Trial By Error: Letter to BMJ Editor Seeking Correction in New Review of Interventions for Long Covid

By David Tuller, DrPH

The BMJ recently published a review of interventions for Long Covid that–surprise!–recommended CBT and a rehabilitation program as treatments. The review is full of holes. I have focused on one in particular. The review relies for its rehabilitation recommendation on an earlier BMJ study–even though that study has itself already been corrected for having misrepresented its findings in key sections. This morning, I sent the following letter to Dr Kamran Abbasi, editor-in-chief of The BMJ:

Dear Dr Abbasi—

A recent paper in The BMJ, Interventions for the management of long covid (post-covid condition): living systematic review, from Zeraatkar et al,drew a crucial conclusion from a trial whose findings were seriously misrepresented. That trial report, also published by The BMJ, has already been corrected. The review needs a similar correction.

Zeraatkar et al recommended a mental and physical health rehabilitation program and cognitive behavior therapy as reasonable interventions for people suffering from the prolonged symptoms that characterize Long Covid. Each recommendation was based on a single clinical trial.

The basis for the first recommendation was Clinical effectiveness of an online supervised group physical and mental health rehabilitation programme for adults with post-covid-19 condition (REGAIN study): multicentre randomised controlled trial, from McGregor et al. The paper was published by The BMJ in February of this year and then corrected in May.  The initial version failed to note in major sections—such as the conclusion of the abstract—that the sample included only patients who had been hospitalized for acute Covid-19. Given the significant differences between Long Covid patients who have and have not been hospitalized, the trial findings cannot automatically be extrapolated to everyone with prolonged symptoms. The corrected version now makes that clear.

Unfortunately, the review from Zeraatkar et al committed the same error as the pre-corrected version of McGregor et al. The review did not mention in key passages—such as the abstract and conclusion–that its expansive recommendation for mental and physical rehabilitation came from a trial including only patients who had been hospitalized.  While the review noted this salient detail deep in the text, it nonetheless suggested that the intervention be offered far more broadly than warranted by the trial itself.

In short, if the trial paper required a correction for not highlighting prominently enough an indisputable limitation of its findings, then the review requires the same.

David Tuller (corresponding author)
Center for Global Public Health
University of California, Berkeley
Berkeley, California, USA
davetuller@berkeley.edu

Nicola Baker
School of Health Sciences
University of Liverpool
Liverpool, England, UK

Svetlana Blitshteyn
Department of Neurology
Jacobs School of Medicine and Biological Sciences
University of Buffalo
Buffalo, New York, USA

Todd Davenport
Department of Physical Therapy
University of the Pacific
Stockton, California, USA

David Davies-Payne
Department of Radiology
Starship Children’s Hospital
Auckland, New Zealand

Andrew Ewing
Department of Chemistry and Molecular Biology
University of Gothenburg
Gothenburg, Sweden

Mark Faghy
Human Sciences Research Centre
University of Derby
Derby, England, UK

Keith Geraghty
Centre for Primary Care and Health Services Research
Faculty of Biology, Medicine and Health
University of Manchester
Manchester, England, UK

Mady Hornig
CORe Community (COVID Recovery through Community)
New York, New York, USA

Brian Hughes
School of Psychology
University of Galway
Galway, Ireland

Leonard Jason
Center for Community Research
DePaul University
Chicago, Illinois, USA

Binita Kane
Respiratory Medicine
Manchester University NHS Foundation Trust
Manchester, England, UK

Douglas Kell
Institute of Systems, Molecular and Integrative Biology
University of Liverpool
Liverpool, England, UK

Asad Khan
North West Lung Centre
Manchester University Hospitals
Manchester, England, UK

Resia Pretorius
Department of Physiological Sciences
Stellenbosch University
Stellenbosch, South Africa

David Putrino
Department of Rehabilitation and Human Performance
Icahn School of Medicine at Mt Sinai
New York, New York, USA

Charles Shepherd
ME Association
Gawcutt, England, UK

John Swartzberg
Division of Infectious Diseases and Vaccinology
School of Public Health
University of California, Berkeley
Berkeley, California, USA

Susan Taylor-Brown
Department of Pediatrics, Developmental & Behavioral Pediatrics
University of Rochester Medical Center
Rochester, New York, USA

6 thoughts on “Trial By Error: Letter to BMJ Editor Seeking Correction in New Review of Interventions for Long Covid”

  1. Well done David. You responded to this with the urgency required.

    The press, (namely, The Scottish Herald in its article, “Long Covid: Do people recover – and how do they do it?”) has already cited this review. I suspect it won’t be long before it is cited in many more newspapers unless this is nipped in the bud and exposed, QUICKLY.

  2. Seems a bit absurd, and besides the point, for a systematic review to look at various treatment options with no relation to one another, then make not one but two recommendations for two interventions both each based on a single trial. Regardless of the amount of bias in the methodology, a single randomized trial cannot reasonably form the basis for recommendations in the same way that a systematic review analyzing a larger set of trials all featuring the same treatment.

    Then again in the case of psychobehavioral woowoo, the interventions are never actually the same in substance, only in style, and simply get lumped together in some overarching label, whether CBT, non-pharmaceutical intervention or mind-body technique. It seems to be completely off the basic idea of a systematic review looking at multiple trials of the same treatment. This is nothing like pharmaceutical trials where the molecule is the same but modality and posology may vary.

    I guess it’s one of those aberrations that managed to sneak through the industry because no one really seems to know how to do any of this without adding extreme biases, as otherwise nothing out of clinical psychology works. Which is true, and is an inconvenient truth they can’t handle, to mix metaphors.

  3. It seemed obvious that when the long struggle to get graded exercise recognised as harmful and CBT as useful as supportive but not curative in revised guidelines for ME/CFS, those whose income and reputation depended on promoting these ‘treatments’ would seek new patients, and Long Covid provided a much bigger pool.
    Snd the new Labour government is seeking ways to get sick people back to work.
    The false promise that enforcing treatments known to make patients worse will get them back to work is being swallowed despite the fact that Long Covid is virtually the same as ME/CFS.
    Patients whose hospital treatments have left them with predominantly respiratory problems, and do not suffer from Post Exertional Malaise (worsening of all symptoms following exertion) -the defining symptom of ME/CFS – may benefit from, or at least not be harmed by these treatments, but the growing numbers of patients whose illness has followed even a mild case of covid will be made worse.

  4. The core defining symptom of PEM appearing in the ME like phenotype seems to be the thing the so called experts from a psych perspective misunderstand the most. There’s too much being published which still fails to differentiate and recognise the importance of PEM, for more than 4 years in the case of long covid, and who knows how long for other post viral illnesses with this presentation (?decades?)
    thank goodness there are those out there that are fighting back against this for the patients

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