Internet-Based Cognitive Behavioral Therapy for Chronic Fatigue Syndrome Integrated in Routine Clinical Care: Implementation Study

Background: In a clinical trial, internet-based cognitive
behavioral therapy (I-CBT) embedded in stepped care was established
as noninferior to face-to-face (f2f) cognitive behavioral therapy
(CBT) for chronic fatigue syndrome (CFS). However, treatment
effects observed in clinical trials may not necessarily be retained
after implementation. Objective: This study aimed to investigate
whether stepped care for CFS starting with I-CBT, followed by f2f
CBT, if needed, was also effective in routine clinical care.
Another objective was to explore the role of therapists’
attitudes toward electronic health (eHealth) and manualized
treatment on treatment outcome. Methods: I-CBT was implemented in 5
mental health care centers (MHCs) with 9 treatment sites throughout
the Netherlands. All patients with CFS were offered I-CBT, followed
by f2f CBT if still severely fatigued or disabled after I-CBT.
Outcomes were the Checklist Individual Strength, physical and
social functioning (Short-Form 36), and limitations in daily
functioning according to the Work and Social Adjustment Scale. The
change scores (pre to post stepped care) were compared with a
benchmark: stepped care from a randomized controlled trial (RCT)
testing this treatment format. We calculated correlations of
therapists’ attitudes toward manualized treatment and eHealth
with reduction of fatigue severity. Results: Overall, 100 CFS
patients were referred to the centers. Of them, 79 started with
I-CBT, 20 commenced directly with f2f CBT, and 1 did not start at
all. After I-CBT, 48 patients met step-up criteria; of them, 11
stepped up to f2f CBT. Increase in physical functioning (score of
13.4), social functioning (20.4), and reduction of limitations
(10.3) after stepped care delivered in routine clinical care fell
within the benchmarks of the RCT (95% CIs: 12.8-17.6; 25.2-7.8; and
7.4-9.8, respectively). Reduction of fatigue severity in the MHCs
was smaller (12.6) than in the RCT (95% CI 13.2-16.5). After I-CBT
only, reduction of fatigue severity (13.2) fell within the
benchmark of I-CBT alone (95% CI 11.1-14.2). Twenty therapists
treated between 1 and 18 patients. Therapists were divided into 2
groups: one with the largest median reduction of fatigue and one
with the smallest. Patients treated by the first group had a
significantly larger reduction of fatigue severity (15.7 vs 9.0;
t=2.42; P=.02). There were no (statistically significant)
correlations between therapists’ attitudes and reduction in
fatigue. Conclusions: This study is one of the first to evaluate
stepped care with I-CBT as a first step in routine clinical care.
Although fatigue severity and disabilities were reduced, reduction
of fatigue severity appeared smaller than in the clinical trial.
Further development of the treatment should aim at avoiding dropout
and encouraging stepping up after I-CBT with limited results.
Median reduction of fatigue severity varied largely between
therapists. Further research will help understand the role of
therapists’ attitudes in treatment outcome.

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Internet-Based Cognitive Behavioral Therapy for Chronic Fatigue Syndrome Integrated in Routine Clinical Care: Implementation Study