The ‘gold standard’ method for testing the effectiveness of a treatment is the ‘randomised, placebo-controlled’ trial. Here, a group of individuals are randomly allocated to received an active treatment (e.g. a drug) or placebo (inactive pill). If the drug leads to benefits that are statistically more significant than any achieved with the placebo, the drug is generally deemed effective. If there’s no statistically significant difference, the treatment is generally deemed ineffective.
The placebo response, though, is not imagined improvement, but often objective and tangible improvement in someone’s condition. We perhaps don’t understand what drives the placebo response, but there’s no denying it’s real. It can also be very powerful.
In general terms, though, the placebo response is viewed negatively by many scientists and doctors. For example, many doctors will refer to any benefits natural medicine appears to have as ‘just the placebo response’. Well, often we have no idea whether it’s placebo or not, because often the approach has not been subjected to rigorous and study. Even if any improvement is down solely to the placebo response, would that be such a bad thing?
I was thinking about this recently while talking to a colleague about a piece of research regarding a light-emitting device (see here). Basically, this piece of kit shines light into the ears and this might have the ability to alleviate low mood and anxiety states, particularly where this is related to low light exposure (such as the winter months). A piece of research supports its effectiveness, though as I pointed out in the original post, the research was hampered by the lack of a placebo group. I mentioned this to my colleague, who responded: “So what?”
Now my colleague is a clinical psychologist, and holds a PhD. He reads and assimilates lots of research. He’s just the sort of person who might be expected to seize on the lack of a placebo group in the study as a fatal flaw. But actually, his reaction was one of not caring. Why not? Well, my colleague is a clinical psychologist, and sees individuals with psychological issues. His focus, ultimately, is to help his clients think and function more effectively. He does not care so much how the benefits might be achieved: He’s results-driven.
So, in the absence of a placebo group in the study I linked to, what are my colleague’s beliefs? Well, the study showed that a simple and easy intervention led to a significant improvement in the mood state of the great majority of people who used it. To my colleague, this is what matters. It does not matter to him (nor does it to I) that the benefits may have been as the result of light exposure, the placebo response, or a bit of both. In essence, all he cares about is that a person feels better.
I have seen thousands of people over the years and tried lots of different approaches in the hope that they can reduce or even rid themselves of symptoms such as fatigue, irritable bowel syndrome, low mood, skin complaints and arthritis. The great majority of the approaches I use (just as much of conventional medicine) have not been subjected to systematic study. However, I would not advocate the approaches if I’d not found them to be generally effective in practice.
Now, a lot of the clients I’ve seen over the years are informed individuals who are only to aware of the placebo response, and the fact that any benefit they see might be driven by this rather than the dietary or other approach they have taken. However, not once has a patient who has seen significant improvement in their condition abandoned it because it might have been due to the placebo response. On many occasions I have even had discussions about this. Invariably, even when individuals are well aware that we have no idea whether their improvement was down to the placebo response or not, they simply don’t care. All they care about is that they’re better.
This is all so true. I tried without success for years to get my OB/GYN to prescribe the natural progesterone supplement that my internist had prescribed for PMS. He refused on the grounds that the research did not support the treatment, despite the fact that he had done testing on me (after multiple miscarriages) that showed that my progesterone level was almost non-existent during that time and despite the fact that he had prescribed the supplementation for each of my successful pregnancies. He actually told me that it was a placebo effect and I had used those exact words: “Who cares? It worked for me and I want it back.” My internist had since given up his license so I felt stuck. But I do know that on the progesterone, I did not gain five pounds, did not put 3 to 5 inches on around my waist and did not think that God wanted me to get rid of all those irritating people (on progesterone I still found them irritating but didn’t think I was responsible for taking them out;-).
I feel the same way about my bite plate (TMJ): I wear it on my lower teeth and dentists keep trying to tell me that wearing it on the upper teeth works for “everyone” — and I keep telling them I tried that and they can’t say it works for everyone any more because it does not work for me.
I am quite encouraged reading your blog and emphasis on what actually works — keep it up. thanks.
S
John, You wrote:
“To my colleague, this is what matters. It does not matter to him (nor does it to I)”
I greatly admire you, John, but think again about “to I.” What about “to me”?
