And Now–No Surprise–CBT for Post-Covid Fatigue

By David Tuller, DrPH

Old habits die hard. So do bad ideas. Especially when these old habits and bad ideas have formed the basis for prominent academic and medical careers in the UK and the Netherlands.

In the UK, Professor Trudie Chalder of King’s College London has advised patients with prolonged fatigue after an acute bout of Covid-19 that they should get back to regular activities quickly and avoid resting too much. The effort from the UK National Health Service called “Your COVID Recovery” promotes a course of increasing exercise based on what appears to be a deconditioning model–despite lack of evidence that the exhaustion experienced by many post-Covid patients is mainly the result of deconditioning.

In the Netherlands, the Dutch health research agency ZonMw has proposed a welcome and long-overdue investment of almost $30 million (€25 million) over ten years in biomedical research into ME/CFS (more about that later). At the same time, the agency has also announced support for another effort by Professor Hans Knoop in his longstanding campaign to promote cognitive behavior therapy. His new study, highlighted along with dozens of others about Covid-19 on the ZonMw website, is called: ReCOVer: Can Cognitive Behavioral Therapy via the Internet prevent the fatigue symptoms of COVID-19 patients from becoming chronic? A controlled and randomized trial

Here we go again.

Professor Knoop, a psychologist at Amsterdam University, demonstrated his willingness to make preposterous claims with a co-authored commentary published alongside the 2011 PACE trial report in The Lancet. Professor Knoop and his co-author falsely claimed that 30 percent of those who received CBT or graded exercise therapy met a “strict criterion” for recovery. The commentary was disinformation–I documented its Trumpian misrepresentations and misstatements a few years ago. It remains an embarrassment to the medical literature, as does the PACE trial itself.

So I’m not surprised Professor Knoop would propose a course of CBT to prevent post-Covid fatigue from becoming chronic. I’m somewhat more surprised that Dutch funders are falling for the same sort of biopsychosocialbabble all over again. Perhaps they needed to allow Professor Knoop to save face after the decision to throw their weight behind the biomedical research effort.


Here’s the description of the Professor Knoop’s study on the ZonMw site:

A substantial subgroup of COVID-19 patients is expected to develop chronic fatigue, that is, severe fatigue persisting for more than 6 months with associated adverse effects on the patient’s health, functioning and social participation. It is hypothesized that the timely provision of internet-based cognitive behavioral therapy (iCBT) for fatigue leads to a significant and clinically relevant reduction in fatigue severity after the intervention.

The study consists of a randomized, controlled study, in patients with fatigue symptoms 3 to 6 months after discharge from the hospital or after the diagnosis of COVID-19. One group is treated with iCBT and the other group in the regular manner.

The trial rests on a questionable notion: that CBT will prevent fatigue from becoming chronic. The available information does not elaborate on the hypothesis behind the study. Based on Professor Knoop’s history, the idea is likely to be that people recovering from acute Covid-19 will need therapeutic encouragement and psychological intervention to get back to their regular activities–that for a range of reasons they will be less willing or able to do so without professional assistance. In selling the premise, Professor Knoop perhaps cited the PACE trial, his own FITNET trial and/or other methodologically challenged studies from the CBT/GET ideological brigades.

The basis of such an assumption, especially in the case of a completely new viral disease, is not clear. Many, many people are suffering from overwhelming exhaustion and a range of other symptoms as part of post-covid syndrome. Perhaps it is true that, after the awful experience of the acute illness, some are mis-interpreting normal deconditioning as an excuse not to test the bounds of their capacities. Perhaps they will need psychotherapy to convince them to get moving again.

However, in the many accounts of post-Covid syndrome being posted online and discussed in news articles, I have seen little to suggest that patients’ reported exhaustion and other symptoms are related to unhelpful beliefs about their state of health or an irrational fear of engaging in activities they enjoy. Most of them sound desperate to get back to their lives. So the CBT approach does not sound promising to me, although it would be helpful to have more information.

In any event, the premise is likely not far from the animating concept behind the CBT/GET treatment paradigm for what these investigators prefer to call chronic fatigue syndrome. So it makes sense that Professor Knoop would like to apply the same template to post-Covid syndrome patients. But reanalyses of the PACE data have demonstrated that the interventions produced either null results or self-reported benefits well within the range of a placebo response. Moreover, all the reported benefits had dissipated by the follow-up study. Despite inflated claims of treatment efficacy, other methodologically challenged CBT studies of CFS have yielded similarly unimpressive results.

I assume that, like most of these studies, Professor Knoop’s new research will rely on subjective outcomes of fatigue and other indicators. Subjective or self-reported outcomes are not a problem when participants and clinicians are blinded to treatment assignment. But when interventions cannot be blinded, as in this case, subjective responses are likely to be fraught with bias. They are essentially uninterpretable.

