and supervised staff I think we could argue that given a very careful management of PACE was challenged to properly control delivery then even this would be a challenge. Another significant issue is we don't know how much people in the PACE trial increased their activities - it may be (judging from the 6mwt) that very little activity increase was encouraged so as to get a good safety record!

Even if we were to believe the PACE trial scaling out such a service would be very hard.

 

[Valentijn]

Tahnks Bio. I' not up to coherent narrative this morrow! It did strike me however that they simply take no account of ME being an illness that continues. What I mean is that they seem to figure it begins and it ends. That 'recovery' to 'normal' is not only possible but proved by PACE. Bloody daft if you ask me.......................................

I think they're doing a very good job of outing themselves as people who read media summaries, or abstracts at best. They can't be bothered with reading the details of something before drawing conclusions about it and assuring everyone else that they know what they're talking about. It's also quite possible that as "authorities" themselves they have an increased likelihood of relying on other authority as a persuasive tactic.

 

[Sam Carter]

CFS/ME: More heat, some light - directions for research and clinical practice: http://jnnp.bmj.com/content/early/2013/02/12/jnnp-2012-304824.short?rss=1

The above editorial was written by Richard Morris and published 13 February 2013 in the journal JNNP and relates to the breakdown in CPPG in Scotland - the argument being that such disputes are unhelpful when considering treatment a la PACE. Here's the full text: http://jnnp.bmj.com/content/early/2013/02/12/jnnp-2012-304824.extract.jpg

It sucks but might help in trying to understand their point about objective measures for exercise not being seen as relevant/useful should anyone be considering a contra argument.

And this is the same Richard Morris who worked on PACE's 'sister' trial, FINE? He seems to have forgotten all about that.

 

[biophile]

One of the things that Morris claims is that GET has been delivered safely and reliably within the context of a RCT but patient reports suggest the dangers of delivery by untrained people.

However it should be noted that 15% (24 out of 160) people treated in the GET group received in adaquate treatment. Where as Morris concludes that GET should only be delivered by trained and supervised staff I think we could argue that given a very careful management of PACE was challenged to properly control delivery then even this would be a challenge. Another significant issue is we don't know how much people in the PACE trial increased their activities - it may be (judging from the 6mwt) that very little activity increase was encouraged so as to get a good safety record!

Even if we were to believe the PACE trial scaling out such a service would be very hard.

PACE may have also been more careful than some random clinic to exclude those unsuited for GET. I'll guess that poorly applied GET is part of the problem in the wild, but I also think another problem lies with how harm is being defined. Patients' ideas of harm may be different than what has been defined for research.

GET participants did not have to increase activity if they did not want to or could not tolerate it, there is no evidence to show they are increasing total activity levels, and as you said, the available data suggests they are not doing so to any major degree, so it would be questionable to imply that increasing total activity levels is therefore safe.

Fifty-one percent of survey respondents (range 28-82%, n=4338, 8 surveys) reported that GET worsened their health while 20% of respondents (range 7-38%, n=1808, 5 surveys) reported similar results for CBT.

Before PACE was published there was almost no published data from previous RCTs on adverse effects (the safety profile was based on dropout rates and group averages in scores).

There has been a FOI request for the data on deterioration rates using the opposite threshold for improvement. I'm not sure if this will reveal much, as this is compared from baseline to 52 weeks (adverse events are more time constrained), and patients had 6 months after therapy to recover.

Without going into all the definitions of the various adverse events, these were recorded by the research assistant at 12 weeks, 24 weeks, and 52 weeks. I'm not sure if patients were required to remember them or write them down before hand, but the form used specified a date start and a date end.

The rates of "non-serious adverse events" were similar for GET vs SMC, but there were different degrees of severity for this outcome, mild/moderate/severe, which have all been lumped together when PACE reported on safety in 2011. It was possible to have a "severe" non-serious adverse event which was relatively incapacitating for up to 4 weeks.