You and your colleague should care, or else we might as well return to the days of shamanism. The placebo effect, while real, depends on patients believing a falsehood, which violates the part of the Hippocratic oath, “First do no harm.” Deception on the part of a doctor is per se harmful, because if uncovered, shatters the trust between doctor and patient. That potential alone should be enough to invalidate the “Placebo — so what?” approach.
Second, placebo effects are not consistently reproducible, either in a study or outside it. When a doctor prescribes a medication or a therapy, the doctor should be able to predict how the patient will respond if the medication or a therapy is effective: fevers should break, lesions should heal, schizophrenic voices should disappear. With a placebo, there’s no way to predict what will happen, because the medication or a therapy prescription itself is is bogus. Prescribing bogus cures is what charlatans do, not doctors.
jake3_14
With all due respect, I think you might be missing the point. If something has not been studied, then how do we know whether when something appears to works, that’s through the placebo response, something real, or a bit of both? The answer is we don’t.
Even when something has been proven successful through randomised trials, we still don’t know when, in an individuals, any apparent benefit was real, a placebo-response, or both.
If your argument is that only things that have been subjected to randomised trial should be ‘allowed’, then that will mean much (possibly most) of what we do as doctors will need to be junked. Almost all surgery would need to go for a start. You can’t have one rule for one thing (doctors/conventional medicine) and another rule for another (shamans/supposed charlatans). Otherwise, it smacks of bias.
There is a fascinating documentary about the placebo effect at http://www.youtube.com/watch?v=QvbQnMvhQFw&list=FLRbXriW5ZNIYg_VBaws2UvQ&index=10&feature=plpp_video …
At least some scientists have the sense to take it seriously!
There is a fascinating documentary about the placebo effect at http://www.youtube.com/watch?v=QvbQnMvhQFw&list=FLRbXriW5ZNIYg_VBaws2UvQ&index=10&feature=plpp_video.
At least some scientists have the sense to take it seriously!
In his book “How your mind can heal your body”, David Hamilton, PhD, gives a great review of medical/scientific literature of the placebo effect and other aspects of the body – mind connection, which is what this may all come down to. Highly recommended book, be it just for these reviews. The book actually goes on to discuss the power of visualisation.
I think the importance of our mind in health and dis-ease is very often overlooked in conventional medicine.
The science (yes, science) of psycho-neuro-immunology gives us information about the placebo response and how very valuable it can be. In physiological terms, a happy, relaxed mind has a positive influence on body systems, including the immune system. Ergo, if a patient takes a medicine, or undergoes a therapy, or anything which gives them a more positive outlook (i.e. “relaxes the mind”) it switches off the “fight or flight” response (sympathetic nervous system) and activates the parasympathetic NS, positively influencing healing, promoting anti-inflammation, reducing adrenal output, and relieving muscle tension, including that within the digestive system – all good stuff. I think this argument alone is more than enough to justify treatments which (may or may not) rely on the placebo effect. As Dr. John says, these effects are not “imaginary” – they can often be verified by hospital tests.
My 17 year old’s asthma puffer had run out but he told me it was OK as he was using it as a placebo – and it was working!
There is a book written by Jon Kabat-Zinn about mindfulness meditation with the aim of helping people with chronic pain / stress / disease. When the brains of people with chronic pain were examined under MRI / CT, those who meditated regularly appeared to have ‘less’ pain than those who did not. If meditation appears to work, then why not a placebo – perhaps it really is all in the mind! Many of the supposed ‘charlatans’ seem to be able to take a more open minded and holistic approach to chronic complaints. Let’s face it, when conventional medicine is unable to find a cure, many (but by no means all) doctors believe there isn’t one. Surely the point is to help relieve symptoms and most patients willing to participate in these alternative treatments are actively engaging in their own wellbeing – a positive move for a start.
