Review Applicability and adaptation of cognitive behavior therapy for long COVID neuropsychiatric symptoms: a review with insights from ME/CFS 2025 Takamatsu

[Andy]

Abstract​

Background
Long COVID presents a spectrum of persistent symptoms that substantially overlap with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), including debilitating fatigue, post-exertional malaise, cognitive dysfunction, and neuropsychiatric manifestations. Despite growing evidence of shared pathophysiological mechanisms, neither condition has established diagnostic biomarkers or disease-modifying treatments. Cognitive behavior therapy (CBT), when appropriately implemented, may serve as one component of comprehensive care. This review examines the neuropsychiatric manifestations, management principles, and implementation considerations for CBT in long COVID, drawing insights from ME/CFS experience.

Main body
Our analyses revealed substantial overlap between patients with long COVID and ME/CFS including immune dysregulation, neuroinflammation, and metabolic dysfunction while identifying distinct features in disease trajectories. Evidence suggests ME/CFS may represent a severe phenotype in a subset of patients with long COVID. Management principles applicable to both conditions include patient validation, comprehensive needs assessment, individualized energy management, symptom-specific interventions, and comorbidity management. Current clinical trials demonstrate methodological evolution in CBT implementation, from traditional protocols to digital platforms. Moderate-certainty evidence indicates CBT may reduce fatigue and improve cognitive function in long COVID. However, substantial heterogeneity exists in both intervention characteristics and condition definitions. Implementation success requires provider competency, terminological precision, and individualized approaches that respect energy limitations. Careful monitoring for post-exertional symptom exacerbation is essential. We emphasize that these approaches do not imply these conditions are primarily psychological.

Conclusion
Our review synthesizes current evidence on CBT in long COVID management, considering lessons from ME/CFS. Substantial challenges remain in standardizing terminology, strengthening trial methodology, and determining optimal implementation strategies. Future research should incorporate objective outcome measures alongside subjective reports, while clinical practice should consider how cognitive-behavioral approaches might contribute to comprehensive care plans tailored to individual patient needs. This approach recognizes that addressing both physical and psychological dimensions of these conditions may enhance treatment outcomes, while acknowledging the individualized nature of patient responses to different therapeutic elements.

Open access

 

[rvallee]

This is mostly a buzzword-filled marketing speech, not an academic study. The kind where there is a massive oversupply of something for which there is barely any natural demand, unable to accept this simple fact, and instead of back-pedalling tries to keep propping up artificial demand to preserve the supply's stakeholders.

But because evidence-based medicine mostly works like modern propaganda, pushing out multiple competing versions of reality with hardly any concern about whether any of it holds up, they do recognize some of the salient facts, yet somehow completely fail to take them into consideration, conclusions unchanged:

Beyond the general methodological challenges affecting this field, specific key trials warrant targeted examination. The ReCOVer trial [11], while demonstrating statistically significant reductions in self-reported fatigue, presents specific methodological considerations that influence interpretation of its findings. Most notably, the trial’s reliance on subjective self-report measures without corresponding objective outcomes creates vulnerability to response bias in a non-blinded intervention context. The absence of objective measures that were specified in the original protocol (such as actometer results) leaves important questions about physical function improvements unaddressed [12].

The trial’s design also lacked active control conditions with equivalent expectation-setting and therapeutic contact time, creating difficulty in distinguishing specific intervention effects from non-specific factors such as increased attention and support. These design elements parallel methodological concerns previously raised regarding the PACE trial for ME/CFS [65], where post-hoc outcome definition changes, lowered thresholds for recovery, and discrepancies between subjective improvements and objective measures generated substantial controversy in the field [66, 67].

It is worth noting that current clinical guidelines have shifted away from recommending graded exercise therapy for patients with post-exertional malaise, a core symptom in many ME/CFS and long COVID patients. While a recent Cochrane review [68] maintained earlier conclusions supporting exercise therapy for chronic fatigue syndrome, it is important to recognize that despite its 2024 publication date, its evidence base remains unchanged from earlier versions, with literature searches ending in 2014. Five of the eight included studies employed the Oxford criteria, which do not require post-exertional malaise as a diagnostic criterion, potentially introducing significant patient population heterogeneity. This historical context underscores the importance of rigorous methodology, appropriate patient selection, and careful monitoring of adverse events in current and future research.

It is important to acknowledge that psychotherapy research broadly, including CBT trials for long COVID, faces inherent methodological challenges. Most notably, the inability to fully blind participants to their treatment condition creates unavoidable awareness of intervention receipt, potentially influencing expectation effects and subjective outcome reporting. This limitation underscores the importance of incorporating objective outcome measures and carefully designed active control conditions that can help distinguish specific therapeutic effects from non-specific factors related to therapeutic attention and expectation.

I cannot interpret this any other way than "but if you believe that CBT works, then CBT must work":

These findings can be interpreted within a more nuanced framework of CBT mechanisms in long COVID

The data they present simply have nothing to do with their conclusions. It's obvious. But the conclusions matter more, they have prior buy-in and a massive over-supply.

This is a mess. A giant mess, with millions of people stuck not between a rock and a hard place, but simply crushed under a giant immovable rock, for no other reason than the rock was placed there long before anyone presently alive was even born, and so it must remain there, crushing millions, for this is what this rock must do.

Historical experiences from ME/CFS highlight the imperative to rigorously uphold the “do no harm” principle, with careful attention to adverse events, particularly post-exertional symptom exacerbation.

The massive harm that has already been done demands a much more serious imperative. Harm was done, on an industrial scale. All poorly but more than sufficiently documented. The question, always, with such ideas as having 'principles' like this one is the only thing that ever matters: and then what? Massive harm was done. Then what happens? Nothing at all? Pretending that it didn't actually happen?

Then it's not a principle. And the rules that are supposed to protect us not being applied means they aren't actual rules.

In clinical practice, providers should adopt a balanced, evidence-informed approach that positions CBT as one component of multidisciplinary care, emphasizing individualization, rigorous safety monitoring, and continuous adaptation based on evolving evidence.

Right. Just have them do what no one has ever managed to do, because it's impossible. Always chasing the white dragon of "just right" rehabilitation. It's not that there's anything wrong with it, it's that it has to be done the "just right" way. When that happens it works. When it doesn't work it's because it wasn't done "just right".

A fairy tale by professionals, for professionals, about professionals. Nothing about us. Never anything actually about us, that's forbidden, I guess.

 

[Utsikt]

In clinical practice, providers should adopt a balanced, evidence-informed approach that positions CBT as one component of multidisciplinary care, emphasizing individualization, rigorous safety monitoring, and continuous adaptation based on evolving evidence.

Imagine writing what’s essentially a scathing review of the evidence base for CBT, and then still not being able to say that CBT should not be used in the absence of evidence of efficacy. That’s even ignoring the fact that we have pretty good evidence against the efficacy of CBT.