Next we have serious adverse events: "The increased rate of serious adverse events with GET compared with SMC is unlikely to be important because serious adverse events were not thought by the independent scrutinisers to be related to treatment." These were also rated as mild/moderate/severe.

Once a serious adverse event was identified, the "independent scrutiniser" was unblinded to allocation to help determine whether it was a reaction to treatment. Who knows what effect that had, there were more SAEs for GET but when the scrutinisers found out it was for GET suddenly the difference disappeared.

PACE used the CGI but collapsed the scores. The "very much worse" and "much worse" scores were merged for "negative change". However the "a little worse" score is merged with "no change" and "a little better".

Definitions for serious deterioration were fairly strict.

 

[Bob]

I'm very late coming to this thread. I've read through it, but might have missed or forgotten a lot of discussion.

The composite/cumulative "trial recovery" criteria is outlined in the top half of section 'b' of Table 1: "Cumulative criteria for trial recovery."
It uses the Oxford criteria (not the CDC or London criteria) and I think these are the results that are quoted in the abstract.

This composite trial recovery criteria consists of:
Both CFQ and SF-36-PF in normal range
And Oxford criteria not met
And CGI 1 or 2 (95% CI)


I want to comment on the SF-36 PF scores for the composite "trial recovery" criteria.

This is how I interpret it:

The 'normal range' individual recovery criteria requires an SF-36 PF score of 60, and above, for 'recovery'.

The 'Oxford criteria not met' individual recovery criteria requires an SF-36 PF score of 70 of more. (For a diagnosis of CFS using the Oxford criteria, in terms of assessing 'recovery' for this paper, participants had to have a score of 65 or less. And the SF-36 PF scores go up in increments of '5', so the next possible score above '65', for an individual, is a score of '70'.) But, importantly, a score of 70, and above, is only required for a 'recovery' (for 'Oxford criteria not met' individual recovery criteria) if all of the other criteria for the Oxford criteria are met. For example, if a patient fails to meet the 'Oxford criteria' for a reason other than the SF-36 PF scores, then the patient will be considered 'recovered', whatever their SF-36 PF scores. So, for example, if 'fatigue' is no longer the main symptom, then a participant will fail the 'Oxford criteria not met' recovery criteria (i.e. they will be considered 'recovered') whatever their SF-36 PF score.
As another example, if a patient has a SF-36 PF score of 50, but 'fatigue' is not their main symptom (i.e. 'post exertional malaise' or 'pain' is now the main symptom), then they will not be eligible for a diagnosis using the Oxford criteria, and will be considered 'recovered' for the 'Oxford criteria not met' individual criteria. Thus a patient could have a SF-36 PF score of 50, and still be considered 'recovered' for the individual 'Oxford criteria not met' recovery criteria.

But, to be considered as 'recovered' for the composite recovery criteria, all participants must pass the 'normal range' test, with a score of 60.

So, my interpretation is that a score of 60 and above is required for the composite trial recovery criteria.
(This will be the case except for specific scenarios with regards to the 'Oxford criteria not met' recovery criteria, for which, in some cases, participants will need a score of 70 or more.)
But generally speaking, patients considered 'recovered', using the main composite trial recovery criteria (as reported in the abstract) must all have a SF-36 PF score of 60 and above, but do not necessarily have to have a SF-36 PF score above 60. In other words, 'recovered' (composite trial recovery) patients only need a score of 60, and do not necessarily have to have a score of 70 or above.

As such, a 'recovery' could theoretically be a 'deterioration', in terms of physical function, after treatment with CBT or GET.


Any thoughts? Have I got this right, or have I missed something vital?


Edit: The paper says that a research assistant assessed patients for the Oxford criteria, and the authors acknowledge that this is a subjective process, making bias possible:

"The assessments of caseness (CDC, London and Oxford criteria) relied on a mixture of self-ratings and research assistant assessments, making some observer bias possible."

