TGI Friday! Our weekly round-up of recently published research abstracts | 16 January 2015

January 16, 2015

From Fatigue: Biomedicine, Health & Behavior, 7 January 2014 (epublished before print).

Long-term follow-up of multi-disciplinary outpatient treatment for chronic fatigue syndrome/myalgic encephalopathy

Amalia Houlton(a,*), Marilyn M. Christie(a), Bozena Smith(b) & Eric Gardiner(c)
a) Department of Clinical Psychology, University of Leicester, Leicester, UK
b) CFS/ME Service, Rehabilitation Services, Royal Derby Hospital, Derby, UK
c) Department of Psychological Health and Wellbeing, University of Hull, Hull, UK



The current study evaluated the long-term effectiveness of a multi-disciplinary approach to chronic fatigue syndrome/myalgic encephalopathy (CFS/ME) in a UK outpatient service.


A longitudinal questionnaire survey was posted to 300 patients, incorporating measures of fatigue, physical functioning, mental health, and pain. Outcome measures administered at baseline (prior to service use) were compared to assessments at discharge, and at follow-up (average 34 months post-intervention).


Linear mixed modelling showed that fatigue, physical functioning, and depression significantly improved, although the improvement was reduced for fatigue, physical functioning, and pain at follow-up. Gainful employment had a significant positive association with most


The targeted multi-disciplinary service appeared to be at least somewhat effective long-term, and highly acceptable to patients. Patients appeared to benefit from individual and group approaches that combined cognitive behavioural therapy, graded exercise therapy, and

From PLosOne, 9 January 2014 (open access journal).

The association between daytime napping and cognitive functioning in Chronic Fatigue Syndrome

Zoe M. Gotts(1,*), Jason G. Ellis(1), Vincent Deary(1), Nicola Barclay (1), Julia L. Newton(2)
1) Faculty of Health and Life Sciences, Northumbria University, Newcastle-upon-Tyne, United Kingdom
2) Institute of Cellular Medicine, Medical School, Newcastle University & Newcastle Hospitals NHS Foundation Trust and UK NIHR Biomedical Research Centre in Ageing, Newcastle-upon-Tyne, United Kingdom
* Correspondence to



The precise relationship between sleep and physical and mental functioning in chronic fatigue syndrome (CFS) has not been examined directly, nor has the impact of daytime napping. This study aimed to examine self-reported sleep in patients with CFS and explore whether sleep quality and daytime napping, specific patient characteristics (gender, illness length) and levels of anxiety and depression, predicted daytime fatigue severity, levels of daytime sleepiness and cognitive functioning, all key dimensions of the illness experience.


118 adults meeting the 1994 CDC case criteria for CFS completed a standardised sleep diary over 14 days. Momentary functional assessments of fatigue, sleepiness, cognition and mood were completed by patients as part of usual care. Levels of daytime functioning and disability were quantified using symptom assessment tools, measuring fatigue (Chalder Fatigue Scale), sleepiness (Epworth Sleepiness Scale), cognitive functioning (Trail Making Test, Cognitive Failures Questionnaire), and mood (Hospital Anxiety and Depression Scale).


Hierarchical Regressions demonstrated that a shorter time since diagnosis, higher depression and longer wake time after sleep onset predicted 23.4% of the variance in fatigue severity (p <.001). Being male, higher depression and more afternoon naps predicted 25.6% of the variance in objective cognitive dysfunction (p <.001). Higher anxiety and depression and morning napping predicted 32.2% of the variance in subjective cognitive dysfunction (p <.001). When patients were classified into groups of mild and moderate sleepiness, those with longer daytime naps, those who mainly napped in the afternoon, and those with higher levels of anxiety, were more likely to be in the moderately sleepy group.CONCLUSIONSNapping, particularly in the afternoon is associated with poorer cognitive functioning and more daytime sleepiness in CFS. These findings have clinical implications for symptom management strategies.

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From The Lancet Psychiatry, 13 January 2014.

Rehabilitative therapies for chronic fatigue syndrome: a secondary mediation analysis of the PACE trial

Prof Trudie Chalder PhD†, Kimberley A Goldsmith PhD†, Prof Peter D White MD, Prof Michael Sharpe MD, Prof Andrew R Pickles, PhD
† Contributed equally



Cognitive behaviour therapy (CBT) added to specialist medical care (SMC), or graded exercise therapy (GET) added to SMC, are more effective in reducing fatigue and improving physical function than both adaptive pacing therapy (APT) plus SMC and SMC alone for chronic fatigue syndrome. We investigate putative treatment mechanisms.


We did a planned secondary mediation analysis of the PACE trial comparing SMC alone or SMC plus APT with SMC plus CBT and SMC plus GET for patients with chronic fatigue syndrome. 641 participants were recruited from six specialist chronic fatigue syndrome clinics in the UK National Health Service between March 18, 2005, and Nov 28, 2008. We assessed mediation using the product of coefficients method with the 12 week measure of the mediators and the 52 week measure of the outcomes. The primary outcomes were fatigue measured by the Chalder fatigue scale and physical function measured by the physical function subscale of the SF-36. We included confounder covariates and used treatment by mediator interaction terms to examine differences in mediator–outcome relations by treatment group.


The largest mediated effect for both CBT and GET and both primary outcomes was through fear avoidance beliefs with an effect of larger magnitude for GET (standardised effects ×10, CBT vs APT, fatigue −1·22, 95% CI −0·52 to −1·97, physical function 1·54, 0·86 to 2·31; GET vs APT, fatigue −1·86, −0·80 to −2·89, physical function 2·35, 1·35 to 3·39). Increase in exercise tolerance (6 min walk distance) was a potent mediator of the effect of GET (vs APT, fatigue −1·37, 95% CI −0·76 to −2·21, physical function 1·90, 1·10 to 2·91), but not CBT.


Our main finding was that fear avoidance beliefs were the strongest mediator for both CBT and GET. Changes in both beliefs and behaviour mediated the effects of both CBT and GET, but more so for GET. The results support a treatment model in which both beliefs and behaviour play a part in perpetuating fatigue and disability in chronic fatigue syndrome.


UK Medical Research Council, Department of Health for England, Scottish Chief Scientist Office, Department for Work and Pensions, National Institute for Health Research (NIHR), NIHR Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust, and Institute of Psychiatry, Psychology, and Neuroscience, King's College London.

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