France: Guidelines for Post-Covid Syndrome, 2021, Haute Autorité de la Santé

Cheshire

Cheshire

Senior Member (Voting Rights)
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Cheshire said:
The official guidelines for post-covid syndrome have been posted by the Haute Autorité de la Santé.
When there are symptoms without clear organic explanation, doctors should diagnose the patient as having a "functional disorder", caused by personality or trauma.

:cry:

https://www.has-sante.fr/upload/doc.../fiche_-_troubles_somatiques_fonctionnels.pdf
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This is only an annex to the full "rapid reply" from the HAS: https://www.has-sante.fr/jcms/p_323...-19-de-l-adulte-diagnostic-et-prise-en-charge (see Documents at the bottom)

The rapid reply is extremely BPS-oriented (exercise therapy, holistic, etc) but in the main text I don't think they talk about MUS specifically. There's some nuance.
 
I find it very worrying. The mere fact that they encourage diagnosing a somatic syndrome when there is no organic cause (and nothing else) is opening the door for psychologising patients.
In this annex, they say that it is diagnosable in the absence of obvious organic cause, that it is not always associated with anxiety or depression, that it is caused by trauma, personality or too much focus on the symptoms, causing a vicous circle.

I don't see any reason to be optimistic.
 
Cheshire said:
I find it very worrying. The mere fact that they encourage diagnosing a somatic syndrome when there is no organic cause (and noting else) is opening the door for psychologising patients.
In this annex, they say that it is diagnosable in the absence of obvious organic cause that it is not always associated with anxiety or depression, that it is caused by trauma, personality or too muc focus on the symptoms, causing a vicous circle.

I don't see any reason to be optimistic.
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Yes, I'm not optimistic either. Millions Missing France was consulted and tried to push back against MUS and overzealous prescription of exercise therapy and CBT, but the rapid reply and the annexes were clearly written by doctors with very little input from patients (even the Long Covid patient group, #apresJ20). :banghead:

The rapid reply says it will evolve as new evidence is published, so I really hope that there will be studies on PEM and possibly the harms of GET for Long Covid...
 

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Snowdrop said:
Maybe there is an opportunity there between now and the next update to discover how they rate evidence. As we've seen with the NICE guidance the BPS studies were rated with more accuracy this time round.
@cassava7
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The HAS doesn't rate evidence stringently for rapid replies so that they can be put out quickly. Here is a translation of their methods (last page of the rapid reply):
Method of elaboration and warning

The method chosen for this rapid response is based on a narrative synthesis of the most relevant available data, national and international recommendations, and stakeholder consultation (by electronic means).

These documents were developed collegially between the High Authority for Health and experts appointed by the National Professional Councils, learned societies and relevant patient associations.
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The response hinges on doctors' current experiences with treating Long Covid patients in their clinics. Patient associations were able to provide their comments and suggestions but few were kept.

Rapid responses from the HAS are supposed to evolve into full guidelines, but this takes months and currently there isn't much data on PEM in Long Covid (a lot of BPS gibberish has been published though...).

rvallee said:
It explicitly advises CBT and GET. Complete disaster. Basically the Wessely BPS model in full.
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Also note that the diagram on p.14 assumes the only possible outcome is remission, with a straight arrow going from "symptoms >4 weeks" through "holistic rehabilitation" to "return to pre-Covid19 health". Concurrently, the press release puts the responsibility of recovering on patients (bolding original):
The High Authority of Health considers that the involvement of patients suffering from prolonged symptoms of Covid-19 contributes to the success of their treatment. It therefore invites physicians to motivate their patients to identify themselves the circumstances and efforts that trigger their symptoms, so that they are able to manage them themselves. The HAS advises to provide them with all the information they may need to invest in their [exercise therapy]: contact lists, reliable sources of advice (support groups, patient associations), validated sources of information on Covid-19, social services...
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The press release also labels patients who don't recover after the first line of treatment (GP-provided) as "the most complex cases". I very much worry that these 3 points set them up to be diagnosed with a functional somatic syndrome.

(And reading this paragraph as someone who knows about PEM is so weird because they advise LC patients to find their PEM triggers and to learn about pacing LC, while promoting exercise therapy. So weird.)
 