I've underlined the criteria that I think were assessed subjectively by a research assistant, to assess for 'recovery':

"Research assessors judged whether participants still met Oxford criteria for CFS at 52 weeks; specifically they determined if : (1)fatigue was the main symptom, (2) it was of definite onset
and not lifelong, (3) fatigue was severe, disabling and affected physical and mental function, and (4) fatigue had persisted for 6 months or more and was present 50% of the time (Sharpe et al. 1991)."

 

[Dolphin]

I'm very late coming to this thread. I've read through it, but might have missed or forgotten a lot of discussion.

The composite/cumulative "trial recovery" criteria is outlined in the top half of section 'b' of Table 1: "Cumulative criteria for trial recovery."
It uses the Oxford criteria (not the CDC or London criteria) and I think these are the results that are quoted in the abstract.

This composite trial recovery criteria consists of:
Both CFQ and SF-36-PF in normal range
And Oxford criteria not met
And CGI 1 or 2 (95% CI)


I want to comment on the SF-36 PF scores for the composite "trial recovery" criteria.

This is how I interpret it:

The 'normal range' individual recovery criteria requires an SF-36 PF score of 60, and above, for 'recovery'.

The 'Oxford criteria not met' individual recovery criteria requires an SF-36 PF score of 70 of more. (For a diagnosis of CFS using the Oxford criteria, in terms of assessing 'recovery' for this paper, participants had to have a score of 65 or less. And the SF-36 PF scores go up in increments of '5', so the next possible score above '65', for an individual, is a score of '70'.) But, importantly, a score of 70, and above, is only required for a 'recovery' (for 'Oxford criteria not met' individual recovery criteria) if all of the other criteria for the Oxford criteria are met. For example, if a patient fails to meet the 'Oxford criteria' for a reason other than the SF-36 PF scores, then the patient will be considered 'recovered', whatever their SF-36 PF scores. So, for example, if 'fatigue' is no longer the main symptom, then a participant will fail the 'Oxford criteria not met' recovery criteria (i.e. they will be considered 'recovered') whatever their SF-36 PF score.
As another example, if a patient has a SF-36 PF score of 50, but 'fatigue' is not their main symptom (i.e. 'post exertional malaise' or 'pain' is now the main symptom), then they will not be eligible for a diagnosis using the Oxford criteria, and will be considered 'recovered' for the 'Oxford criteria not met' individual criteria. Thus a patient could have a SF-36 PF score of 50, and still be considered 'recovered' for the individual 'Oxford criteria not met' recovery criteria.

But, to be considered as 'recovered' for the composite recovery criteria, all participants must pass the 'normal range' test, with a score of 60.

So, my interpretation is that a score of 60 and above is required for the composite trial recovery criteria.
(This will be the case except for specific scenarios with regards to the 'Oxford criteria not met' recovery criteria, for which, in some cases, participants will need a score of 70 or more.)
But generally speaking, patients considered 'recovered', using the main composite trial recovery criteria (as reported in the abstract) must all have a SF-36 PF score of 60 and above, but do not necessarily have to have a SF-36 PF score above 60. In other words, 'recovered' patients only need a score of 60, and do not have to have a score of 70 or above.

As such, a 'recovery' could theoretically be a 'deterioration', in terms of physical function, after treatment.

Is it me, or does this seems like a nice little con-trick?

Any thoughts? Have I got this right, or have I missed something vital?


Edit: The paper says that a research assistant assessed patients for the Oxford criteria, and the authors acknowledge that this is a subjective process, making bias possible:

"The assessments of caseness (CDC, London and Oxford criteria) relied on a mixture of self-ratings and research assistant assessments, making some observer bias possible."

