Q J Med 2004; 97: 378-379
QJM vol. 97 no. 6 © Association of Physicians 2004; all rights reserved.
Correspondence |
Cost-effectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome
Sir,In their economic evaluations of treatments for chronic fatigue syndrome (CFS), Severens et al.1 compared the cost-effectiveness of cognitive behaviour therapy (CBT) with those of other interventions, and found that the percentage of CFS patients who improved with CBT performed for 8 months was 31% vs. 9% and 12% for other treatments.1 Considering that, in one study, 28% of CFS patients treated with low-dose hydrocortisone over just one month virtually recovered,2 Severens et al.1 also should have compared the cost-effectiveness of CBT with that of low-dose hydrocortisone.
Treatment with low-dose hydrocortisone for CFS, besides being intuitively far less costly than CBT, is also better-founded clinically than any psychological therapy, because hydrocortisone corrects the hypocortisolism that characterizes at least some CFS patients.3 Given that ‘frank hypocortisolism’, rather surprisingly, was one of the exclusion criteria for enrolment in the trial of Cleare et al.,2 the percentage of CFS patients who can be effectively treated with low-dose hydrocortisone in day-to-day health care is likely to be higher than the 28% found in that trial.2
In view of the 42 clinical features that CFS shares with Addison's disease,4 including all the physical and neuropsychological symptoms listed in the diagnostic criteria for CFS,4 this syndrome should be treated with the two classic drugs for Addison's disease, namely, hydrocortisone in combination with fludrocortisone,5 not with CBT. This psychological treatment was of benefit only to some patients fulfilling arbitrarily modified criteria for CFS, which ignore the physical signs and symptoms that discriminate CFS from depression.4 Therefore, CBT may have actually benefited depressed subjects, rather than patients with CFS.4
Retired Medical Inspector Italian State Railways Fortaleza Brazil
References
1. Severens JL, Prins JB, van der Wilt GJ, van der Meer JWM, Bleijenberg G. Cost-effectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome. Q J Med 2004; 97:153–61.
2. Cleare AJ, Heap E, Malhi GS, Wessely S, O’Keane V, Miell J. Low-dose hydrocortisone in chronic fatigue syndrome: a randomised crossover trial. Lancet 1999; 353:455–8.[CrossRef][Web of Science][Medline]
3. Roberts AD, Wessely S, Chalder T, Papadopoulos A, Cleare AJ. Salivary cortisol response to awakening in chronic fatigue syndrome. Br J Psychiatry 2004; 184:136–41.
4. Baschetti R. Chronic fatigue syndrome: an endocrine disease off limits for endocrinologists? Eur J Clin Invest 2003; 33:1029–31.[CrossRef][Medline]
5. Baschetti R. Fludrocortisone and chronic fatigue syndrome. N Z Med J 2003; 116:U549.[Medline]
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