Expert forum Covid-19 interview: Michael Sharpe

Michael Sharpe, Professor of Psychological Medicine at Oxford University Hospital, shared his insights from the post-COVID clinic he helped set up

 

Swiss Re Institute: Professor Sharpe, thank you for giving us a bit of your valuable time. The 'Long COVID' diagnosis is relatively recent – can you offer a definition?
Professor Sharpe (find his CV here): The post-COVID-19 syndrome is defined by NICE (National Institute for Health and Care Excellence) as 'signs and symptoms that develop during or after an infection with COVID-19, continue for more than 12 weeks and are not explained by an alternative diagnosis.' This definition may not be universally accepted, but it does clarify what we are talking about.

Swiss Re Institute: As this is a new illness, what are the early research findings?
Professor Sharpe: This is a tough time for academics and a lot of the research has been done in the form of internet surveys. These give us some clues, but we are aware that there is a deluge of poor-quality research with unclear denominators. Better research is on the way but there simply hasn't yet been enough time for randomized trials. Based on current understanding, we think that 5 to 10% of patients, at three months, have some kind of severity of symptoms and disability. Many more may have lesser symptoms and lesser disability. These patients tend to be older, with a predominance of females, and pre-morbid vulnerabilities.

Swiss Re Institute: Tell us about the post-COVID clinic you helped set up in Oxford.
Professor Sharpe: Our clinic is a multi-disciplinary one-stop shop that initially focused on people admitted to hospital, but today the majority of patients are referrals from primary care. We have a multi-disciplinary team, where we can bring in cardiology, neurology, etc., as needed. These clinics have been a very interesting development and I think it is how medicine should be practiced. A major concern is that all of this is made possible through short-term funding. Long-term funding is promised, but we'll have to wait and see.

Swiss Re Institute: What can you tell us about the causes of Long-COVID?
Professor Sharpe: It is all-too easy to talk about post-COVID syndrome as if it were one thing, like lung cancer, for example. We must allow for the fact that it is heterogeneous and be wary of thinking in terms of a single cause. Based on our clinical experience, there are biological, psychological and social causal factors. Patients often have a lot of symptoms, as many as 20-30 – but we must remember that multi-symptom illness does not mean multi-symptom pathologies.

There are striking psychological factors, we might call it health anxiety. Some of our patients experience significant anxieties because of an understandable focus on their bodily symptoms, but about a third to half of our patients are negatively impacted by the media. Consumption of newspaper articles that proclaim 'Long-COVID could mean lifelong-COVID' and that 'the effects could be horrible,' can hinder patients' recovery. Another, perhaps surprising, social factor has to do with online support groups. These have proven to be of great benefit for many worried patients. However, people who recover tend to leave such groups, leaving the group with only people with poor prognosis. There's concern that such groups can then exacerbate pessimistic views of the illness and transfer those to vulnerable patients.

Swiss Re Institute: You mentioned those who recover – tell us about rehabilitation.
Professor Sharpe: Right now, with the many as-yet unknowns of this illness, there can be excessive investigation. While the intent may be noble, it won't necessarily be helpful to the patient as it can entrench them in worries and distract from the task of rehabilitation. Some of my colleagues are inclined to do as many tests as possible, while others simply treat for anxiety or chronic fatigue. I think one of the real challenges for managing Long-COVID is to find the right balance between the two.

When people come to our clinic, the crucial first step is that they are taken seriously. Patients must feel listened to and believed. From there, physicians have to manage the patient's uncertainty and their own uncertainty in deciding how many avenues to go down with possibilities and tests, and how much to be pragmatic. We must remember that is heterogeneous and we do find treatable conditions. I think what's really important is that, as far as we know, most people improve and so to give an overall positive message rather than this is a very worrying alarming condition that we don't understand and we don't know what's going to happen to you. At the moment, the best approach to post-COVID seems to accept that it will take time. Psychologically informed rehabilitation addresses patients' worries and helps them gently return to activity.

Swiss Re Institute: What are the challenges you see for the long term?
Professor Sharpe: Well, the obvious challenge is that there aren't many multi-disciplinary rehabilitation teams. They are being set up in some places in the UK – but it's patchy and made possible with short-term funding. The UK's National Health Service is generally good when it comes to acute illness, not quite as good when it comes to rehabilitation. There are currently also challenges with guidelines – these may complicate treatment for post-COVID patients.

Swiss Re Institute: What are your expectations with regard to chronic disabilities?
Professor Sharpe: The syndrome hasn't been around long enough, so we simply don't know. Still, our experiences to date show that most patients do improve – for many this means months, not weeks – but they do improve. In the absence of good data, physicians usually fall back on the rule of thirds. And so, if we say we've got 5% and we apply the rule of thirds, my guess would be that something like 1% of patients may have some long-term chronic disability and chronic work disability. Again, that is a guess, and it will depend on the care patients get, but given the number of people with COVID, that could potentially be quite a lot of people.