I've underlined the criteria that I think were assessed subjectively by a research assistant, to assess for 'recovery':

"Research assessors judged whether participants still met Oxford criteria for CFS at 52 weeks; specifically they determined if : (1) fatigue was the main symptom, (2) it was of definite onset
and not lifelong, (3) fatigue was severe, disabling and affected physical and mental function, and (4) fatigue had persisted for 6 months or more and was present 50% of the time (Sharpe et al. 1991)."

Yes, I think that's a good summary.
Small point: You switched between "research assistant" and "research assessor" - I don't think the former is appropriate language as I am presuming they are a doctor (the SMC doctor)? (but I haven't checked to answer this)
ETA: biophile checked the striked through bit - two posts down

I think many people could read it that everything has to be outside the baseline criteria (or at least both the CFQ and SF-36 PF have to be). I think the record of the thread showed I was confused at one stage (I think I crossed that out) and I've seen various people show signs of confusion here and elsewhere. And these are people who are familiar with the other PACE Trial papers and the protocol, while many people will just read this paper on its own and probably a bigger number will just read the abstract.

 

[biophile]

Bob.

I'm not convinced the CFQ and SF-36/PF entry requirements mentioned along side the Oxford criteria are actually part of the criteria for recovery, and even if they were, as you said they did not both have to be satisfied, many reasons could lead to no longer meeting Oxford criteria despite ongoing illness, not just from the participants (eg, fatigue not main symptom, etc) but also from those assessing CFS caseness (eg, post-trial optimism), knocking them out of diagnosis. I agree with the argument that a proportion of those diagnosed with Oxford criteria at the start of the trial may have already been close to no longer meeting Oxford criteria and being within normal range for fatigue and physical function.

As you say, someone could theoretically have "Oxford criteria not met" and a SF-36/PF score of 50. However, this alone was not classified as a recovery, the normal range in both fatigue and physical function was the first base criteria in the composite definition for recovery. To be classified as recovered, the participant first had to meet this normal range first, which would exclude those with SF-36/PF scores of <60. If scoring 65 at entry, 60 would still be a slight deterioration.

No longer meeting Oxford criteria does not seem to be that robust when comparing to the other outcomes:

No longer meeting Oxford criteria was 41% for SMC and 54% for CBT (100% at baseline for both).
Normal CFQ and SF-36/PF was 15% for SMC and 30% for CBT.
Normal CFQ and SF-36/PF, and, no longer meeting Oxford criteria, was 14% for SMC and 28% for CBT.

End-point thresholds overlap with the entry criteria for disabling fatigue, but almost all participants within normal range for both measures at the end of the trial did not meet Oxford criteria, yet a large proportion of participants no longer meeting Oxford criteria, roughly half but better for CBT, still had abnormal levels of fatigue and/or physical function.

Bolting on the CGI criterion to the above tightened it up, but again, not itself a recovery and not necessarily much better compared to if they had been in the SMC group ("much better" was compared to their own baseline, not compared to SMC). It reduced the figures down to 7% for SMC and 22% for CBT, which shows some subjects declared normal and without CFS did not in fact get "much better" but "a little better" at best, as the next choice down the list on the CGI is "a little better". Perhaps those participants who would have scored "a little better" if in the SMC group were helped slightly by CBT and were more likely to report feeling "much better"?

As others have pointed out, there should have been additional criteria to compare with. Dr Charles Shepherd recently noted that sickness benefits are incompatible with recovery, and pointed out that the rate of receipt even increased slightly in the CBT and GET groups (without significant difference between any group in the trial), despite all this "recovery" going on.

 

[biophile]

Small point: [Bob] switched between "research assistant" and "research assessor" - I don't think the former is appropriate language as I am presuming they are a doctor (the SMC doctor)? (but I haven't checked to answer this)

I just had a look. On page 53 of the complete protocol, it was the research nurse/assistant that did the Oxford criteria assessments. It also looks like the 6MWT was done at 24 weeks too.

 

[Dolphin]

(This point may been referred to before - apologies if it has) If people are doing letters, one possible useful angle would be to quote any long-term follow-up studies where benefit deteriorated in the long-term.

