The Updated NICE Guidance Exposed the Serious Flaws in CBT and Graded Exercise Therapy Trials for ME/CFS
Open accessAbstract
The British National Institute for Health and Care Excellence (NICE) recently published its updated guidelines for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). NICE concluded, after an extensive review of the literature, that graded exercise therapy (GET) is harmful and should not be used, and that cognitive behavioural therapy (CBT) is only an adjunctive and not a curative treatment. Leading proponents of the cognitive behavioural model (CBmodel) find it difficult to accept this paradigm shift. In, for example, an article in The Lancet, they try to argue that the new NICE guideline is based on ideology instead of science. In this article we reviewed the evidence they used to support their claims. Our analysis shows that the trials they used in support suffered from serious flaws which included badly designed control groups, relying on subjective primary outcomes in non-blinded studies, including patients in their trials who didn’t have the disease under investigation or had a self-limiting disease, selective reporting, outcome switching and making extensive endpoint changes, which created an overlap in entry and recovery criteria, using a post-hoc definition of recovery which included the severely ill, not publishing results that contradict their own conclusion, ignoring their own (objective) null effect, etc. The flaws in these trials all created a bias in favour of the interventions. Despite all these flaws, treatments that are said to lead to recovery in reality do not lead to objective improvement. Therefore, these studies do not support the claim that CBT and GET are effective treatments. Moreover, the arguments that are used to claim that NICE was wrong, in reality, highlight the absence of evidence for the safety and efficacy of CBT and GET and strengthen the decision by NICE to drop CBT and GET as curative treatments for ME/CFS.
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One major criticism of psychotherapy trials in CFS is a lack of blinding.
“For example, one major criticism of psychotherapy trials in CFS is a lack of blinding [56].”
From Efficacy and Acceptance of Cognitive Behavioral Therapy in Adults with Chronic Fatigue Syndrome: A Meta-analysis. (2024) · cites this paper as [56]
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Gloeckl, R., Zwick, R. H., Fürlinger, U., Schneeberger, T., Leitl, D., Jarosch, I., Behrends, U., Scheibenbogen, C., & Koczulla, A. R. (2024) · Sports Medicine - Open · doi:10.1186/s40798-024-00695-8 · Cited by 83 · see citing works
Lived experience of patients with Long COVID: a qualitative study in the UK
Thomas, C., Faghy, M. A., Owen, R., Yates, J., Ferraro, F., Bewick, T., Haggan, K., & Ashton, R. E. M. (2023) · BMJ Open · doi:10.1136/bmjopen-2022-068481 · Cited by 82 · see citing works
Thoma, M., Froehlich, L., Hattesohl, D. B. R., Quante, S., Jason, L. A., & Scheibenbogen, C. (2023) · Medicina · doi:10.3390/medicina60010083 · Cited by 32 · see citing works
Hoffmann, K., Hainzl, A., Stingl, M., Kurz, K., Biesenbach, B., Bammer, C., Behrends, U., Broxtermann, W., Buchmayer, F., Cavini, A. M., et al. (2024) · Wiener klinische Wochenschrift · doi:10.1007/s00508-024-02372-y · Cited by 30 · see citing works
van Campen, C. M. C., & Visser, F. C. (2022) · Healthcare · doi:10.3390/healthcare10102058 · Cited by 30 · see citing works
Pagen, D., van Herck, M., van Bilsen, C. J. V., Brinkhues, S., Konings, K., den Heijer, C. D., Spruit, M., Hoebe, C., & Dukers-Muijrers, N. (2023) · medRxiv · doi:10.3389/fmed.2023.1292446 · Cited by 21 · see citing works
Maas genannt Bermpohl, F., Kucharczyk-Bodenburg, A.-C., & Martin, A. (2024) · International Journal of Behavioral Medicine · doi:10.1007/s12529-023-10254-2 · Cited by 29 · see citing works
“This has partly been criticized [56].”
