Review Cognitive behavioural therapy for the treatment of chronic fatigue syndrome in adults – a meta-analysis, 2025, Kolala et al

Dolphin

Dolphin

Senior Member (Voting Rights)
Now published, see post #5
-----------------

https://journals.sagepub.com/doi/pdf/10.1177/ANPA_59_1S

RANZCP Abstract Book, 2025

COGNITIVE BEHAVIOURAL THERAPY FOR THE TREATMENT OF CHRONIC FATIGUE SYNDROME IN ADULTS – A META-ANALYSIS

V Kolala1, B La Rosa2, V Vangaveti3, K Chen4

1Canberra Health Services, Canberra, Australia 2Serco, Townsville, Australia
3Research Division, James Cook University, Townsville, Australia 4Queensland Health, Townsville, Australia

Background: The efficacy of cognitive behavioural therapy (CBT) for the treatment of chronic fatigue syndrome (CFS) remains controversial.

Objectives: The purpose of this meta-analysis was to understand the short-term and long-term efficacy of CBT on different outcome measures on patients with CFS, as well as explore its potential adverse effects. The primary outcome was change in level of fatigue, with secondary outcomes being physical functioning, pain, quality of life, anxiety and depression.

Methods: The authors conducted a meta-analysis in accordance with PRISMA guidelines to include randomised controlled trials (RCT) on the efficacy of CBT for adults with CFS. Findings: 12 studies were included in this review. Individual face to face CBT was found to have a large effect size in reducing fatigue (Cohen’s d = 2.91, 95% CI 0.51 to 5.31, p=0.02). Self-directed CBT was found to have a large effect size in improving physical functioning (Cohen’s d = –2.76, 95% CI –5.06 to –0.47, p = 0.04). No serious adverse effects were reported.

Conclusions: CBT as a treatment modality inherently leads to difficulties with blinding and bias. The results suggest that patients with milder disease may benefit more from self-directed CBT. It is unclear why individual face to face CBT and self-directed CBT were only efficacious for fatigue and physical functioning respectively, but not both outcomes. Current guidelines have mixed recommendations with CBT as treatment, however we suggest CBT be offered to all patients with CFS.

Conflicts of interest Nil conflict of interests to report.
 
Last edited by a moderator:
I disagree with their conclusion. They clearly haven't spent time properly researching CBT, just done a meta-analysis on the available studies and despite all the bias and problems they acknowledge and consider that the evidence doesn't amount to anything i.e. is "mixed" - suggests it should be offered to all pwME.

Why? I think CBT/mental health therapist's time is a precious resource (in NZ, not sure about Australia, a richer country that pays for private therapy, which is not the case in NZ) and is to be used for specific mental health conditions which is not the case for ME.

First time I have seen any mention of CFS publicly by my college for years, basically since Hickie et al did the Dubbo study and they had two psychiatrists with ME give a talk at the Gold Coast Congress in 2007 (which I didn't attend as I didn't get there early enough, there was no chairs left, the room was packed and people straining to hear at the door).
 
Full paper now published:

Frontiers | Cognitive behavioural therapy for the treatment of chronic fatigue syndrome in adults – a meta-analysis

The treatment efficacy of Cognitive Behavioural Therapy (CBT) for chronic fatigue syndrome (CFS) remains controversial. The purpose of this meta-analysis was...
www.frontiersin.org www.frontiersin.org

Cognitive behavioural therapy for the treatment of chronic fatigue syndrome in adults – a meta-analysis​

Vivek Kolala*&#x;Vivek Kolala1*†
Billie La Rosa,&#x;
Billie La Rosa2,3†Venkat Vangaveti&#x;Venkat Vangaveti4†
Kai Yang Chen&#x;
Kai Yang Chen4†
  • 1Canberra Health Services, Canberra, ACT, Australia
  • 2Serco, Townsville, QLD, Australia
  • 3Queensland Health, Townsville, QLD, Australia
  • 4James Cook University, Townsville, QLD, Australia
The treatment efficacy of Cognitive Behavioural Therapy (CBT) for chronic fatigue syndrome (CFS) remains controversial.

The purpose of this meta-analysis was to understand the short-term and long-term efficacy of CBT on different outcome measures on patients with CFS, as well as explore potential adverse effects.

