While COVID is no longer regarded as a global health emergency, it remains a serious disease. Notably, even mild cases can result in persistent symptoms known as long COVID, which can have wide-reaching effects on physical health, mental health and quality of life.
Fatigue is a common symptom of both COVID and long COVID – around eight in ten adults report experiencing it during a COVID infection. And while many people find their fatigue improves within a few weeks, this is not the case for everyone. Estimates suggest that between one in ten and one in three people still have fatigue six months post-COVID. They may or may not have received a formal diagnosis of long COVID.
A recent study has suggested that cognitive behavioural therapy (CBT), a widely used form of “talking therapy”, could help people experiencing persistent fatigue after COVID. So what can we make of this?
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CBT is commonly used to treat mental health issues such as anxiety and depression, but it can also be used for fatigue. For example, CBT has been used as a treatment for people with chronic fatigue syndrome, which has features that overlap with post-COVID fatigue.
CBT for persistent fatigue is based on the idea that by changing what we think, feel and do about our symptoms, we can improve functioning and quality of life.
A review of the evidence on CBT for fatigue published in 2008 indicated that this approach was effective in reducing symptoms of fatigue. However, these conclusions have since been challenged due to inconsistent findings and concerns about the quality of evidence.
A more recent review from 2019 concluded that the benefits of CBT for chronic fatigue syndrome are typically modest and short-lived. And around one in five patients who have received CBT for chronic fatigue report worsening health following therapy.
UK guidelines on the management of chronic fatigue syndrome recommend that CBT be discussed as an option for people living with the condition to support them with managing their symptoms, improving functioning, and reducing the distress associated with persistent fatigue. However, it should be made clear to people considering CBT that it will not cure their condition.
In the absence of evidence to support one approach over another in the context of post-COVID fatigue, World Health Organization clinical guidelines also recommend discussing CBT as an option with patients who have persistent fatigue after COVID to support coping and improve functioning.
What about this new study?
Across multiple centres in the Netherlands, 114 patients who had severe fatigue three to 12 months after COVID were randomly assigned either to a CBT intervention or to care as usual. Usual care might include supervision by their GP, specialist physiotherapy and occupational therapy.
On average, the 57 people in the CBT group underwent 18.7 weeks of therapy with a psychologist. The treatment was delivered through a combination of video, email, face-to-face and telephone consultations, which enabled therapy to continue if physical distancing restrictions were in place.
The CBT programme focused on providing personalised support which addressed factors that can perpetuate fatigue using education, goal setting, and building skills to manage fatigue. There was also a focus on addressing unhelpful beliefs about fatigue, worries about COVID, coping with pain, and improving relationships.
The researchers found that people in the CBT group reported less severe fatigue after the treatment than people in the care-as-usual group, and this was sustained at a six-month follow-up. The CBT group also reported being chronically fatigued less often, fewer problems with concentration, less severe physical symptoms, and improved physical and social functioning after completing CBT and six months later.
Some things to keep in mind
While these results are promising, this was a relatively small study, and most participants referred themselves to the trial. As such, they may have been more motivated to take part in CBT than people with long COVID routinely accessing outpatient services.
Also, the care as usual comparison group doesn’t control for placebo effects or general benefits of seeing a therapist, such as receiving motivation, warmth and encouragement. Without a control group that can account for these effects – such as having people spend time with a therapist without undergoing an “active” form of therapy, or having them receive an alternative type of psychological therapy – it’s difficult to know for sure whether differences observed between the groups were specific to the CBT.
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New or worsening symptoms since starting therapy were recorded for eight people in the CBT group and 20 people in the care-as-usual group. While CBT compared well with usual care in this sense, this highlights the need to consider potential risks as well as benefits of CBT in the management of post-COVID fatigue.
CBT may well prove to be useful as part of multi-disciplinary care for people with post-COVID fatigue. But we need more high-quality evidence using appropriate control groups, and ensuring that potential harms as well as benefits of CBT are fully considered.
And importantly, while CBT could play a role in supporting people with post-COVID fatigue, it doesn’t treat or cure the underlying condition. Long COVID is a complex condition potentially caused by multiple factors such as damage to the organs from COVID, dysfunctional immune responses, and chronic viral infection. It’s vital that we learn more about prevention and treatment of long COVID generally.
Rhiannon Phillips receives funding from Welsh Government, Public Health Wales, Medical Research Council, Health and Care Research Wales, Cancer Research UK, and the National Institute for Health Research. She is affiliated with the British Psychological Society.