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Reports of recovery in chronic fatigue syndrome may present less than meets the eye

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By Fred Friedberg and Jenna Adamowicz


The definitions of recovery in chronic fatigue syndrome (CFS) are numerous, as are the amount of intervention and naturalistic studies designed to assess illness recovery.1 In a recent systematic review of 22 studies, recovery percentages ranged from 0% to 66%.1 White et al report a recovery rate of 22% to 23% in their active behavioural intervention conditions. This rate corresponds with findings of a previous intervention study in CFS that used similar recovery criteria. 2


  • A controlled comparison of three recognised behavioural interventions for CFS incorporating an unusually large sample (thus, greater power) in comparison to previous clinical trials.

  • The use of multiple case definitions of CFS with varying criteria to assess clinical recovery. Thus, the percentage of patients who no longer met full illness criteria can be determined with reference to several definitions, rather than just one.

  • Operationalised criteria for recovery that include both symptom and functional changes as  informed by population data. Such precise criteria make clear how recovery is defined and facilitate cross-study comparisons.


  • The absence of data on patients’ perceptions of their recovery status and their pre-morbid functioning, both of which could inform the extent of recovery. Population norms may not capture health restoration if an individual’s pre-morbid function was superior to his or her post-treatment improvements.

  • The qualification acknowledged by the authors of this study that ‘recovery’, their central construct, refers only to recovery from the current episode, rather than sustained recovery over long periods.

  • We would argue that ‘remission’ is a more accurate term—which the authors appear to agree with. This term is less prone to misinterpretation and exaggeration.

  • The lack of available behavioural treatment for most patients with CFS indicates that the recovery emphasis in this paper has little real-life impact on patient quality of life beyond the research setting.


Recovery in CFS should be more broadly defined, with reference to patients’ pre-morbid functioning and their perceptions of their recovery status. Also, sustainability of recovery (as opposed to shorter term remission) over longer periods (5+ years) should be investigated.

Common understandings of recovery as a full return to health may not be applicable to outcome studies where criteria indicate remission rather than sustained recovery. Health services research is needed to incorporate behavioural interventions for CFS into clinical care.


These findings are unlikely to change the author’s practices as the recovery definitions and rates presented replicate previous reports from behavioural intervention studies in CFS. It is important to recognise that a recovery rate below 25%, even if accepted as a full or nearly full restoration of health (a questionable assumption), still leaves the vast majority of these patients with significant symptoms and impairments. Yet the publicity generated by trumpeting recovery outcomes in CFS far exceeds the relatively modest results found for most patients in behavioural treatment research.3

Competing interests: None.


1. Adamowicz J,Caikauskaite I, Friedberg F. Defining recovery in chronic fatigue syndrome: a critical review.Qual Life ResIn press.

2. Deale A,Husain K, Chalder T,et al. Long-term outcome of cognitive behavior therapy versus relaxation therapy for chronic fatigue syndrome: a 5-year follow-up study.Am J Psychiatry2001;158:2038–42.

3. Price JR,Mitchell E, Tidy E,et al. Cognitive behaviour therapy for chronic fatigue syndrome in adults. Cochrane Database Syst Rev2008;(3):CD001027

Commentary on:

ABSTRACT FROM: White PD, Goldsmith K, Johnson AL,et al. Recovery from chronic fatigue syndrome after treatments given in the PACE trial. Psychol Med. 2013;43:2227–35.

Patients: Six hundred and forty-one people (mean age 38 years) meeting Oxford criteria for chronic fatigue syndrome (CFS).

Setting: Six secondary care CFS clinics in England and Scotland; study duration not reported.

Intervention: Four treatment strategies were assessed: specialist medical care (SMC) delivered by specialist CFS doctors (n=160); SMC plus adaptive pacing therapy (APT) delivered by occupational therapists (n=159); SMC plus cognitive behavioral therapy (CBT) delivered by clinical psychologists
(n=161); and SMC plus graded exercise therapy (GET) delivered by physiotherapists (n=160).

Comparison: Between-arm comparisons: GET vs SMC, GET vs APT, CBT vs SMC, CBT vs APT and APT vs SMC (CBT vs GET not analysed) Follow-up 95% had primary outcome data at 52 weeks follow-up.

Dropout did not alter significantly by treatment group.

Allocation: Not reported

Blinding: Not reported

OUTCOMES: Recovery at 52 weeks (composite measure of normal range of fatigue, normal range of physical function, not meeting Oxford criteria of CFS, and Clinical Global Impression (CGI) score of 1 or 2):

Recovery at 52 weeks was achieved by 11 (7%) patients in the SMC alone group (95% CI: 4 to 13); 43 (28%) patients in the GET plus SMC group (95% CI: 16 to 30), number needed to treat (NNT): 7; 32 (22%) patients in the CBT plus SMC group (95% CI: 16 to 30; NNT: 7); 12 (8%) patients in the APT plus SMC group (95% CI: 4 to 14).

Patients randomised to GET plus SMC had significantly higher odds of recovery compared to SMC alone (OR: 3.71; 95% CI: 1.78 to 7.74) or APT plus SMC (OR: 3.38, 95% CI: 1.65 to 6.93). Patients randomised to CBT plus SMC had significantly higher odds of recovery compared to SMC alone (OR: 3.69; 95% CI: 1.77 to 7.69) or APT plus SMC (OR: 3.36; 95% CI: 1.64 to 6.88). There were no significant differences between the APT plus SMC group and SMC alone (OR: 1.10; 95% CI: 0.47 to 2.58).

Source: Fred Friedberg, Jenna Adamowicz. Psychological interventions: Reports of recovery in chronic fatigue syndrome may present less than meets the eye. Evid Based Mental Health doi:10.1136/eb-2013-101652

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