A meta-analysis was conducted in accordance with PRISMA 2020 guidelines (PROSPERO: CRD42023391926).

PubMed, PsycINFO, CINAHL, SCOPUS, Web of Science, and EMBASE were searched from inception to September 2024 for randomised controlled trials (RCTs) of CBT in adults with CFS excluding Oxford-defined cohorts.

Interventions included individual face-to-face, self-directed, and group CBT.

The primary outcome was fatigue, with secondary outcomes of physical functioning, anxiety, depression, pain and quality of life.

Risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool.

There were 12 studies included in this review, with 1799 total participants.

All forms of CBT, when analysed together, was not found to have a statistically significant result (p = 0.12).

Individual face-to-face CBT was found to have a large effect size in reducing fatigue (Cohen's d = 2.91, 95% CI 0.51 to 5.31, p=0.02).

Self-directed CBT was found to have a large effect size in improving physical functioning (Cohen's d = -2.76, 95% CI -5.06 to -0.47, p=0.04).

All other sub-analyses did not yield statistically significant results.

There was inconsistent reporting of adverse effects, however no serious adverse effects were reported.

High heterogeneity and incomplete reporting limit certainty.

CBT as a treatment modality inherently leads to difficulties with blinding and bias.

The results suggest that patients with milder disease may benefit more from self-directed CBT.

Group CBT may not be as beneficial as other modalities.

Guidelines provide mixed recommendations regarding CBT, therefore CBT may be offered as a supportive, non-curative option for adults with CFS.

No funding was received for this review.

Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42023391926.
 
IMG_0447.png
All studies were rated as «low risk of bias» in the category «risk of bias in measurement of outcome».

This category includes these questions:

4.1 Was the method of measuring the outcome inappropriate?

4.2 Could measurement or ascertainment of the outcome have differed between intervention groups?

4.3 If N/PN/NI to 4.1 and 4.2: Were outcome assessors aware of the intervention received by study participants?

4.4 If Y/PY/NI to 4.3: Could
assessment of the outcome have been
influenced by knowledge of
intervention received?

4.5 If Y/PY/NI to 4.4: Is it likely that
assessment of the outcome was
influenced by knowledge of
intervention received?

The Cochrane RoB version 2 tool makes it abundantly clear that trials with subjective self-reported outcomes and no blinding should be rated as at least some concern of bias. Given the nature of most CBT where reframing thoughts and feelings are central components, they should be labelled as high risk of bias.
For participant-reported outcomes, the assessment of outcome is potentially influenced by knowledge of intervention received, leading to a judgement of at least ‘Some concerns’. Review authors will need to judge whether it is likely that participants’ reporting of the outcome was influenced by knowledge of intervention received, in which case risk of bias is considered to be high.
Click to expand...
IMG_0445.jpeg

The guidance also says that the total risk of bias should be at least equal to the highest level of bias in any domain, or at high risk if multiple domains were rated as some concern in a way that substantially lowers the confidence in the result.
IMG_0446.jpeg

I think it’s fair to say that all of the studies realistically should have been categorised as high risk. Both because of the subjective + no blinding issue that in itself should result in a rating of high risk, and because of various other issues that in sum make the results completely unreliable.

This demonstrates that the authors are not even able to use a simple tool correctly. Alternatively, they have decided to deviate from the tool without explaining why. How this got past peer review and the editors is beyond me.
 
Last edited:
The paper said:
There was inconsistent reporting of adverse effects, however no serious adverse effects were reported.

High heterogeneity and incomplete reporting limit certainty.

CBT as a treatment modality inherently leads to difficulties with blinding and bias.

The results suggest that patients with milder disease may benefit more from self-directed CBT.

Group CBT may not be as beneficial as other modalities.

Guidelines provide mixed recommendations regarding CBT, therefore CBT may be offered as a supportive, non-curative option for adults with CFS.
Click to expand...
Given this, the only valid conclusion is that there is no valid evidence and it should not be recommended to anyone. When a treatment is controversial literally for decades, the only rational position to take is that it cannot meet any burden of evidence.

A dead horse has never been beaten so completely. They've long dug through the corpse and are deep underground at this point.
 
