Tired all the time: can new research on fatigue help clinicians? (Harvey&Wessely, 09)

Dolphin

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(Not a recommendation)

Br J Gen Pract. 2009 Apr;59(561):237-9.

Tired all the time: can new research on fatigue help clinicians?
Harvey SB, Wessely S.

Comment on:

Br J Gen Pract. 2009 Apr;59(561):e93-100.

I thought some people might be interested to see what Simon Wessely was advising GPs. The article has just become publicly available I think.

html:
http://rcgp.publisher.ingentaconnec...00000059/00000561/art00008&mimetype=text/html

pdf: http://rcgp.publisher.ingentaconnec...59/00000561/art00008&mimetype=application/pdf
 

Mithriel

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So Wessely has taken us from ME a serious neurological disease caused by a virus through Chronic Fatigue Syndrome to chronic fatigue to tired all the time.....

That in itself explains why his methods don't help us.

Mithriel
 

MEKoan

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What I find fascinating about this article is that it is all about addressing the "anxiety" of the treating physician.

Over 10% of patients attending primary care clinics describe at least one month of substantial fatigue.1 Despite its prevalence, many clinicians feel uncertain or dissatisfied with the level of care they are able to provide patients with persistent fatigue.2 These anxieties are not without basis; up to two-thirds of patients with chronic fatigue report being dissatisfied with the quality of care they receive.3 GPs will tend to stereotype patients with chronic fatigue as having certain undesirable traits and will feel a sense of hopelessness regarding treatment options.4 However, there is now an emerging body of research evidence which should provide GPs with a greater sense of certainty regarding their management decisions. Incorporating this evidence base into clinical practice should allow clinicians to feel less helpless, and will hopefully result in improved outcomes for patients suffering from the debilitating effects of fatigue.

One of the main anxieties when managing a complaint of fatigue is how to begin and when to end...
It's all about MD, MD, MD.
 

oerganix

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Yeah, capture the physicians by making THEM less anxious and you might be able to get away with blaming patients for everything: their own illness, the physician's response to them and lack of a good outcome for anyone.

Koan said:
"What I find fascinating about this article is that it is all about addressing the "anxiety" of the treating physician.



'Over 10% of patients attending primary care clinics describe at least one month of substantial fatigue.1 Despite its prevalence, many clinicians feel uncertain or dissatisfied with the level of care they are able to provide patients with persistent fatigue.2 These anxieties are not without basis; up to two-thirds of patients with chronic fatigue report being dissatisfied with the quality of care they receive.3 GPs will tend to stereotype patients with chronic fatigue as having certain undesirable traits and will feel a sense of hopelessness regarding treatment options.4 However, there is now an emerging body of research evidence which should provide GPs with a greater sense of certainty regarding their management decisions. Incorporating this evidence base into clinical practice should allow clinicians to feel less helpless, and will hopefully result in improved outcomes for patients suffering from the debilitating effects of fatigue.

One of the main anxieties when managing a complaint of fatigue is how to begin and when to end... '



"It's all about MD, MD, MD. "
 

MEKoan

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Yeah, capture the physicians by making THEM less anxious and you might be able to get away with blaming patients for everything: their own illness, the physician's response to them and lack of a good outcome for anyone.
What you said.
 

Dolphin

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One related online comment

Good observations so far.

As I pointed out in another thread, one patient posted a comment on a related paper:

Date: 3 April 2009
Topic: Response to: Ordering blood tests for patients with unexplained fatigue in general practice: what does it yield? Results of the VAMPIRE trial

Comments by: Jacqui Footman BA(Hons) PGCE, Information Officer, South Molton ME Support Group, North Devon


I am concerned that this article by Koch et al1 may discourage GPs from thorough testing for patients with CFS/ME. At the ME Research UK conference in 2008 Dr Gavin Spickett, consultant leading one of the NHS specialist CFS/ME services, stated that significant numbers of patients referred to the service in fact turned out to have other (more treatable) conditions.



I have a particular and personal interest in this topic in so far as I languished under a diagnosis of CFS/ME for 4 years without further medical testing. I did receive what could be considered the best NHS care currently available for CFS/ME but nevertheless in my prime at age 43 waved goodbye to a promising teaching/management career. I was subsequently found (sort of by accident) to have Crohn's disease, which had clearly gone undiagnosed for many years.



