Elsevier

The Lancet

Volume 379, Issue 9824, 14–20 April 2012, Pages 1412-1418
The Lancet

Articles
Effectiveness of internet-based cognitive behavioural treatment for adolescents with chronic fatigue syndrome (FITNET): a randomised controlled trial

https://doi.org/10.1016/S0140-6736(12)60025-7Get rights and content

Summary

Background

Chronic fatigue syndrome is characterised by persistent fatigue and severe disability. Cognitive behavioural therapy seems to be a promising treatment, but its availability is restricted. We developed Fatigue In Teenagers on the interNET (FITNET), the first dedicated internet-based therapeutic program for adolescents with this disorder, and compared its effectiveness with that of usual care.

Methods

Adolescents aged 12–18 years with chronic fatigue syndrome were assigned to FITNET or usual care in a 1:1 ratio at one tertiary treatment centre in the Netherlands by use of a computer-generated blocked randomisation allocation schedule. The study was open label. Primary outcomes were school attendance, fatigue severity, and physical functioning, and were assessed at 6 months with computerised questionnaires. Analysis was by intention to treat. Thereafter, all patients were offered FITNET if needed. This trial is registered, number ISRCTN59878666.

Findings

68 of 135 adolescents were assigned to FITNET and 67 to usual care, and 67 and 64, respectively, were analysed. FITNET was significantly more effective than was usual care for all dichotomised primary outcomes at 6 months—full school attendance (50 [75%] vs 10 [16%], relative risk 4·8, 95% CI 2·7–8·9; p<0·0001), absence of severe fatigue (57 [85%] vs 17 [27%], 3·2, 2·1–4·9; p<0·0001), and normal physical functioning (52 [78%] vs 13 [20%], 3·8, 2·3–6·3; p<0·0001). No serious adverse events were reported.

Interpretation

FITNET offers a readily accessible and highly effective treatment for adolescents with chronic fatigue syndrome. The results of this study justify implementation on a broader scale.

Funding

Netherlands Organisation for Health Research and Development.

Introduction

Chronic fatigue syndrome, also known as myalgic encephalomyelitis or myalgic encephalopathy, is characterised by disabling persistent (>6 months) or relapsing severe unexplained fatigue that is not the result of ongoing exertion and cannot be alleviated by rest. This fatigue is accompanied by other symptoms such as muscle pain and difficulty concentrating.1 In adolescents, chronic fatigue syndrome often has a protracted course that can lead to much absence from school and long-term detrimental effects on their academic and social development.2, 3, 4, 5

The prevalence of chronic fatigue syndrome has been estimated to be between 0·11% and 1·29% in Dutch, British, and US adolescent populations, with a female-to-male ratio from 2:1 to 5:1.6, 7, 8, 9, 10, 11 Most recent estimations of incidence and prevalence based on diagnosis by the physician are lower than those based on population surveys.6 The lack of treatment options might contribute to physicians being reticent about diagnosing chronic fatigue syndrome.

The results of a 13 years' follow-up study showed that most adolescents had persistent mild-to-moderate symptoms and disruption of school attendance.11 Although untreated chronic fatigue syndrome has a better prognosis in adolescents than in adults, the risk of disruption to social development and education in adolescents requires prompt diagnosis of the syndrome and an effective and accessible treatment.11, 12, 13

The cause of chronic fatigue syndrome is not known, but research has shown that differentiation of triggering, sustaining, and precipitating factors at the biological and psychosocial levels, especially for treatment, would be useful.12, 14 Patients' cognition of perpetuating factors is used in cognitive behavioural therapy, which seems promising in adolescents. Until now, cognitive behavioural therapy for adolescents with chronic fatigue syndrome has only been compared with patients being on a waiting list or receiving psychoeducation, but not treatment as usual, and resulted in a clinically significant improvement of 60–70% directly after treatment.12, 15 The biggest challenge associated with cognitive behavioural therapy is its restricted availability due to the requirement for specialised skills,12, 15 leading to unequal access for adolescent patients. Therefore, alternative ways to enhance the availability of cognitive behavioural therapy are of paramount importance.

Internet-based cognitive behavioural therapy might improve access to treatment.16, 17 It was shown to be effective in patients with illnesses other than chronic fatigue syndrome, but mostly in adults. For adolescents, it has been developed for disorders such as depression,18 anxiety,19 and headache,20 and for smoking cessation,21 but not for chronic fatigue syndrome.

We developed Fatigue In Teenagers on the interNET (FITNET), a comprehensive internet-based application based on existing protocols and a theoretical model of effective face-to-face cognitive behavioural therapy for adolescents,12, 22, 23 specifically for those with chronic fatigue syndrome and their parents. In this program, a skilled therapist would provide support through regular e-mail consultations (e-consultations). We compared the short-term effectiveness of the FITNET program with usual care in reduction of fatigue, school absence, and physical dysfunction in adolescents with chronic fatigue syndrome.

Section snippets

Study population

A detailed description of the study protocol and FITNET program has been reported elsewhere.24 This trial was undertaken at the Wilhelmina Children's Hospital, University Medical Centre Utrecht (UMCU), Utrecht, and the Expert Centre for Chronic Fatigue (ECCF, treatment coordinating centre), Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands. All children were referred to, examined, and randomly assigned at the UMCU.

To achieve nationwide referral, all Dutch paediatricians were

Results

148 adolescents who were diagnosed with chronic fatigue syndrome were screened for eligibility between January, 2008, and February, 2010. 135 (96%) of 141 eligible patients were enrolled (figure). The baseline characteristics of the enrolled adolescents (n=135) and those who did not want to participate (n=6) did not differ (data not shown). No patients were excluded after randomisation. Table 1 shows the baseline characteristics of both groups. All patients started the treatment they were

Discussion

Internet-based cognitive behavioural therapy was much more effective than was usual care, resulting in higher school attendance, diminished severity of fatigue, improved physical functioning, and better self-rated improvement. In patients who recovered with FITNET, treatment success persisted at the 12 months' reassessment. Patients who continued FITNET treatment or switched to FITNET had similar success by 12 months. FITNET is the first randomised controlled trial in which the effectiveness of

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