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Cheshire said:
Just have a look at their bibliography...
View attachment 13299
https://www.has-sante.fr/upload/doc.../fiche_-_troubles_somatiques_fonctionnels.pdf
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The Cochrane exercise review. Of course. Because the warning that it is under review (if it really is) is well-hidden. Cochrane keeping it published is doing enormous harm. And it uses several similarly flawed Cochrane reviews. The lawsuits, oh the lawsuits. Cochrane deserves to be sued out of existence, the organization is not capable of its obligations.

They quite literally just cherry-picked stuff to support CBT-GET and went no further. They started with the goal that this was a functional/somatoform/whatever thing and picked stuff to back it up. It explicitly advises not to allow rest.

Etiology is explicitly stated as trauma and/or troubled personality.

They completely failed at the task, did a different assignment entirely. What a disaster. Honestly Wessely could have written this verbatim.
 
The general document looks a bit like the rapid NICE guideline. It doesn't say much and doesn't mention the possibility of patients developing ME/CFS. They only mention:
Le temps de récupération, de retour à un état de santé préexistant, peut-être plus ou moins long en fonction des patients comme lors d’autres infections virales (ex. : mononucléose infectieuse, hépatites virales, autres coronavirus (SARS, MERS)).
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The additional document "troubles somatiques fonctionnels" is indeed very problematic. It refers to Fink's bodily distress syndrome. As Cheshire mention, the text explicitly states although the cause of these symptoms is not well understood, they are often maintained by psychological factors and social circumstances. In French:
Ces symptômes sont d’origine multifactorielle et leur étiologie n’est pas clairement établie, mais ils sont le plus souvent pérennisés par des facteurs psychologiques et sociaux prédisposants (traumatisme psychologique et/ou personnalité favorisante).
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As we have seen before in literature on functional disorders, this suggests using a language that doesn't suggest to the patient that they see their symptoms as psychosomatic or psychiatric. One can say for example that the cause is poorly understood but that there is a connection between the psyche and the body (such as diarrhoea caused by stress).
Il convient de nommer et d’expliquer le trouble somatique fonctionnel et d’éviter les étiquettes stigmatisantes, notamment de rapprocher ces troubles de la psychiatrie. On peut reconnaitre que les mécanismes de ces troubles sont encore mal connus, mais qu’il existe un lien fort entre le psychisme et le corps : tachycardie, sueurs, diarrhées induites par le stress, larmes induites par la tristesse, etc.
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The text advises to avoid vicious circles such as deconditioning, focusing too much on symptoms etc. Reconditioning is seen as very important.
Il faut briser les cercles vicieux de pérennisation des troubles. Notamment, Il convient d’agir pour réduire les conduites d'évitement et notamment le repos prolongé induisant un déconditionnement musculaire [...] La réadaptation à l’effort est donc capitale : l’activité physique doit être reprise progressivement en l’absence de contre-indications (myocardite etc.)
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Hutan said:
Has there been any reaction from Long Covid groups?
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Few and mixed so far. Some hopeful simply because it has the words saying to take it seriously. Some negative because they actually read the words and how they contradict the obvious platitude. None seem familiar with what CBT and GET entail. I follow a few, will update (if I remember to...).

It takes a long time to accept that medicine is not up to the task. People are hopeful that help is on the way. How else should it work? It's too absurd to consider that this is all they intend to do. Don't criticize the hand that could feed if it ever chose to, and all that.

Next Wednesday, some French LC patients are planning to do an online event to push for recognition, kind of like our ME awareness hour. This was before this document came out. There is growing anger that nothing is happening, but relatively small numbers. Some are getting truly pissed off. Haven't seen reactions from those accounts about this document yet.
 
Cheshire said:
The mere fact that they encourage diagnosing a somatic syndrome when there is no organic cause (and nothing else) is opening the door for psychologising patients.
In this annex, they say that it is diagnosable in the absence of obvious organic cause, that it is not always associated with anxiety or depression, that it is caused by trauma, personality or too much focus on the symptoms, causing a vicous circle.
Click to expand...

So every doctor in France never misses an organic cause? They are brilliant diagnosticians, always? This is simply laughable, as well as being arrogant beyond belief. I have the same beliefs about doctors in the rest of the world, I'm not just picking on French doctors. The sheer arrogance of saying that patients must be mentally ill just because the doctor is crap at his or her job is just jaw-dropping.
 
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