Placebo Effects in Medicine

[MeSci]

Interesting NEJM article.

Placebo effects are often considered the effects of an “inert substance,” but that characterization is misleading. In a broad sense, placebo effects are improvements in patients' symptoms that are attributable to their participation in the therapeutic encounter, with its rituals, symbols, and interactions. These effects are distinct from those of discrete therapies and are precipitated by the contextual or environmental cues that surround medical interventions, both those that are fake and lacking in inherent therapeutic power and those with demonstrated efficacy. This diverse collection of signs and behaviors includes identifiable health care paraphernalia and settings, emotional and cognitive engagement with clinicians, empathic and intimate witnessing, and the laying on of hands.

Full article here

There's also a Comments section

 

[A.B.]

Worth noting that Kaptchuk has built a career on the supposed benefits of placebos. If placebos can only affect subjective symptoms that are "measured" by questionnaires, then one should reasonably consider the possibility that placebo effects are nothing but an artefact of imperfect methods, and the neurotransmitter responses nothing more than the normal reaction to positive events. What any of this has to do with curing disease I don't know.

 

[MeSci]

Worth noting that Kaptchuk has built a career on the supposed benefits of placebos. If placebos can only affect subjective symptoms that are "measured" by questionnaires, then one should reasonably consider the possibility that placebo effects are nothing but an artefact of imperfect methods, and the neurotransmitter responses nothing more than the normal reaction to positive events. What any of this has to do with curing disease I don't know.

Well, at least he says that placebos can't do that. Not really sure how his approach might affect us, esp. re CBT/GET/PACE and the like. Encourage their use because they can supposedly improve symptoms? Or discourage them because they can't treat the underlying illness...unless it is a psychosomatic one...

 

[jimells]

placebo effects are improvements in patients' symptoms that are attributable to their participation in the therapeutic encounter, with its rituals, symbols, and interactions.

I never knew that rituals, symbols, and interactions can cure disease. Sounds like Mind Magic to me.

Why can't they just admit that "placebo effect" means "we don't know what caused the improvement"? Do doctors go through some kind of indoctrination that causes them to choke on the words "we don't know"?

an experiment in patients with asthma showed that placebos do not affect patients' forced expiratory volume in 1 second (FEV1) but can nonetheless dramatically relieve perceived symptoms

So when I showed up at the urgent clinic, barely able to stand, I didn't need albuterol from the respiratory therapist, just a sugar pill? I guess I should've believed the intake nurse who tried to tell me I was only hyperventilating, in spite of rather scary numbers on the pulse oximeter.

Incorrectly attributing the experience to the recent action of taking a therapy (in this case a placebo) is not a nocebo effect. It is the erroneous attribution of causality based on a temporal association.

It's good to see that one doctor understands that correlation does not equal causation.

Yet we believe such [placebo] effects are at the core of what makes medicine a healing profession.

Silly me. All this time I've been thinking it was effective treatments that makes medicine a healing profession instead of a religion.

 

[Woolie]

This guy (Kaptchuk) is interesting, because he has historically taken a view that placebos have "real" effects that should be acknowledged and exploited by medicine. This contrasts with the view of a lot of other researchers, who argue that a big chunk of the placebo effect is an artefact (for example, people who think they've had a treatment are more likely to recall instances recently when they felt good vs. those when they felt bad, leading to an overall rating of better health despite no real improvement).

What's interesting is that in this study he gets together with one of his opponents and together they talk about problems and issues in measuring the placebo effect. This hardly ever happens in science!

The conclusion is pretty much that when you control for all the biases, etc, the only place you see any convincing evidence that placebos can actually work is in pain management.

So no, I say don't encourage the use of placebos in MECFS.

 

[Snow Leopard]

It is funny how as soon as the "placebo effect" is mentioned, otherwise rational doctors suddenly become quacks in believing all sorts of myths about it.

 

[A.B.]

According to Wessely, placebos are one of the most effective treatments in psychiatry. Which suggests that most treatments don't work at all or are harmful.

 

[Kyla]

https://www.painscience.com/articles/placebo-power-hype.php#open-label

It’s always called “the” placebo effect, but placebo is not just one thing. The term is almost hopelessly imprecise. It is actually category of phenomena, many of them clinically meaningless.5 We truly need to learn and use more precise terminology. It’s not just word-nerd nitpickery! Speaking only of “placebo” is about as useful as saying only “furniture” when you mean “chaise longue” or “credenza” or “futon.”

There are many ways for the appearance or illusion of a treatment effect to occur. Some of those illusions are biologically interesting, but many are not. For instance, a placebo effect may occur due to illusions and distortions in data collection and reporting — almost embarassingly trivial and boring factors, like regression to the mean or comparing endpoints to baseline instead of to inert treatment.6 Paperwork placebo!

Another example: being better is not equivalent with actually feeling better, and feeling better is not the same as saying you feel better. People can and do say things that don’t accurately represent their internal experience. A classic example is doctor-pleasing exaggeration of benefit. Placation placebo!

These complexities of human psychology and behaviour are why researchers often look at placebo effects as an annoyance: they are irritating distractions in research, and difficult to eradicate. There are myriad ways in which both treatment and placebo effects may not be what they seem. A placebo might be an interesting mind-powered effect on biology … or it might just be a statistical mirage! Here’s a good example…

 

[Woolie]

@Kyla, I always enjoy your posts, and this one was especially interesting!

Do you know of any other articles that discuss these issues - specifically some of the lesser-known components of the placebo effect? I'd like to learn more.

 

[Kyla]

@Kyla, I always enjoy your posts, and this one was especially interesting!

Do you know of any other articles that discuss these issues - specifically some of the lesser-known components of the placebo effect? I'd like to learn more.

Thanks Woolie

Not sure I have exactly what you are looking for.

This researcher is trying to debunk the entire idea of placebo (and seems to be doing a pretty good job of it):
http://www.project-syndicate.org/commentary/the-placebo-myth
He has a number of meta-analyses and studies on placebo, they might be behind a paywall though.