Postacute Sequelae of COVID (PASC or Long COVID): An Evidenced-Based Approach
Griffin, D. O. (2024) · Open Forum Infectious Diseases · doi:10.1093/ofid/ofae462 · Cited by 27 · see citing works
Kielland, A., Liu, J., & Jason, L. A. (2023) · Journal of Health Psychology · doi:10.1177/13591053231169191 · Cited by 24 · see citing works
Designing and optimizing clinical trials for long COVID
Vogel, J. M., Pollack, B., Spier, E., McCorkell, L., Jaudon, T. W., Fitzgerald, M., Davis, H., & Cohen, A. K. (2024) · Life Sciences · doi:10.1016/j.lfs.2024.122970 · Cited by 16 · see citing works
Kingdon, C. C., Lowe, A., Shepherd, C., & Nacul, L. (2022) · Healthcare · doi:10.3390/healthcare10122438 · Cited by 11 · see citing works
A new clinical challenge: supporting patients coping with the long-term effects of COVID-19
Goldberg, N. C., Poirier, S., Kanas, A., McCorkell, L., McGinn, C. A., Re’em, Y., Kuehnel, K., Muirhead, N., Ruschioni, T., Taylor-Brown, S., et al. (2022) · Fatigue Biomedicine Health & Behavior · doi:10.1080/21641846.2022.2128576 · Cited by 9 · see citing works
Nagra, G., Ezeugwu, V. E., Bostick, G. P., Branton, E., Dennett, L., Drake, K., Durand-Moreau, Q. V., Guptill, C. A., Hall, M., Ho, C., et al. (2025) · PLoS ONE · doi:10.1371/journal.pone.0321891 · Cited by 7 · see citing works
Dekerle, J., Wrightson, J. G., & Greenhouse‐Tucknott, A. (2025) · Sports Medicine · doi:10.1007/s40279-025-02252-z · Cited by 5 · see citing works
Contested and neglected: Social and medical marginalization in severe Chronic Fatigue Syndrome
Nezamdoust, B., & Ruel, E. E. (2025) · Social Science & Medicine · doi:10.1016/j.socscimed.2025.118766 · Cited by 4 · see citing works
Lipedema Research RoadmapPreprint
Daftuar, F., Eakin, G. S., Galia, S., Harmacek, L. D., Kartt, J., & Peterson, S. D. (2023) · doi:10.31219/osf.io/bx6rt · Cited by 4 · see citing works
Ammari, T. (2026) · Social Science & Medicine · doi:10.1016/j.socscimed.2026.119593 · Cited by 4 · see citing works
Monaco, F., Vignapiano, A., D’Angelo, M., Raffone, F., Stefano, V. D., Boccia, A., Longobardi, A., Gruttola, B. D., Fornaro, M., Corrivetti, G., et al. (2025) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2025.1576179 · Cited by 3 · see citing works
Adamowicz, J. L., Thomas, E. B. K., Lund, B. C., Driscoll, M., Weg, M. W. V., & Hadlandsmyth, K. (2023) · Fatigue Biomedicine Health & Behavior · doi:10.1080/21641846.2023.2239977 · Cited by 3 · see citing works
Die Übersicht zur aktuellen Evidenz ignoriert die aktuelle Evidenz
Jason, L. A., Behrends, U., Blitshteyn, S., Gerner, P., Grande, B., Grande, T., Hammer, S. S., Hoffmann, K., Kohl, M., Renz‐Polster, H., et al. (2023) · Der Nervenarzt · doi:10.1007/s00115-023-01515-2 · Cited by 2 · see citing works
Self-citationExploring the influence of long-COVID on physical activities
Nadesan, T. T., Thethwayo, M. S., Maddocks, S. T., & Chetty, V. (2025) · South African Journal of Physiotherapy · doi:10.4102/sajp.v81i1.2267 · Cited by 1 · see citing works
Tuina therapy for patients with chronic fatigue syndrome: a randomized controlled trial
Wang, S., Ren, J. Y., Zhou, X., Fang, S., He, T., Wu, Z., Xu, S., Kong, L., & Fang, M. (2026) · Journal of Translational Medicine · doi:10.1186/s12967-025-07624-7 · Cited by 1 · see citing works