That will be the situation with this study. The investigators will claim success anyway, if past is any guide. The question is whether anyone will believe them this time around.





9 responses to “And Now–No Surprise–CBT for Post-Covid Fatigue”

  1. Dr E Goudsmit Avatar
    Dr E Goudsmit

    As expected. Let’s hope the victims, many of whom will be medics, don’t fall for this ridiculous narrative. And use the strongest arguments against it.

  2. Barry C Avatar
    Barry C

    The ‘treatment’ is for patients supposedly suffering from deconditioning, and supposedly having unhelpful beliefs preventing them exercising their way back to health. Supposedly. The ‘treatment’ therefore directs patients to ignore their body’s distress signals and push through regardless of symptoms,

    So the only way people discover about being harmed … is once it is too late and they have been permanently harmed!

    These unblinded, subjective outcome trials not only fail to preempt such problems, but are designed to actively mask their detection. The presumption of deconditioning, without strong safeguards for those not suffering from it, is fraught with dangers for patients as well as trial participants.

    A ‘treatment’ that embodies the concept of Russian roulette.

  3. CT Avatar

    Thanks for flagging up this new study.

    I wonder if the ‘regular manner’ of treating fatigued patients in the Netherlands is with contempt and derision too?

  4. Lou Corsius Avatar
    Lou Corsius

    @CT: it is. In spite of the Health Council advice d.d. 2018 ME/cfs is considered by most professionals to be MUS. The assumption of sickness maintaining beliefs and deconditioning is still promoted by the bps scientists. The longtime obsolete guideline cfs still advises to apply CBT. Prof Knoop and his colleagues still promote their null result treatment.

  5. Meghan Shannon Avatar
    Meghan Shannon

    Of course.
    What is missing David, is the USA’s large part in making up new disease calling iT CFS.
    And how USA’CDC and NIH- NIAID came together with Stephen Strauss/ NIAID and William Reeves Jr. / CDC, and Anthony Fauci ( whatever position he claims) in large USA federal health meetings inviting UK’ Wessley, Sharpe and White to invent CFS in 1988. Invented a new name Fatigue Syndrome. Then this new name CFS took ove ME.
    Post viral Syndromes are serious and very different from each other depending on the virus and the individual who gets sick, sicker and or dies, genetics .

  6. Anil van der Zee Avatar
    Anil van der Zee

    They will indeed use subjective measures and keep focusing on “chronic fatigue”

    Both #LongCovid and ME are not about being tired or fatigue. It’s just a symptom of many others. They know this. It’s so misleading.

    Very worrying study for those suffering from covid-19. I’m so sorry…

    “It is hypothesized that timely offering iCBT for fatigue, i.e. 3 to 6 months after COVID-19 diagnosis or hospital discharge, will lead to a significant and clinically relevant reduction in fatigue severity (primary outcome) following the intervention, will reduce the proportion of patients who progress to chronic fatigue at follow-up and foster patients’ work ability, physical and social functioning and reduce other somatic symptoms as compared to care as usual.


    We propose a 2-arm randomised controlled trial l in which patients who have recovered from acute COVID-19 but suffer from ongoing severe and debilitating fatigue are randomised to either iCBT or care as usual. The project will be conducted within 24 months. Primary outcome is patients’ fatigue severity, as assessed with the CIS-fatigue at follow up (T1, T2).”

  7. Kim Wilson Avatar
    Kim Wilson

    I can’t believe they are attempting to save historical PACE face by doing this.

    How embarrassing. Something tells me the general public will get behind Post- Covid patients ( when they inevitably decry it’s flawed premise ) in a way they they never bothered to listen to us. After all, everyone is at risk of Covid.

  8. Penny Lloyd Avatar
    Penny Lloyd

    As a retired psychiatrist, and with a daughter aged 47 with long covid, I cannot see where the rationale for this is coming from. The Chronic fatigue/ME folks who have been sorely neglected all these years, will confirm that the only way forward with post viral fatigue is by NOT over doing it. Not over doing anything. CBT is excellent therapy for certain conditions but not only irrelevant for post covid fatigue but contraindicated as it is likely to suggest sufferers and their families that it is “all I the mind” when it is most certainly not.

  9. jimells Avatar

    People have got to fact the fact that there is no room in society for people who can not do a day’s work. The message is stark: chronic illness is a personal moral failing and will not be tolerated. People who can not be profitably exploited will be thrown away.

    Forced sterilization and locking people up in state institutions is presently expensive and unfashionable, so the policy is to deny access to resources. People who ignore the constant implied messages that Useless Eaters should kill themselves, will instead die slowly while living under bridges and eating out of dumpsters.

    Welcome to the New Eugenics.