Internet-based Cognitive Behaviour Therapy (I-CBT) for chronic fatigue syndrome integrated in routine clinical care: an implementation study. (Preprint)

BACKGROUND In a clinical trial, web-based cognitive behaviour therapy (I-CBT) embedded in stepped care was found to be non-inferior to face-to-face (f2f) CBT for chronic fatigue syndrome. However, results of clinical trials are not necessarily retained after implementation. OBJECTIVE Our aim was to investigate whether stepped care starting with I-CBT, followed by f2f CBT is also effective in routine clinical care. Second aim was to explore the role of therapist attitudes towards e-health and manualised treatment on reduction of fatigue severity. METHODS I-CBT was implemented in five mental health care centres (MHCs) with nine treatment sites throughout the Netherlands. All patients with chronic fatigue syndrome were offered I-CBT, followed by f2f CBT if still severely fatigued or disabled after I-CBT. Outcomes were fatigue severity (Checklist Individual Strength), physical and social functioning (SF-36) and limitations in daily functioning (Work and social adjustment scale). The change scores were compared to a benchmark, derived from an RCT testing this treatment format. We calculated correlations of therapists' attitudes towards manualised treatment and e-health with reduction of fatigue severity. RESULTS In total, 100 CFS patients were referred to the centres. Of them, 79 started with I-CBT, 20 commenced directly with f2f CBT and one did not start at all. After I-CBT, 11 stepped up to f2f CBT. Increase in physical functioning (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 was smaller in the MHCs (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). Therapists were divided into two groups, one with the largest median reduction of fatigue and one with the smallest median reduction. Patients treated by first group had a significantly larger reduction of fatigue severity (15.7 versus 9.0, T=2.42 (P=.02)). There were no (statistically significant) correlations between therapists’ attitudes and reduction of fatigue severity. 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 after the treatment form, there are indications that the reduction of fatigue severity is lower than in the clinical trial. Further development of the treatment should aim at avoiding drop-out and at encouraging stepping up after I-CBT with limited results. Median reduction of fatigue severity varied largely between therapists. An investigation with more patients per therapist is needed to draw conclusions on the role of therapists' attitudes in treatment outcome.