 

[Firestormm]

Interesting:
Reporting on Evidence Requires More Than Spin

 

[Dolphin]

ME Association response to PACE trial recovery paper | 15 February 2013
by Dr. Charles Shepherd:
http://www.meassociation.org.uk/?p=14460

Useful letter, has a chance of being published I would have thought.

Note: I wouldn't recommend making your letter public until the letters are published in the journal (or you are told it is not going in) but perhaps the ME Association can get away with it.

Charles Shepherd has posted this on the MEA FB page today:

I have just received a reply from the editor of Psychological Medicine to say that they cannot publish our response as it has already been published on the MEA website. We have been invited to submit a revised response - avoiding polemical statements - which we will do next week.

 

[alex3619]

Interesting:
Reporting on Evidence Requires More Than Spin

See: http://forums.phoenixrising.me/index.php?threads/science-media-centre-uk-spin.22006/

 

[Dolphin]

(from Discussion)
Two studies of recovery in adults after CBT found similar proportions in recovery: 23% and 24% (Deale et al. 2001; Knoop et al. 2007), compared with 22% in the PACE trial.

It most likely has been pointed out that Knoop used a different definition of recovery (incl. SF36 PF score >=80).

I'm not sure it has been pointed out that the post-treatment mean in the Knoop et al. study was 76.3 (23.0), which is a lot different from the CBT: 58.2 (24.1) and GET: 57.7 (26.5) results in the PACE Trial.

 

[Dolphin]

(Apologies if this point has been made before)
In

A randomized controlled trial of cognitive behavior therapy for multiple sclerosis fatigue.
Psychosom Med. 2008 Feb;70(2):205-13. doi: 10.1097/PSY.0b013e3181643065. Epub 2008 Feb 6.
van Kessel K, Moss-Morris R, Willoughby E, Chalder T, Johnson MH, Robinson E.
Free at: http://www.psychosomaticmedicine.org/content/70/2/205.full.pdf

(which involved one of the PIs), they used this approach:

To define clinically significant improvement in fatigue, a normative approach was used (27), which assessed whether patients’ fatigue levels after treatment were equivalent to fatigue levels in healthy people. In order to do this, we collected Fatigue Scale data from a matched healthy comparison group recruited during baseline assessments. The 72 MS participants were matched to 72 healthy participants by age, gender, and ethnicity. Healthy participants were screened via interview to exclude the presence of an existing chronic mental or physical illness.

Ref 27 is:

Normative comparisons for the evaluation of clinical significance.
Kendall, Philip C.; Marrs-Garcia, Abbe; Nath, Sanjay R.; Sheldrick, Radley C.
Journal of Consulting and Clinical Psychology, Vol 67(3), Jun 1999, 285-299. doi: 10.1037/0022-006X.67.3.285

Has anyone read it? I think it could contain useful arguments against some of what they did, but I don't want to pay for it if it is of no use. Thanks.

 

[Dolphin]

If anyone had the time, it'd be interesting to find studies out there on other groups who were said to have fatigue but we know that some of these fatigued group had Chalder fatigue questionnaire (CFQ) Likert scores of 18 or less.

I'm thinking of other illnesses, where CFQ would be lower than in ME/CFS

This one is a possibility but not perfect:

A randomized controlled trial of cognitive behavior therapy for multiple sclerosis fatigue. Psychosom Med. 2008 Feb;70(2):205-13. doi: 10.1097/PSY.0b013e3181643065. Epub 2008 Feb 6. van Kessel K, Moss-Morris R, Willoughby E, Chalder T, Johnson MH, Robinson E. Free at: http://www.psychosomaticmedicine.org/content/70/2/205.full.pdf

At baseline, in two groups with MS fatigue:

CBT group: Mean: 20.94 (SD: 4.25)
Relaxation: Mean: 20.32 (SD: 4.28)

Scores where Interquartile ranges were given would be better as that would likely confirm for many studies that 25%+ had scores of <=18. Some might even have means of <=18 which means there are definitely one or more patients with scores of <=18*.

