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THERE is one treatment for conditions ranging from depression to back pain to irritable bowel syndrome that produces impressive results with minimal side effects. Yet clinicians are often reluctant to prescribe it.
Why? Because this particular silver bullet is the placebo effect.
Although the mechanisms of placebo remain largely mysterious, the belief that we are receiving a helpful treatment somehow seems to have the ability to make us feel better.
And there’s the rub. If we need to believe in it for placebo treatment to work, then surely the clinicians dispensing it would have to practise a certain level of deception.
But maybe it’s not that clear cut.
Canadian psychologist Dr Susan Huculak argues we need more open discussion about the role of placebo in medicine as well as clear guidelines for clinicians on how and when to use it.
Competing viewpoints on placebo — from scorn to veneration — have impeded progress, Huculak writes in an opinion article that uses psychiatry as a case study.
Clinical trial researchers tend to see placebo as no more than a contaminant, and they strive to design trials to minimise its effects, she writes, quoting one research team writing that the placebo “problem” is “probably the most common reason for negative trials”.
So it’s not the “drugs not working as they’re supposed to” problem that’s at fault here then. Phew.
In any case, Dr Huculak asks, should researchers be seeking to reduce the placebo effect in the first place?
“If the effects following placebo are as real and potent as the drug effects (ie, are legitimate), it would make little sense to try and reduce them”, she writes.
This may be particularly relevant in psychiatry where a number of studies have shown antidepressants are no more effective than placebo in mild to moderate depression, despite showing efficacy in severe depression.
Given the known side effects of antidepressants, should we be exploring placebo as a treatment in less-severe forms of the disease?
Clinicians, Dr Huculak writes, are “generally uncomfortable or even baffled” when it comes to the placebo effect.
Despite that discomfort, several studies have suggested many doctors do use placebos in clinical practice — whether it’s a recommendation of vitamins, an unwarranted prescription for antibiotics, or a subtherapeutic dose of antidepressants.
One of the reasons for the enduring popularity of alternative health therapies may be that the practitioners are particularly skilled at stimulating a placebo response.
Deliberate use of a placebo without the patient’s knowledge raises clear ethical issues, but is deception always necessary for the placebo effect to work?
It seems extraordinary, but maybe not.
Researchers from the Harvard Medical School conducted a controlled trial in irritable bowel syndrome, with placebo as the active treatment. The control in this case was no treatment at all, though participants in both arms received the same level of interaction with providers.
Participants in the active treatment (ie, placebo) arm of the trial were told they were being given “placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes”.
Those given the sugar pills experienced significantly greater improvements in their condition than those who did not get the placebo.
So there’s the question: could openly giving a placebo, accompanied by the information that placebos have been shown to work, offer an ethical way to harness this powerful tool?
Jane McCredie is a Sydney-based science and medicine writer.
If Placebo is s the effect of mind over body maybe we should advise the patient to just tell their body to heal itself.
Generating expectancy can be done without deception. Our current society expects us to avoid being paternalistic and to form an honest therapetic relationship with patients. The relationship itself can be therapeutic, together with professional reassurance (as Mick Vagg points out). “Do no harm” might be first, but ”don’t tell lies” should be second, no?
“What’s in a name?”. The word “placebo” has unwanted associations with insincerity, inauthenticity, even lying.
And yet we all benefit from expectancy. Whenever any of us has a problem, whatever the magnitude, we always have a mood of resignation with it. No-one would say “I have a problem, and I’m expecting it to be resolved at any moment” and be expected to be taken seriously.
I am increasingly impressed with the nbenefit of enhancing expectancy in my clients over the 40 years as a therapist, and aplaud Jane in her raising our awareness of this important factor.
All those centuries Soranus declared “Primum no nocare” – “First do no harm” – and placebos or generating expectancy are both wonderful examples of Soranus’ reminder.
For those who are interested – and it seems that many are – this paper develops the idea of context effects occurring in our daily practices further. In essence, we should be cognisant of the effect of our agency on our patients in all our therapeutic endeavours. Arnold MH, Finniss D, Kerridge I. Medicine’s inconvenient truth: The placebo/nocebo effect. Internal Journal of Medicine 2014;44:398-405.
There is still a problem of deception. Just because the doctor explains the placebo does not mean the patient has understood. This study really demonstrates the problem of informed consent. If anyone really understood they were taking the placebo, it would not work. The mind -body explanation implies a certain magical effect and that the tablet imbues a mystical power which is fundamentally deceptive. Remember placebos can also work as a negative if the active arm is also thought to be a negative. ie side effects. The use of a placebo, even if effective, is deceptive and the longer term costs to the entire health systems credibillity is at stake. If someone wants a non-evidence based deceptive panacea, than the homeopaths are there to provide them. The real question is for the author – would she take the placebo? or would her level of knowledge prevent it from working. If it is the latter, no matter what information is said or provided, at some level the patient is being deceived.
I disagree that placebo effects are still regarded as largely mysterious. Fabrizio Benedetti at the University of Turin has written a very elegant pair of books summarizing his career in placebo research entitled The Patient’s Brain (the pop-sci version) and Placebo Effects (the more serious professional version) which should be compulsory reading now in medical schools, and for any doctor who treats patients.
Given what we do know, it is obvious that good medicine combines effective therapies with nonspecific beneficial context effects due to our evolution as social mammals. Tests of therapeutic efficacy need to account for the nonspecific context effects as much as possible, and this will not change no matter how well we understand placebo effects.
When providing care to patients, the context effects occur regardless of whether we intend them to or not. Good clinicians always provide social support and an appropriate context with all their treatments, so the obligation to be rigorous about efficacy is all the more important.
In a sense we DO all presribe placebo, because the professional interaction and the provision of a remedy DO have placebo effects. That;s why medications are tested AGAINST placebo, because all therapies have the potential for placebo effect, but therapeutic ones are those whose effect is greater than the placebo control. If one gets around the ethical issues by declaring that ”this therapy doesn;t do much but it’s safe and might help you” then the patient can choose. It’s the deception that is unethical, as well as false claims for known placebo like homeopathic ”remedies”.