Authors' replyBMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7038.1098 (Published 27 April 1996) Cite this as: BMJ 1996;312:1098
- Michael Sharpe,
- Keith Hawton,
- Tim Peto
- Clinical tutor Senior clinical lecturer Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX
- Consultant physician Nuffield Department of Medicine, John Radcliffe Hospital, Oxford OX3 9DU
EDITOR,—We addressed a clinical question of practical importance to ourselves and our colleagues—namely, could we improve the disability and fatigue of patients referred to a hospital clinic with severe medically unexplained fatigue (the chronic fatigue syndrome)? The available evidence indicated that the prognosis for these patients was poor1 and (contrary to S A Chilton's suggestion) that there were no treatments of proved and accepted effectiveness.2 3 We chose cognitive behaviour therapy because it is effective in related conditions4 and because (for reasons given in the paper) we did not agree with Charles Shepherd's suggestion that its application to the chronic fatigue syndrome has been adequately evaluated. We chose to compare this therapy with sympathetic medical care from physicians experienced in assessing the syndrome as this is the best care available to most patients referred to hospital. Our results clearly show that patients who received cognitive behaviour therapy improved substantially more than those who were given only medical care.
Many of the methodological points raised by the correspondents were addressed in our original paper. Several correspondents ask, however, whether a simpler or alternative intervention might not have produced a similar benefit when compared with simple medical care. We agree that both replication of our result and the evaluation of alternative approaches are needed. Some data are already available. Colleagues at King's College Hospital, London, recently compared a similar form of cognitive behaviour therapy with a relaxation treatment matched for time (A Deale et al, world congress of cognitive and behavioural therapies, Copenhagen, Denmark, Jul 1995). They found that the cognitive behaviour therapy was substantially more effective, which suggests that neither simple attention nor relaxation treatment is adequate for this condition. We agree with the correspondents who suggest that the next steps for research should include identification of the effective ingredients of cognitive behaviour therapy and the delineation of factors relating to the patient that predict a good response.
Shepherd, Ray Gibbons and colleagues, and K K Eaton all suggest that we neglected the biological component of our patients' illness. In fact (and contrary to Stephen M Lawrie's selective quotation), we take an explicitly biopsychosocial view of the chronic fatigue syndrome. We have been at pains to point out that the relative effectiveness of cognitive behaviour therapy does not mean that the illness is “all in the mind.” While biological factors are likely to be important, however, their precise nature remains uncertain.
Many more questions still need answers: Gibbons and colleagues ask whether cognitive behaviour therapy is effective for extremely disabled patients, Shepherd suggests that homoeopathy can work as well, and D O Ho-Yen speculates that his treatment has a similar effectiveness. We hope that these questions will be addressed in randomised controlled trials as only in this way will it be possible to adopt an evidence based approach to treatment. For the time being, intensive and individually tailored cognitive behaviour therapy is one of the few approaches that has been found to help most patients attending hospital outpatient clinics with this chronic and disabling illness.