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Background Severe fatigue following coronavirus disease 2019 (COVID-19) is prevalent and debilitating. This study investigated the efficacy of cognitive-behavioral therapy (CBT) for severe fatigue following COVID-19. Methods A multicenter, 2-arm randomized controlled trial was conducted in the Netherlands with patients being severely fatigued 3–12 months following COVID-19. Patients (N = 114) were randomly assigned (1:1) to CBT or care as usual (CAU). CBT, targeting perpetuating factors of fatigue, was provided for 17 weeks. The primary outcome was the overall mean difference between CBT and CAU on the fatigue severity subscale of the Checklist Individual Strength, directly post-CBT or CAU (T1), and after 6 months (T2). Secondary outcomes were differences in proportions of patients meeting criteria for severe and/or chronic fatigue, differences in physical and social functioning, somatic symptoms, and problems concentrating between CBT and CAU. Results Patients were mainly nonhospitalized and self-referred. Patients who received CBT were significantly less severely fatigued across follow-up assessments than patients receiving CAU (−8.8 [95% confidence interval {CI}, −11.9 to −5.8]); P <.001), representing a medium Cohen's d effect size (0.69). The between-group difference in fatigue severity was present at T1 (−9.3 [95% CI, −13.3 to −5.3]) and T2 (−8.4 [95% CI, −13.1 to −3.7]). All secondary outcomes favored CBT. Eight adverse events were recorded during CBT, and 20 during CAU. No serious adverse events were recorded. Conclusions Among patients, who were mainly nonhospitalized and self-referred, CBT was effective in reducing fatigue. The positive effect was sustained at 6-month follow-up. Clinical Trials Registration Netherlands Trial Register NL8947. [ABSTRACT FROM AUTHOR]