Dear Dr Smith, 

I’m saddened to see that the BMJ have maintained their tradition of publishing flawed research on chronic fatigue syndrome (CFS).  Here are just a few of the ‘oddities’, which I noticed in the paper by Powell et al¹. 

1. Use of out-dated criteria, which are known to lack specificity.
2. Use of a fatigue scale, which does not differentiate between patients with CFS and depression.
3. Use of a scoring system, which does not distinguish between degrees of   fatigue (e.g. there’s no distinction between feeling worse than usual and much worse than usual.)
4. Use of a subscale from the MOS, which gives only minimal information about one aspect of disability (ability to walk one block, climb one flight of stairs, carry groceries etc but only one question on self-care).
5. There is no information on the extent of the avoidance behaviour reported at baseline and no data on the activity levels after treatment.
6. There is no information on the percentage of patients with marked or clinical anxiety and depression.
7. The only symptoms assessed were fatigue, emotional distress and sleeping problems. There is no indication that these patients also had post-exertional malaise, sore throats, unusual headaches, or any of the other complaints documented in more strictly defined populations with CFS.
8. The explanation assumes that inactivity and lack of fitness play a major role in the perpetuation of the illness. However, deconditioning cannot explain symptoms such as sore throats, tender glands, vertigo, visual disturbances and intolerance to alcohol. 
9. Research has also failed to support the authors’ rationale. Studies have shown that most of these individuals do not avoid minimal activity and that lack of fitness is not related to the fatigue in CFS^{2 3 4}. Moreover, deconditioning cannot explain the documented delay between the end of exertion and the exacerbation of symptoms, the upregulated immune system etc⁵. In short, one would think that the explanation wouldn’t have made much sense to the majority of patients.  At least, not if they were representative of this population.  
10. It is hard to believe that a disabling disorder like CFS will respond to three hours of explanation and encouragement. If it were that easy, I’d have been a millionaire years ago and none of us would be wasting our time doing expensive research on immune function etc.

I don’t know what these patients were suffering from, other than fatigue, anxiety and depression. The information provided suggests that a significant proportion of these patients were tired because of various psychological problems, which would explain why they accepted the explanation so readily (three hours!) and the positive response to treatment.

I’m surprised the paper was accepted in this form. Would a trial on breast cancer have been published if the authors used out-of -date criteria, measured tumour size from poor quality mammograms and totally ignored relevant variables like the effect on metastases? Until the BMJ starts applying the same rules to CFS as it does to studies on cancer, arthritis and MMR, I’ll continue to get my information on this illness from the American journals and Medline!  Even the News of the World publishes more accurate articles on CFS!

Yours faithfully,

Ellen Goudsmit
Chartered Health Psychologist and Medical Archivist