*given the max score is 33, one can probably say with certainty there were more under 18, depending on the sample size of an individual study

 

[Dolphin]

A wiki was mentioned earlier. I suggested people should concentrate on letters for the moment. But I know some people are not going to send in a letter so if you're not going to do a letter, or you've already sent one in, if you could do up a wiki it would be great. It's hard to keep track of the points that were made - it could be a useful resource for anyone considering doing a letter.

 

[Dolphin]

Has this finding been mentioned in the thread? Probably worth repeating even if it has been:

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60688-0/fulltext

The Lancet, Volume 377, Issue 9780, Pages 1831 - 1832, 28 May 2011 <Previous Article|Next Article>
doi:10.1016/S0140-6736(11)60688-0Cite or Link Using DOI
Published Online: 17 May 2011
The PACE trial in chronic fatigue syndrome

Sarah M Feehan a, on behalf of the Liverpool ME Support Group

Peter White and colleagues1 say that normal fatigue is represented by a figure of 18 or less on the Chalder fatigue questionnaire (Likert scoring), rather than the validated definition of fatigue caseness (4 or more, bimodal scoring) used in the trial's protocol.2, 3 A score of 18 represented the mean plus 1 SD (14·2 + 4·6) for a control group who had attended their general practitioner in the previous 12 months.4 This figure almost certainly would have been lower if those who had not attended their general practitioner had also been included when deriving population data. Indeed, normative data from a Norwegian study gave a mean of 12·2 (SD 4·0).5 Interestingly, the Norwegian data were stratified by health condition (unfortunately, only means were published): “No disease/current health problem”: 11·2; “Past or current disease”: 12·1; “Current health problem”: 12·5, and “Disease and current health problem”: 14·2.

Furthermore, 17·6% of chronic fatigue syndrome patients diagnosed at the Chronic Fatigue Unit (South London and Maudsley NHS Trust) had a score of 18 or less before they were treated.4 This suggests either that the Chronic Fatigue Unit diagnoses and treats fatigue problems in patients with normal levels of fatigue or, alternatively, that the threshold of 18 to represent normal fatigue is not suitable.

Given this information, and the fact that those with a Chalder fatigue questionnaire Likert score of 18 could still meet the trial's entry criteria (bimodal score of 6 or more),1, 3 it would be good if White and colleagues would now recalculate the data using the original definition of “fatigue caseness”.2, 3

I declare that I have no conflicts of interest.

References

1 White PD, Goldsmith KA, Johnson AL, et alon behalf of the PACE trial management group. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet 2011; 377: 823-836. Summary | Full Text | PDF(309KB) | CrossRef | PubMed
2 Chalder T, Berelowitz G, Pawlikowska T, et al. Development of a fatigue scale. J Psychosom Res 1993; 37: 147-153. CrossRef | PubMed
3 White PD, Sharpe MC, Chalder T, DeCesare JC, Walwyn Ron behalf of the PACE trial group. Protocol for the PACE trial: a randomised controlled trial of adaptive pacing, cognitive behaviour therapy, and graded exercise, as supplements to standardised specialist medical care versus standardised specialist medical care alone for patients with the chronic fatigue syndrome/myalgic encephalomyelitis or encephalopathy. BMC Neurol 2007; 7: 6. CrossRef | PubMed
4 Cella M, Chalder T. Measuring fatigue in clinical and community settings. J Psychosom Res 2010; 69: 17-22. CrossRef | PubMed
5 Loge JH, Ekeberg O, Kaasa S. Fatigue in the general Norwegian population: normative data and associations. J Psychosom Res 1998; 45: 53-65. CrossRef | PubMed
a Liverpool ME Support Group, Bootle, Liverpool L20 9LD, UK

 

[Dolphin]

From Knoop et al. (2007) full recovery paper

Improvement and not meeting research criteria for an illness are different from recovering [18, 19]

18 Pasquali R: The biological balance between psychological well-being and distress: a clinician’s point of view. Psychother Psychosom 2006; 75: 69–71.

