Treatment of Chronic Fatigue Syndrome: the evidence. Trudie Chalder King s College London

Transcription

1 Treatment of Chronic Fatigue Syndrome: the evidence Trudie Chalder King s College London

2 Agenda Understanding CFS Treatment evidence The PACE Trial

3 Viruses & fatigue Severe infections can contribute to fatigue syndromes More likely to happen if past psychiatric history, longer bed rest or convalescence, beliefs are catastrophic

4 Muscle Dysfunction in CFS Fatigue in CFS is not primarily of peripheral origin, but rather results from abnormal central drive which reflects the importance of behavioural factors (Wood et al (1991)

5 Psychiatric Disorder Close link between CFS and clearly defined psychiatric disorders e.g. depression, anxiety Explanations: overlapping criteria misdiagnosed cases of depression or anxiety Depression could be response to a physical illness controlled studies show lower rates of psychiatric disorder in medical controls

6 Current psychiatric disorder in CFS compared with medical controls Reference Control group Psych disorder in CFS Psych disorder in controls Wessely & Neuromuscular 72% 36% 2.0 Powell Katon et al Rheumatoid 45% 6% 7.5 Wood et al Myopathy 41% 12.5% 3.3 Pepper et al Multiple sclerosis 23% 8% 2.9 Fischler et al ENT/ dermatology 77% 50% 3.4 Johnson et al Multiple sclerosis 45% 16% 2.8 Relative risk

7 Terminology There is often a mismatch between patients experience and health professionals perspective Health professionals tend to dichotomise i.e. the problem is either medical or psychiatric If seen by Physician, patient is often told there is nothing wrong with you and sent to see the Psychiatrist Misunderstandings often occur and communication starts to break down

8 Treatment Evidence No evidence for pharmacological treatments Evidence for graded exercise therapy Evidence for cognitive behavioural psychotherapy

9 Pacing, graded Activity and Cognitive behaviour therapy: a randomised Evaluation White et al (2011) The Lancet; 377; 9768;

10 Design A randomised controlled trial was conducted to compare cognitive behaviour therapy (CBT), graded exercise therapy (GET), adaptive pacing therapy (APT) when added to specialist medical care (SMC) and SMC alone.

11 Design At least 3 sessions of SMC over 52 weeks 14 sessions of therapy over 23 weeks (+ booster session at 36 weeks) Outcome assessed at 12, 24 & 52 weeks (main outcome 52 weeks)

12 Specialist Medical Care Patient provided with a diagnosis after appropriate investigations Advice and education Sleep, activity and rest Medication for symptom management Self-help books could be recommended 12

13 Differences between manual based therapies APT was based on a model of adapting to the illness and it was assumed that the organic disease process could not be reversed by behavioural change CBT was based on model of fear avoidance i.e that fear of activity leads to avoidance of activity GET was based on model of deconditioning and exercise intolerance

14 Primary outcomes Fatigue Chalder Fatigue Scale (0-33: higher score more severe fatigue) Disability - SF36 physical functioning subscale (0-100: higher score = better functioning)

15 Therapy quality APT CBT GET N sessions Confident before Satisfied after 72 % 57 % 70 % 85 % 82 % 88 % Alliance Adherence

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18 CBT and GET are more effective than SMC alone and APT. APT is no different from SMC alone The effectiveness of CBT and GET is moderate The effect is similar however CFS/ME is defined and in those also depressed Treatments are safe, if given as described Pushing limits BETTER than staying within

19 Good news? We found not one but two treatments were effective and safe...

20 Some ME groups reactions When is the Lancet going to retract this fraudulent study?..there are deep problems with the credibility of the PACE trial. This is not a good day for people with ME/CFS. MEA We find the trial results extremely worrying MEA The results are surprising and disappointing. AfME that the trial has shown the therapies to be safe and effective is hugely damaging. AfME

21 Resources - CFS Research & Treatment Unit website Coping with Chronic Fatigue by Trudie Chalder, Sheldon Press Overcoming Chronic Fatigue Syndrome by Mary Burgess & Trudie Chalder, Constable & Robinson

22 Its good to talk CBT style!