Friedberg, A., McConnell, E., Stanwick, S., Perez, L. F., MacEwan, S. R., Rush, L. J., Burpee, S. B., Smith, R. M., Joshi, S., Woschkolup, K., et al. (2026) · Journal of General Internal Medicine · doi:10.1007/s11606-026-10307-8 · Cited by 1 · see citing works
Reframing ME/CFS: toward a unified mechanistic model of chronic post-infectious diseases
Watton, P. N., & Prusty, B. K. (2026) · Journal of Translational Medicine · doi:10.1186/s12967-026-08319-3 · Cited by 1 · see citing works
Portch, E., Moseley, R. L., Wignall, L., Turner‐Cobb, J. M., Taylor, Z., & Gondelle, M. (2023) · Psychology and Health · doi:10.1080/08870446.2023.2220009 · Cited by 1 · see citing works
Interdisziplinäre multimodale Schmerztherapie bei postviralen Syndromen und ME/CFS
Luchting, B., Behrends, U., Eigner, B., STOJANOV, S., Warlitz, C., Haegele, M., Neuwirth, E., Mihatsch, L., & Richter, H. P. (2023) · Der Schmerz · doi:10.1007/s00482-023-00761-2 · Cited by 1 · see citing works
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Spickett, G. (2025) · doi:10.1093/med/9780198962137.003.0008
Managing myalgic encephalomyelitis/chronic fatigue syndrome: a new narrative
Grach, S. L., Seltzer, J. L., Bell, J., Ganesh, R., & Yellman, B. P. (2025) · Elsevier eBooks · doi:10.1016/b978-0-443-24080-5.00039-4
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Gloeckl, R., Zwick, R. H., Fürlinger, U., Schneeberger, T., Leitl, D., Jarosch, I., Behrends, U., Scheibenbogen, C., & Koczulla, A. R. (2024) · Figshare · doi:10.6084/m9.figshare.25687420
Fricke, C., Deibert, P., Maier, P., Kern, W. V., Krumnau, O., & Barsch, F. (2026) · BMJ Open · doi:10.1136/bmjopen-2025-113095
Epistemology, pharmacology, knowledge sources, and legal responsibility for accurate information
Gillman, P. K. (2026) · Drug Science Policy and Law · doi:10.1177/20503245261446531
Sirotiak, Z., Oberhauser, A. M., Sirotiak, A. M., Nettleton, K. A., Lee, D.-C., Thomas, E. B. K., & Brellenthin, A. G. (2026) · PLoS ONE · doi:10.1371/journal.pone.0350121
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- Authors
- Vink, M., & Vink-Niese, A.
- Affiliations
- Independent Researcher, 1096 HZ Amsterdam, The Netherlands
- Independent Researcher, 30159 Hannover, Germany
- Corresponding author
- Vink, Mark
- Venue
- Healthcare
- Publisher
- MDPI AG
- Published
- 2022-05-12
- Volume
- 10
- Issue
- 5
- Pages
- 898
- ISSN
- 2227-9032 (ISSN-L)
- PMC
- PMC9141828
- OpenAlex
- W4280620338
- Cited by
- 38
- References
- 77
- Citations by year
- 2026: 8 · 2025: 10 · 2024: 7 · 2023: 10 · 2022: 3
- FWCI
- 1.29
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Healthcare (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Fibromyalgia and Chronic Fatigue Syndrome Research
- Health Sciences › Medicine › Neurology › Long-Term Effects of COVID-19
- Health Sciences › Medicine › Epidemiology › Traumatic Brain Injury Research
- Keywords
- chronic fatigue syndrome, NICE guidelines, cognitive behavioral therapy, graded exercise therapy, trial design flaws, selective reporting, self-limiting disease, recovery criteria, treatment efficacy and safety, evidence-based medicine
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
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