Chronic Fatigue Syndrome—Trials and Tribulations
Authors: Simon Wessely
Journal: JAMA (2001)

SYSTEMATIC REVIEWS HAVE 2 AIMS. THE FIRST IS TO PROduce an unbiased, detailed, and comprehensive synthesis of a particular subject. The second is to permit the emergence of consensus, informing but not mandating clinicians as to which interventions work for which patients. In this issue of THE JOURNAL, Whiting and colleagues report a major systematic qualitative review of the interventions used for treatment of chronic fatigue syndrome (CFS). The results highlight the strengths of the systematic approach, the weakness of the CFS evidence base, and the destructive ideological fault lines that continue to divide the field, to the benefit of no one. The authors have succeeded in satisfying the first requirement, that of producing a systematic synthesis of the literature on the treatment of CFS. This is no small achievement in a subject for which previous efforts have been notable for the evidence they provide of the deficits of the traditional narrative review. That 2 independent review teams, neither with any CFS axes to grind, have reached similar conclusions that permit a single article is also reassuring. The combined review comes to 2 firm conclusions. The first is that those treatments that the authors group together as broadly behavioral in nature—namely, either graded exercise therapy (GET) programs or cognitive behavioral therapy (CBT)—are currently the most effective treatments that have been submitted to the test of the clinical trial. The second conclusion is that there is little evidence available for review and that much of what exists is poor quality, made worse by the chaos surrounding case definitions, nonstandardized outcome measurements, and variations in study duration and follow-up. In response to these findings, members of the CFS research community would, in an ideal world, acknowledge these deficiencies and get together to agree on sounder methodologies, most particularly in the area of valid and reliable outcome measures. However, there is no clearly defined “CFS community.” Instead, several different communities exist, each answering to particular constituencies and each united not so much in what they believe, but in what they do not believe, about the nature of CFS and its treatment. Indeed, the conclusions of the report by Whiting et al will be a litmus test for determining to which particular community any individual researcher or advocate owes allegiance. If treatment for CFS were governed more by evidence and less by passion, several events might be expected to follow publication of this review. For instance, consumer advocacy groups might join forces to lobby for better provision of the 2 interventions—GET and CBT—that have shown promising results, while pointing out that neither approach is commonly provided. Patients might join forces with health service researchers to insist that when these treatments are introduced to the wider world, quality and standards are maintained. Care must be taken to ensure that the cautious GET programs that have shown benefit in randomized trials are not replaced by crude, military style fitness programs. Likewise, the skilled CBT practitioners who delivered the interventions that also have been shown to provide benefit in the clinical trial setting must not be replaced by enthusiastic amateur therapists. Clinical researchers and funding agencies would note that, even though these interventions appear effective, the evidence is based on a small number of studies and neither approach is remotely curative, and would continue their efforts to develop better treatments. But CFS is a condition for which every possible etiology has several diverse hypotheses. Accordingly, it is regrettable but likely that this review article will not be universally welcomed. Some consumers, and researchers alike, will make it their mission to discredit the authors and their conclusions. At the other end of the spectrum, some patients and clinicians will welcome the findings, and view these approaches as commonsense ways to reduce disability and enhance control over symptoms. Still others may see the findings, especially related to the benefits of CBT, as confirming their prejudices as to the mental instability of patients with