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

[John Mac]

Ineffective or effective? Interpreting the effect of CBT on fatigue in ME/CFS. A short analysis of a meta-analysis

Mark Vink
Friso Vink-Niese

This article is a commentary on:

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

Frontiers | Ineffective or effective? Interpreting the effect of CBT on fatigue in ME/CFS. A short analysis of a meta-analysis

The meta-analysis by Kolala et al. (2025a) selected 12 studies and was set up to examine "whether a non-protocol based CBT is effective in a population ...

www.frontiersin.org

 

[bobbler]

Now published, see post #5
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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.

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.

That is interesting - could it be as simple as the treatment never was a treatment given how poor their design was vs the illness but operates as a filter

So the face-to-face simply filtered out those who were the least able to keep attending something face-to-face which involved travel and energy communicating with someone else. In an illness where exhaustion cumulates and most are on a scale of not having enough function to meet basic needs so are having to choose what to not do adding in that task is likely to cause .... exhaustion cumulatively, and those most harmed by it will drop-out leaving those who were least ill in the first place, even if they are also made more exhausted and ie harmed that 'average' is apparently less. ie attending the 'class' causes PEM = fewer people who get bad PEM complete. But even those who could complete it didn't have the extra left in their tank to 'pace up' on top of that extra activity of attending these extra sessions, just cut out grocery trips or took days off work in order to make those sessions

And the self-directed only for physical functioning but not 'fatigue' just means it isn't filtering out the most unwell quite as effectively by giving them crippling PEM by travelling to sessions, but surprise surprise those who find increasing their activity makes them crash don't complete it leaving behind the weller ones who can 'pace up'.

Given it is a review of others studies, but doesn't seem to have put any focus on checking the drop-out rates for those studies - which is exactly what would explain this

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

You'd have at least have thought after this 'conclusion' that would be its number one reccommendation for future reviews - that it should be checking the drop-outs as much as those 'left behind' to stop 'researching' the illness on an 'anything but' basis where only the ones left after the people with ME/CFS have been filtered out by the treatment are then analysed...

the old 'anything but', collateral damage of those with the actual illness by filtering them out with their treatments approach lives on?

 

[bobbler]

View attachment 29045
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.

View attachment 29044

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.
View attachment 29046

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.

DO you mean they are trying to bias the assessment of bias tools ?

From the very people who have done a lot of these studies that have bias risks sewn through them, and seem to with each study they do choose to change their method to increase that risk (in order to get their desired results) instead of decrease it?

Surely that would say a lot about the people/type of people who would do this type of study

 

[Utsikt]

DO you mean they are trying to bias the assessment of bias tools ?

From the very people who have done a lot of these studies that have bias risks sewn through them, and seem to with each study they do choose to change their method to increase that risk (in order to get their desired results) instead of decrease it?

Surely that would say a lot about the people/type of people who would do this type of study

The authors of the review were biased in their assessment and didn’t explain why they deviated from the suggested guidelines.