Commentary

The well done review by Whiting et al does not help physicians much. In the included studies, the treatment of CFS was done by mental health and other specialists. Thus, as physicians, we must consider the data in regards to whether to refer. Qualified support exists for graded exercise treatment and cognitive behavioural therapy, but it is unknown whether the treatment effect lasts longer than a few months, and some studies reported high drop out rates.

The absence of a standard definition of CFS jeopardises interpretation. Many researchers have found so much overlap with other syndromes, such as the irritable bowel syndrome and fibromyalgia, that they posit that any definition of CFS is meaningless.^1,2 They suggest we view syndromes like CFS as artifacts of specialisation that obscure the true problem of medically unexplained symptoms, which is the appropriate focus for our research and therapeutic efforts.^1,2

I was struck by the erratically positive results across many unrelated studies. I suggest that the provider–patient relationship is the common feature, although it was not reported by the author and I have never seen it reported with controlled interventions in these populations; however, variations in the relationship may account for the variably positive results with so many unrelated treatments. The provider–patient relationship, in any event, is an appropriate focus for physicians in managing patients with CFS and can be useful in arranging referral to mental health specialists.³