My Letter to Psych Medicine About Professor Chalder’s Flawed Systematic Review

By David Tuller, DrPH

Earlier this week, I wrote about the bogus systematic review of treatment trials for “chronic fatigue syndrome” published this month by Professor Trudie Chalder in Psychological Medicine. In many respects, as I noted, this journal functions a an in-house marketing or public relations organ for members of the CBT/GET ideological brigades, of which Professor Chalder is a charter member. (Professors Michael Sharpe and Simon Wessely are on the Psychological Medicine editorial board. Enough said.)

In addition to formally submitting the article through the journal’s online portal, I also posted it on a pre-print server and sent it directly to the two co-editors of the journal. Here it is.


Letter to Psychological Medicine

Dear Professors Kendler and Murray:

In “A systematic review of randomized controlled trials evaluating prognosis following treatment of adults with chronic fatigue syndrome” (Ingman et al, 2022), the authors cite a 2007 guideline from the National Institute for Health and Care Excellence (NICE, 2007). However, they do not mention that it has been replaced by a new version, which was published last year and reversed the agency’s 2007 recommendations (NICE, 2021). This failure is surprising, since the manuscript was submitted to Psychological Medicine in November, 2021–the month after NICE published the revised guideline. In other words, this systematic review was out-of-date as soon as Psychological Medicine published it on September 5th.

The publication of the new guideline was not a surprise event. In November, 2020—a year before submission of the systematic review to Psychological Medicine—NICE published a draft of the guideline. The draft was. accompanied by an analysis of the relevant data, which rated the quality of evidence for cognitive behaviour therapy (CBT) and graded exercise therapy (GET) as either “very low” or merely “low.” Since the senior author of the review is a long-time proponent of the CBT/GET approach, it is understandable that she might disagree with the latest NICE assessment. Nevertheless, it is the most recent authoritative and consequential statement on the matter. The review authors’ decision to omit all reference to it is unacceptable and indefensible.

Furthermore, the review calls for future studies to “report objective outcomes, in addition to self-report measures.” Given that appeal, it is perplexing and disingenuous that the authors chose to ignore objective outcomes from research actually included in the review—and in particular from the PACE trial (White et al, 2011.)

As described in the PACE protocol (White et al, 2007), the trial included multiple objective outcomes—a six-minute walking test, a step-test for fitness, and measures of employment status and of being in receipt of social or welfare benefits. In contrast to the reports of “improvement” and “recovery” on PACE’s subjective measures, all of these objective outcomes yielded null results or—in the case of GET and the six-minute walking test–statistically significant but clinically insignificant findings. Had the review authors incorporated these poor outcomes rather than deciding to exclude them, they would have had to temper any claims of benefits from CBT and GET.

Finally, the review suggests in a brief aside that McCrone et al, one of the many PACE trial papers, documented “modest increases in employment.” This statement appears to be at odds with the fact that the employment outcome in PACE had null results. Here is the relevant phrasing from McCrone et al: There was no clear difference between treatments in terms of lost employment.” This clear misstatement warrants a correction.

Marred by these serious lapses, this systematic review comes across more as a marketing or public relations document than as a legitimate work of science by disinterested investigators. It is troubling that Psychological Medicine’s editors and peer reviewers did not notice or care about these substantive deficiencies.

Best–David Tuller

David Tuller, DrPH
Senior Fellow in Public Health and Journalism
Center for Global Public Health
School of Public Health
University of California, Berkeley


Ingman, T., Smakowski, A., Goldsmith, K., & Chalder, T. (2022). A systematic literature review of randomized controlled trials evaluating prognosis following treatment for adults with chronic fatigue syndrome. Psychological Medicine, 1-13.

McCrone, P., Sharpe, M., Chalder, T., Knapp, M., Johnson, A., Goldsmith, K., & White, P. (2012). Adaptive pacing, cognitive behaviour therapy, graded exercise, and specialist medical care for chronic fatigue syndrome: A cost-effectiveness analysis. PLoS ONE, 7(8), 1–9.

National Institute for Health and Care Excellence. (2007). Chronic fatigue syndrome/myalgic encephalomyelitis (or encephalopathy): Diagnosis and management of CFS/ME. (NICE Guideline No. 53).

National Institute for Health and Care Excellence. (2021). Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome): Diagnosis and management. (NICE Guideline NG 206).

White, P. D., Goldsmith, K., Johnson, A. L., Chalder, T., & Sharpe, M. (2013). Recovery from chronic fatigue syndrome after treatments given in the PACE trial. Psychological Medicine, 43(10), 2227–2235.

White, P. D., Goldsmith, K. A., Johnson, A. L., Potts, L., Walwyn, R., DeCesare, J. C., … Sharpe, M. (2011). Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): A randomised trial. Lancet, 377(9768), 823–836.

White, P.D., Sharpe, M.C., Chalder, T., DeCesare, J.C., Walwyn, R., & the PACE trial group. (2007). Protocol for the PACE trial: A randomised controlled trial of adaptive pacing, cognitive behaviour therapy, and graded exercise as supplements to standardised specialist medical care versus standardised specialist medical care alone for patients with the chronic fatigue syndrome/myalgic encephalomyelitis or encephalopathy. BMC Neurology 7,6.

Conflict of Interest Statement: David Tuller’s academic position at the Center for Global Health at the University of California, Berkeley, is funded largely by donations to the university from members of the ME/CFS patient and advocacy communities.