When lupus tests had come back negative, raised plasma viscosity tests had been ignored as unexplainable and few further tests done for several years. Now, some months on from an ileal resection (but after 5 years on Incapacity Benefit) I am eventually less disabled by fatigue. With testing, I recently discovered I also have osteoporosis and low Vitamin D. Many patients with chronic pain are being found to have low vitamin D, and what a simple thing to resolve once the test is done! How much better would my bone density now be if I had been tested and treated 5 years sooner?



I write to urge GPs to take testing and investigation more seriously and to avoid jumping to conclusions of somatoform illness, particularly when fatigue extends to CFS/ME, in order to help prevent further tragic and possibly avoidable losses. Most patient support groups recommend Health Canada's Clinical Guideline for help with this.2



References
1. Koch H, van Bokhoven M, ter Riet G, van Alphen-Jager JMT, van der Weijden T, Dinant G-J, Bindels P. Ordering blood tests for patients with unexplained fatigue in general practice: what does it yield? Results of the VAMPIRE trial. Br J Gen Pract 2009; 59(561):e93-e100. View abstract online.


2. Carruthers et al. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working Case Definition, Diagnostic and Treatment Protocols. J Chronic Fatigue Syndrome 2003; 11(1). Overview available at http://www.mefmaction.net/Patients/Overviews/tabid/122/Default.aspx
Others could also post comments on the Harvey & Wessely paper at http://www.rcgp.org.uk/publications/bjgp/discussion_forum.aspx although given the paper is a little old, it might reduce the chances they'll put it up a little although one year probably isn't that old and the issue is relevant all the time.

Best to use at least one reference (the original paper is one) to make it look more formal. Putting websites as references is another trick.
 

MEKoan

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Yes, but Tom, the doctors mustn't be anxious that someone could go undiagnosed for 5 years and end up with osteoporosis and a bowel resection that might have been avoided, now should they.

argh
 

Dolphin

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Yes, but Tom, the doctors mustn't be anxious that someone could go undiagnosed for 5 years and end up with osteoporosis and a bowel resection that might have been avoided, now should they.

argh
:Retro smile:

The whole argument about delaying testing (i.e. don't test the patient when they first come - you can wait 4 weeks and see how things goes) is very dodgy:
While their results certainly support the
advice of limiting the range of tests initially
ordered, the issues surrounding the 4-week
delay are less clear cut. Their results
demonstrate that a clinician’s initial
perception about the cause of fatigue is
often inaccurate and that most patients
(78%) will not re-present for blood tests in
4 weeks. This low rate of re-presentation
would be acceptable if patients were selfselecting
on the basis of need, with higher
rates of somatic disease in those who do
return. However, based on the small
numbers returning for tests in this study,
such a selection process does not seem to
occur, with similar levels of positive results
found in both the immediate and the
delayed blood test groups. Therefore, while
some uncertainty remains regarding the
timing of initial blood tests,
The study appears to clearly show that not doing testing the first time is not a good idea.

ukxmrv said:
Is this the same woman who also claimed that the EFT was keeping her "ME" under control though?
Yes.
http://www.eftdevon.co.uk/
 

Esther12

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No fair - they want to charge me $30 for this now.

I'm having trouble searching for it on the forum too as all the words are too short/common.

If anyone d/l a copy when it was free, could they put it up in the library?

I'm interested to know what reference 4 is too.

Ta.
 
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The authors say:

The success of interventions like CBT suggests that behavioural patterns, such as a ‘boom and bust’ cycle of activity, may be particularly important in maintaining fatigue symptoms.
while quoting a couple of CBT references from the '90s.

Yet the most comprehensive study of CBT to date, a Cochrane Review that includes unpublished trials (to help overcome publication bias), concludes that CBT is only modestly helpful (40% improvement at the end of treatment vs 26% for controls; probably even less effective at follow-up 1 year later). Some of the studies within the Cochrane Review are themselves dodgy, but even taking the review results at face value shows that CBT isn't very helpful. So, by Wessely and Harvey's logic, if CBT doesn't help much, behavioural patterns are probably not very important in maintaining fatigue patterns. Yes, the opposite of what the authors claim. Maybe someone should let the GPs know?
 

Sean

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3 GPs will tend to stereotype patients with chronic fatigue as having certain undesirable traits
Gee, I can't imagine why they would do that, Prof Wessely.