19 Ryff CD, Dienberg Love G, Urry HL, Muller D, Rosenkranz MA, Friedman EM, Davidson RJ, Singer B: Psychological well-being and ill-being: do they have distinct or mirrored biological correlates? Psychother Psychosom
2006; 75: 85–95.

I was intrigued by what these might say so read them.
However, I don't believe they are of much use.

Here's the abstract for the second one - it sums up what it is about

Psychological well-being and ill-being: do they have distinct or mirrored biological correlates?

Psychother Psychosom. 2006;75(2):85-95.

Ryff CD, Dienberg Love G, Urry HL, Muller D, Rosenkranz MA, Friedman EM, Davidson RJ, Singer B.

Source
Institute on Aging, Medical Science Center, University of Wisconsin-Madison, Madison, Wisconsin 53706, USA. cryff@facstaff.wisc.edu

Abstract

BACKGROUND:
Increasingly, researchers attend to both positive and negative aspects of mental health. Such distinctions call for clarification of whether psychological well-being and ill-being comprise opposite ends of a bipolar continuum, or are best construed as separate, independent dimensions of mental health. Biology can help resolve this query--bipolarity predicts 'mirrored' biological correlates (i.e. well-being and ill-being correlate similarly with biomarkers, but show opposite directional signs), whereas independence predicts 'distinct' biological correlates (i.e. well-being and ill-being have different biological signatures).

METHODS:
Multiple aspects of psychological well-being (eudaimonic, hedonic) and ill-being (depression, anxiety, anger) were assessed in a sample of aging women (n = 135, mean age = 74) on whom diverse neuroendocrine (salivary cortisol, epinephrine, norepinephrine, DHEA-S) and cardiovascular factors (weight, waist-hip ratio, systolic and diastolic blood pressure, HDL cholesterol, total/HDL cholesterol, glycosylated hemoglobin) were also measured.

RESULTS:
Measures of psychological well-being and ill-being were significantly linked with numerous biomarkers, with some associations being more strongly evident for respondents aged 75+. Outcomes for seven biomarkers supported the distinct hypothesis, while findings for only two biomarkers supported the mirrored hypothesis.

CONCLUSION:
This research adds to the growing literature on how psychological well-being and mental maladjustment are instantiated in biology. Population-based inquiries and challenge studies constitute important future directions.

Copyright 2006 S. Karger AG, Basel

The other article is just an editorial that talks about this paper. Neither really are about recovery - they're just about how "positive well being" (my wording) is not necessarily the opposite of "mental health problems" (my wording).

I noticed before with this journal that odd references of articles from the journal would appear in papers. And a high percentage of publications had articles from the journal. My guess is what happens is the editor or others from the editorial team review articles and suggest certain references be mentioned; researchers just want to get their papers published so go along with them.

 

[user9876]

I noticed before with this journal that odd references of articles from the journal would appear in papers. And a high percentage of publications had articles from the journal. My guess is what happens is the editor or others from the editorial team review articles and suggest certain references be mentioned; researchers just want to get their papers published so go along with them.

I've come across economists who as reviewers insist that their papers are cited even when they are not strictly relevant so it could happen in this journal.

 

[Dolphin]

Reminder for anybody who wants to know about the Chalder Fatigue Sclae and its scoring:

The 11 questions are on page 162
http://evaluatingpace.phoenixrising.me/PACE_Protocol.pdf

With likert scoring, the different answers reading from the left are
0, 1, 2, 3 for each question (i.e. range of 0-33).
With bimodal scoring, the different answers reading from the left are
0, 0, 1, 1 for each question (i.e. range of 0-11).