Utsikt said:
This demonstrates that the authors are not even able to use a simple tool correctly. Alternatively, they have decided to deviate from the tool without explaining why. How this got past peer review and the editors is beyond me.
Click to expand...
Once is a mistake. Twice can be an oversight suggesting problems in procedure or organization.

When it happens almost every single time, it's completely implausible to argue it can be anything but intentional. We are long past thousands of instances, this is beyond ridiculous, it's a system that simply refuses to change out of methods that keep giving them false signals, simply because otherwise they would barely have any positive signals and thus have to change how they do everything.

Which is the whole point!
 
I think the major problem with the ongoing drum on the effectiveness of CBT on ME/CFS is that the details of the therapy are never discussed. At least, I have never seen clearly explained what exactly CBT for pwME/CFS includes/means. For example, I can imagine (based on my personal experience), it's helpful in the early phases of being ill to have psychological support, to help with acceptance, to learn what your pitfalls are when it comes to exertion/load, and to learn how to plan, prioritise, and pace. In theory, I think this could all be part of CBT, and therefore, I can imagine that it's 'effective' for the treatment of ME/CFS (you could potentially even experience 'improvement' because you learn better how to prevent exertion/overload). I would say that that CBT could potentially be effective to learn how to manage your illness to the best of your ability.

As long as we don't discuss the details of 'therapy', a big risk is of course that this type of 'research' suggests (either intentionally or not) that ME/CFS is a behavioural and/or mental issue that can be fixed with CBT.

I don't understand what researchers are trying to accomplish with this vague research.
 
Individual face-to-face CBT was found to have a large effect size in reducing fatigue (Cohen's d = 2.91, 95% CI 0.51 to 5.31, p=0.02). ​
​
Self-directed CBT was found to have a large effect size in improving physical functioning (Cohen's d = -2.76, 95% CI -5.06 to -0.47, p=0.04). ​

Subjectively self-reported effect size, with inadequate blinding, or support from objective outcome measures.

Again.
 
MinIreland said:
I think the major problem with the ongoing drum on the effectiveness of CBT on ME/CFS is that the details of the therapy are never discussed.
Click to expand...
I self referred for CBT since it was one of the listed treatments for ME/CFS and there was an awful lot of GET in that CBT. Their entire strategy seemed to be to encourage people to expand what they were doing and meet friends for coffees while analysing your own thought pattern. But there was so much physical exertion in it. Our entire group was bedbound ME/CFS patients and they were suggesting we meet friends for coffees, it was absurd. I am sure they marked us down as successfully treated of course since we dropped out mid way.
 
BrightCandle said:
I self referred for CBT since it was one of the listed treatments for ME/CFS and there was an awful lot of GET in that CBT. Their entire strategy seemed to be to encourage people to expand what they were doing and meet friends for coffees while analysing your own thought pattern. But there was so much physical exertion in it. Our entire group was bedbound ME/CFS patients and they were suggesting we meet friends for coffees, it was absurd. I am sure they marked us down as successfully treated of course since we dropped out mid way.
Click to expand...
That's awful. Horrendous even. Perhaps I'm wrong in thinking that CBT could be other (in our context; helpful) things. CBT didn't work for me either (this was before I became ill), because the focus was so much on challenging my thoughts and emotions, while what I needed was slowing down.

I don't have a lot of knowledge on CBT and potentially it's even never going to be helpful for chronically ill people. But as long as we don't have more details, we'll never know.
 
MinIreland said:
That's awful. Horrendous even. Perhaps I'm wrong in thinking that CBT could be other (in our context; helpful) things. CBT didn't work for me either (this was before I became ill), because the focus was so much on challenging my thoughts and emotions, while what I needed was slowing down.
Click to expand...
This I think is a big part of the problem with CBT, its a different thing in every department that runs it. Some of its 1 to 1, some of its group therapy, some of it online and the exercises they are taking people through are all different, there is no one CBT training because if there was we would get the slides/notes and know what it was they were doing. There is no one CBT its being done differently everywhere, there are as many variants of it as there are departments. Its impossible to study and impossible to write studies about as a fungible thing because they aren't all talking about the same thing.
 
