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Ingezonden brief

aan de Lancet

m.b.t. kritiek op FITNET

(publicatie afgewezen)






Onderstaande brief, waarin kritiek geleverd wordt op de FITNET CGT/GET-studie,

aan de redacteur van de Lancet werd zonder steekhoudende argumenten geweigerd.


Afgaande op de laatste tien jaar, publiceert The Lancet kennelijk alleen artikelen die de CGT/GET-mythe in stand houden en lichtkritische kanttekeningen op CGT/GET-studies.




Dear Editor,



According to (1) (42/67, 63%) of the adolescents with CFS (2) (12–18 years) recovers with FITNET: internet based-cognitive behavorial therapy (CBT).


Recovery was defined post hoc with cut-off-scores fixed at mean of healthy controls + 2 standard deviations (SDs) of healthy controls, for fatigue (Checklist Individual Strength-20, CIS-20); physical functioning; and school absence in the past 2 weeks, at 6 months. In addition, patients were judged to be recovered if they had rated themselves as being 'completely recovered' or as 'feeling much better' (1).


Face-to-face CBT and/or GET are apparently ineffective. Even if the success rate of usual care is fully attributed to CBT (n=44) or GET (n=33), and even if liberal criteria for "recovery" are applied, the effectiveness of CBT and GET, i.e. 11,4% (5/44) and 15,2% (5/33) respectively, is largely insufficient.


Table 3b (Appendix) shows that using cut-off scores one standard deviation above/below that of healthy adolescents, recovery is just 36%. The vast majority of patients didn't improve substantially, let alone recovered.


A score below a liberal cut-off score for fatigue and physical functioning after CBT/GET is not the same as not recovering from CFS. In addition to unexplainable fatigue, at least 4 out of 8 minor symptoms should be present, e.g. muscle pain, memory and concentration difficulties, and post-exertional "malaise": an increase in symptoms after a minor exertion (1). A (slight) improvement in fatigue and physical functioning doesn’t imply that symptoms have disappeared. Only 39% of the patients judged themselves to be recovered after CBT/GET (1).


No other objective data other than school absence, were collected. A reduction in school absence alone is insufficient to define recovery or improvement, since it is known that in CFS one activity is often at the expense of another.


The conclusions of the FITNET-trial (1) do not match the facts. Internet-based CBT/GET redu-ces some symptoms, e.g. self-rated fatigue, in approximately one-third of the CFS patients.


A large-scale randomized controlled trial (RCT) (3) showed that, based upon the "fatigue" criterion, only 30% "recovers" from CFS by CBT and/or GET (4). Using objective measurements, the clinical improvement was insufficient to conclude that CBT yields some efficacy. Even more, a RCT (5) and patient surveys (6) indicate that CBT/GET has a negative impact on many patients. Because a minor exertion intensifies pre-existing abnormalities in ME/CFS (6), this is not very surprising.



  1. Nijhof SL, Bleijenberg G, Uiterwaal CSPM, Kimpen JLL, M vdPE. Effectiveness of internet-based cognitive behavioural treatment for adolescents with chronic fatigue syndrome (FITNET): a randomised controlled trial. Lancet. 2012 Mar 1. doi :10.1016/S0140-6736(12)60025-7.
  2. Fukuda K, Straus SE, Hickie I, Sharpe M, Dobbins JG, Komaroff AL. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med. 1994;121(12):953-959. doi: 10.1059/0003-4819-121-12-199412150-00009.
  3. White PD, Goldsmith KA, Johnson AL, Potts L, Walwyn R, DeCesare JC, et al. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. The Lancet. 2011 Mar 5;377(9768):823-836. doi:10.1016/S0140-6736(11)60096-2.
  4. Bleijenberg G, Knoop H. Chronic fatigue syndrome: where to PACE from here? The Lancet. 2011 Mar 5;377(9768):786-788. doi:10.1016/S0140-6736(11)60172-4.
  5. Núñez M, Fernández-Solà J, Nuñez E, Fernández-Huerta JM, Godás-Sieso T, Gomez-Gil E. Health-related quality of life in patients with chronic fatigue syndrome: group cognitive behavioural therapy and graded exercise versus usual treatment. A randomised controlled trial with 1 year of follow-up. Clin Rheumatol. 2011 Mar;30(3):381-389. doi: 10.1007/s10067-010-1677-y.
  6. Twisk FNM, Maes M. A review on Cognitive Behavorial Therapy (CBT) and Graded Exercise Therapy (GET) in Myalgic Encephalomyelitis (ME) / Chronic Fatigue Syndrome (CFS): CBT/GET is not only ineffective and not evidence-based, but also potentially harmful for many patients. Neuro Endocrinol Lett. 2009;30(3):284-299.
  7. Ridsdale L, Hurley M, King M, McCrone P, Donaldson N. The effect of counselling, graded exercise and usual care for people with chronic fatigue in primary care: a randomized trial. Psychol Med. 2012. doi:10.1017/S0033291712000256.
  8. Nijhof SL, Bleijenberg G, Uiterwaal CS, Kimpen JL, van de Putte EM. Fatigue In Teenagers on the interNET--the FITNET Trial. A randomized clinical trial of web-based cognitive behavioural therapy for adolescents with chronic fatigue syndrome: study protocol. [ISRCTN59878666]. BMC Neurol. 2011 Feb 19;11:23. doi:10.1186/1471-2377-11-23.