Date sent: Tue, 15 Feb 2000 The clinical evidence is weak and biased 15 February 2000 [ This is an electronic response to:CLINICAL REVIEW Extracts from "Clinical Evidence": Chronic fatigue syndrome Steven Reid, Trudie Chalder, Anthony Cleare, Matthew Hotopf, and Simon Wessely BMJ 2000; 320: 292-296 ] by: Dr. A. Chaudhuri, Clinical Lecturer in Neurology University of Glasgow Email Dr. A. Chaudhuri: ac54p@udcf.gla.ac.uk A number of responses to this review article have appeared since the first submission of my response. It is noteworthy that the responders, who included patients, GPs, medical archivist and neurologist (myself!), have all felt that the review did not objectively address the real and practical issues concerning the management of patients with chronic fatigue syndrome(CFS). Finally, as I see, the authors themselves have felt compelled to reply to the mounting (and fair) criticisms to their review. Normally, sending a second response to the same article is unwarranted. But since I have the fortune of being singled out in the authors' response as someone with a particular narrow view and one who lacks an integrated approach to the management of patients with CFS, I feel the editor of the BMJ,in the best tradition of the British justice,will allow me the opportunity to defend myself, although we know without any doubt, what the juries verdict is on the review and we are only waiting to see if this verdict is accepted by the editorial court or rejected on the ground of "mistrial" as pleaded by the authors! What is purpose of a clinical review? To my mind, a clinical review on any illness is expected to address the following issues: current knowledge on the mechanism of disease , diagnosis, appropriate investigations, management and long term problems. If a clinical review written on multiple sclerosis do not provide succint information under each of these headings, then an average reader will rate the article as poor. Once again, information on a clinical review is based on the best available evidence that may or may not have been tested in "randomised controlled trials" (RCTs). For example, plasmapheresis in the treatment of severe myasthenia gravis is an invaluable treatment option that was never tested in formal RCTs and the only reported RCT found the procedure not as effective. This is perhaps besides the point if the authors were restrained by the Clinical Evidence selection team on the selection of papers on CFS for review. But was the selection entirely unbiased? Why the single-blind, phase-in placebo trial of two escalating doses of selegeline in CFS was not included in the review despite its publication in 1998 (Natelson BH et al, Neuropsychobiology 37: 150-4)? Why no comments were made on the essential investigations one must do in patients with CFS when making the diagnosis (a very fequently asked question). Why the authors did not consider for their review the established tests of neuroendocrine dysfunction in CFS patients(e.g. buspirone-induced prolactin study that has been verified by different workers since its first description from our centre and the hypoactive HPA axis)? Why did the authors disregard evidence from the Rockefeller University that the hypoactive HPA axis in CFS is responsible for symptoms like new-onset or worsening asthma and poor stress response(McEwen BS, NEJM 1998; 338: 171-9)? Why the management strategies for school-going children with CFS were not discussed? These are just a few of the numerous glaring omissions in the review. The truth is, the authors want everyone to view the world of CFS through their own looking glasses and accept that the images of Alice in the Wonderland are real. The rationality that the CFS patients are riddled with thoughts of physical illness and are always expectant of medical treatment to prolong their suffering is an insult to the CFS patients though it is the only ingenious contribution of psychiatry to the science of CFS. This hypothesis is comparable to the psychiatric theories we were offered on the mechanisms of epilepsy and diabetes earlier in the last century. This is what I call psychobabbles when psychiatry becomes just a poor theory and not a science. In their paper, the authors have targeted the review process and treatment approaches on CFS guided by their own belief. The responders have clearly shown whether it was me or the authors whose viewes on CFS are narrow. It is time that the authors should retract their extremely poor and biased review paper. [From: http://www.bmj.com/cgi/eletters/320/7230/292#EL19 ] All electronic responses to:CLINICAL REVIEW Extracts from "Clinical Evidence": Chronic fatigue syndrome Steven Reid, Trudie Chalder, Anthony Cleare, Matthew Hotopf, and Simon Wessely BMJ 2000; 320: 292-296 can be read at http://www.bmj.com/cgi/eletters/320/7230/292 . The original article can be read at http://www.bmj.com/cgi/content/full/320/7230/292