BrightCandle said:
There is no one CBT its being done differently everywhere, there are as many variants of it as there are departments. Its impossible to study and impossible to write studies about as a fungible thing because they aren't all talking about the same thing.
Click to expand...
Yes, exactly. CBT is some kind of framework and methodology, but the term itself does not specify the content and goal of the therapy. To make meaningful statements about a therapy those things must be specified.

It baffles me that professional researchers allow themselves to be so sloppy and unprofessional. They must understand that a minimal amount of specificity is necessary to make sense. How can anyone take them seriously without that.

It's not only the psycho-somatic proponents that do this, either. It is widespread.

I rambled a bit about it recently in this post.
 
@dave30th is this something worth writing to the editor about? The assessment of the quality of the evidence (i.e. risk of bias) is atrocious. Every trial should have been rated as high risk or bias, rendering the subsequent analyses redundant.

The conclusion should have been «there is no evidence of sufficient methodological quality», that «CBT in any form should not be recommended for for ME/CFS for any purpose», and that «substantially better designed and executed trials are needed».
 
MinIreland said:
At least, I have never seen clearly explained what exactly CBT for pwME/CFS includes/means. For example, I can imagine (based on my personal experience), it's helpful in the early phases of being ill to have psychological support, to help with acceptance, to learn what your pitfalls are when it comes to exertion/load, and to learn how to plan, prioritise, and pace.
Click to expand...
The CBT packaging is especially problematic in that all this evidence ultimately works through systematic reviews, and in those there isn't even the barest hint of what the contents are, and they clearly don't matter, so much that no one even actually cares what's in it. It's basically equivalent to a category that says "drugs" and it could be any drug at any dosage and any level of actual purity (in that is it actually what it says? no one can say). Everything gets compressed into the simple label of CBT, and that actually seems to be what's so appealing because anyone can simply have it mean whatever they want for themselves. It's a shapeless volume they can fill with whatever they prefer, it literally makes no difference anyway.

But none of this justifies the use of the CBT packaging. It adds absolutely nothing to the process. All it does is create the fake need to work through accredited professionals/spiritual gurus, even though apps have not only proliferated in recent years, but some of the same people who have pushed for CBT this and that have done studies of CBT apps and they have the same results: no meaningful difference. For all that it matters, it could be some random person who just says CBT 100x over and nothing else. Every word out of their mouth "CBT" while they simply point at the 2 page pamphlet that is the actual relevant material.

One thing this has led to is to massively over-complicate and lengthen something that basically takes 5 minutes into several hours spread over many weeks. Almost everyone who comments on those trials complaints that they're too long, and really the substance that they cover is mostly irrelevant blather, with the useful information taking up about the length of a standard pamphlet, it takes all of 5 minutes to go through it.

Because they try to change something that is simple-but-hard into something that is complex-but-easy, so it's equivalent to when people go to ChatGPT to turn a few bullet points into a 5 page document, even though the bullet points cover everything already, and of course now a lot of people do the opposite, turn 5 page emails into a few bullet points. It's just padding for the sake of making it appear more substantial, but it's so poorly done that everyone understands it's cheap nonsense but there is no courage or leadership to stop this nonsense.
 
Last edited:
Liie said:
It baffles me that professional researchers allow themselves to be so sloppy and unprofessional. They must understand that a minimal amount of specificity is necessary to make sense. How can anyone take them seriously without that.

It's not only the psycho-somatic proponents that do this, either. It is widespread.
Click to expand...
During the infamous tulips craze in the Netherlands, when they became so valuable they were an investment, even the people who understood it was stupid invested anyway, because even if the craze is, well, crazy, the rewards are real. People could and did make fortunes out of it.

Humans are social creatures who don't have access to some objective truth. We determine what's true or not based on social dynanics, and here even though the whole thing here is completely and obviously ridiculous, it's necessary to take it seriously because everyone else does.

What's amazing is that this is as textbook perfection to the emperor's new clothes as can be achieved, and it's all happening within the general confines of psychology, of which a significant area of interest is precisely why people do insane things like that. And yet they pretty much all commit to it, because no one wants to be the one everyone looks at with contempt for daring to remind them that the rich jerk sitting on his throne is buck naked and all their glowing descriptions of the invisible robes mark them as complete fools. The fools always gang on the wise, that's how they justify their folly.
 
Last edited:
You must log in or register to reply here.
Back
Top Bottom