Chronic fatigue in general practice: is counselling as good as cognitive behaviour therapy? A UK randomised trial, Ridsdale et al, 2001

Wessely was the senior author of the article & Chalder was a trial investigator.

Background: Fatigue is a common symptom for which patients consult their doctors in primary care. With usual medical management the majority of patients report that their symptoms persist and become chronic. There is little evidence for the effectiveness of any fatigue management in primary care.

Aim: To compare the effectiveness of cognitive behaviour therapy (CBT) with counselling for patients with chronic fatigue and to describe satisfaction with care.

Design of study: Randomised trial with parallel group design.

Setting: Ten general practices located in London and the South Thames region of the United Kingdom recruited patients to the trial between 1996 and 1998. Patients came from a wide range of socioeconomic backgrounds and lived in urban, suburban, and rural areas.

Method: Data were collected before randomisation, after treatment, and six months later. Patients were offered six sessions of up to one hour each of either CBT or counselling. Outcomes include: self-report of fatigue symptoms six months later, anxiety and depression, symptom attributions, social adjustment and patients' satisfaction with care.

Results: One hundred and sixty patients with chronic fatigue entered the trial, 45 (28%) met research criteria for chronic fatigue syndrome; 129 completed follow-up. All patients met Chalder et al's standard criteria for fatigue. Mean fatigue scores were 23 on entry (at baseline) and 15 at six months' follow-up. Sixty-one (47%) patients no longer met standard criteria for fatigue after six months. There was no significant difference in effect between the two therapies on fatigue (1.04 [95% CI = -1.7 to 3.7]), anxiety and depression or social adjustment outcomes for all patients and for the subgroup with chronic fatigue syndrome. Use of antidepressants and consultations with the doctor decreased after therapy but there were no differences between groups.

Conclusion: Counselling and CBT were equivalent in effect for patients with chronic fatigue in primary care. The choice between therapies can therefore depend on other considerations, such as cost and accessibility.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1313894/

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Cost-effectiveness analysis

Background: There is a paucity of evidence relating to the cost-effectiveness of alternative treatment responses to chronic fatigue.

Aim: To compare the relative costs and outcomes of counselling versus cognitive behaviour therapy (CBT) provided in primary care settings for the treatment of fatigue.

Design of study: A randomised controlled trial incorporating a cost-consequences analysis.

Setting: One hundred and twenty-nine patients from 10 general practices across London and the South Thames region who had experienced symptoms of fatigue for at least three months.

Method: An economic analysis was performed to measure costs of therapy, other use of health services, informal care-giving, and lost employment. The principal outcome measure was the Fatigue Questionnaire; secondary measures were the Hospital Anxiety and Depression Scale and a social adjustment scale.

Results: Although the mean cost of treatment was higher for the CBT group (164 Pounds, standard deviation = 67) than the counselling group (109 Pounds, SD = 49; 95% confidence interval = 35 to 76, P < 0.001), a comparison of change scores between baseline and six-month assessment revealed no statistically significant differences between the two groups in terms of aggregate health care costs, patient and family costs or incremental cost-effectiveness (cost per unit of improvement on the fatigue score).

Conclusions: Counselling and CBT both led to improvements in fatigue and related symptoms, while slightly reducing informal care and lost productivity costs. Counselling represents a less costly (and more widely available) intervention but no overall cost-effectiveness advantage was found for either form of therapy.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1313893/

 

This trial of CBT vs counseling for chronic fatigue is interesting in multiple regards.

First, it found that CBT was no more effective than counseling.

Second, counseling was found to be less costly than CBT, although neither intervention was cost-effective.

The most important point, perhaps, is that the authors avowed that counseling was chosen as a control intervention only because a funding referee refused usual care as the initially proposed control arm. See the authors’ response on pages 317-318: https://bjgp.org/content/bjgp/51/465/318.1.full.pdf

(In the same response, the authors also say that “in our consensus view”, the minimal clinically important difference on the Chalder fatigue scale is 4 points, but later trials of CBT and GET for CFS went on to use 2 (PACE) or 3 points (GETSET).)

Therefore, Chalder and Wessely knew as early as 2001 that 1) they should choose an appropriate control arm for their trials, 2) there was no particular reason to promote CBT as counselling was found to be as effective, especially for CFS, less costly and was more widely available at the time. It did not stop them from doing so, though.

 

And yet they made everything out of CBT and how it "proves" that fatigue is psychological/behavioral based on specific claims about what CBT does (but actually doesn't do). Even though it's just as useless as anything else, a bowl of soup is just as ineffective at treating the flu as salty crackers, a poor and biased evaluation could easily find equivalent "benefits".

How decades could be wasted on obvious quackery makes it clear that EBM is not a valid process, it's completely judgmental and subjective.

 

It's a shame that they didn't include one or more other groups, to test the comparative effectiveness of watching TV or playing computer games or eating donuts. I hereby recommend that all similar types of studies in the future should include such alternative treatments.

 

There was a study some years back on the use of the virtual world Second Life for improving coping in CFS (they did not use ME criteria if I recall correctly), circa 2009 or so. I was in that study. I think they found it helped patients cope better, but I no longer recall details. It was effectively an online support group. We even had at least one scientist turn up to describe their research.

The only disturbing thing that happened, and not a really bad thing, was the support group where a guy with a strong regional British accent turned up. That was not what was disturbing. He was wearing a large pink tutu. The other problem that happened is that people from Europe wound up going in the middle of their night.

A version of that support group still runs today, and I go there every Tuesday (Monday in the US) if I can. Its run privately by a friend of mine but is often cancelled because nobody is well enough on that particular day, and only two of us from the original group use it any more.

I have said it before, and I will again, we should be looking at the impact of regular gift baskets. I think they will help improve mood a lot more than CBT and perhaps other therapies. Prove me wrong by including it in a study, please.