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A high drop-out rate of cognitive behavioural therapy for chronic fatigue

We read the study entitled ‘Cognitive behavioural therapy for chronic fatigue and chronic fatigue syndrome: outcomes from a specialist clinic in the UK’ with interest. Adamson et al. concluded that cognitive behavioural therapy is an effective treatment for chronic fatigue syndrome because fatigue and physical functioning scores improved significantly and 90% were happy with it. However, the results for chronic fatigue and chronic fatigue syndrome were not reported separately which might have inflated their chronic fatigue syndrome results. Also, there were only physical functioning scores at baseline for 77.2% even though it was a primary outcome which also biased the results. According to the study, 31% dropped out, yet at follow-up there were only scores for 50.5% (fatigue), 50.9% (social adjustment), 40.6% (physical functioning) and 36.7% (global improvement). Consequently, up to 63.3% dropped out, which further biased the results as most patients only drop out if therapy is harmful or not effective, making it unlikely that 90% were happy with cognitive behavioural therapy. The study noted that those who dropped out were more ill (worse physical functioning and Work and Social Adjustment scores). Consequently, dropout was non-random, which artificially inflated the results. Despite this, the scores after ‘effective’ treatment were only 18.6 (fatigue) and 58.5 (physical functioning). According to both scores, patients were still ill enough to enter the PACE (Pacing, graded Activity, and Cognitive behaviour therapy: a randomised Evaluation) trial by the corresponding author of Adamson et al. Moreover, according to the literature, a physical functioning score of 65 or less equates to severe disability. Why the study did not use objective outcomes is unclear as PACE showed that cognitive behavioural therapy doesn’t lead to objective improvement (step test and 6-min walking test).