Sadly, the art of healing, which as I understand it was what Hippocrates was about has been hi-jacked by ‘scientists’ and ‘doctors’ who naively believe and postulate that they know it all. I wonder if Jake, why so readily quotes Hippocrates, uses astrology as part of his diagnoses and prescriptions? Hippocrates did, and insisted that a diagnosis without an astrological profile of the patient was wholly inadequate. Jake and his ilk will undoubtedly describe astrology and shaminism too as total ‘pseudo science’, glibly brushing it aside together with the premise that ‘A wise man considers what a fool dismisses out of hand’. Jake’s ‘medicine by numbers’ is to healing as ‘painting by numbers’ is to art. Bitter experience was demonstrated to me by a group of ‘experts’ who experimented with a range of drugs on my mother who suffered advanced Alzeimers and Parkinsons. ‘Look how clever we are – see how long we can keep this old lady alive and suffering’, instead of allowing her to pass away with some vestige of dignity. Do no harm Jake….? Remove the scales from your eyes!
Hi Dr. Briffa:
“If your argument is that only things that have been subjected to randomised trial should be ‘allowed’, then that will mean much (possibly most) of what we do as doctors will need to be junked. Almost all surgery would need to go for a start. You can’t have one rule for one thing (doctors/conventional medicine) and another rule for another (shamans/supposed charlatans).”
I understand that medicine is an art, backed by science, and not pure science. But your admission that most of what doctors do is not well-supported by clinical evidence speaks to the state of medicine today, not to my argument. If we, as a society, are to trust doctors and surgeons, then patients should absolutely hold them to a higher standard of evidence than shamans, charlatans, herbalists, and homeopaths, who don’t make any claims to be following the scientific method (homeopathic “provings” do not meet the criteria for good clincial trials). If any diagnosis or recommendation is not based on rigorous evidence, then it’s incumbent on health care providers to state that when counseling patients, so that they can make an informed choice. This is entirely in keeping with the move towards evidence-based medicine. If this results in lowered compliance with recommendations, then it should act as a spur for medical practitioners to ensure that they don’t foist marginal treatments on patients.
Hedley,
I am sorry that doctors used your mother as a guinea pig rather that respected her as a human being. If they didn’t explain fully explain the probabilities that their treatments would be effective, if they didn’t ask your permission to treat your mother, then shame on them.
Their actions, however, may speak to their ethics, but don’t speak to the placebo effect. In fact, it’s likely that it disproves the placebo effect. I think it’s probable that the doctors told you that they believed that each drug they administered might work to halt the progression of your mum’s Alzheimer’s. That should have created a placebo effect that assisted whatever the drug was designed to do. That your mum got worse despite the series of drugs shows that the effect of raising false hopes on you.
This is my primary objection to using deception or a doctor’s faith to invoke the placebo effect: creating false hope, which can easily result in bitterness against the health care provider and the health care system. If a health care provider wants to invoke the placebo effect, do it ehtically. Give patients full information about what the treatment’s been proven to do in clinical trials; talk about the success rate in the health care provider’s practice; explain how the placebo effect can help improve the treatment’s effectiveness; Offer some techniques the patient can use him/herself to induce the placebo effect. And above all, treat the patient compassionately, as a person, not just a 15-minute appointment.
But don’t use deception, either by commission or omission, to get the patient to be hopeful more hopeful about a treatment than the underlying science warrants.
This is one area I probably disagree with Dr Briffa on, but it is an interesting topic. Firstly, I would like to add to Hedley that Hippocrates is seen as the father of Western medicine, arguing for a rational, natural and often environmental cause to the disease rather than the superstitious/religious. Yes, he cared gently for his patients, but this man who you seem to objectify as the absolute zenith of healing (though as I understand it, separating myth from truth about his practices is close to impossible) would I suspect have been all for the scientific trials you apparently have so much disdain for. His legacy is one of rigor, good records, honesty etc, not some romantic notion of “the art of healing” that you seem to have.
Regarding the placebo effect, it is the reason which I am perfectly happy for patients to seek consultations with aromatherapists, homeopathists, in fact whatever complimentary service they choose… But providing these on the NHS is just not viable. No one is denying that the placebo effect works, but (as Jake points out), knowing that your doctor is telling you the truth, not just giving you something that makes you feel better, is one of the major principles of autonomy in healthcare (as opposed to the paternalism we used to practice).
But more importantly to me, any cost in public healthcare has to be justified. As a tax payer as well as a doctor, I’m not happy to be funding millions of people’s treatment with eye of newt etc. if there’s no proof it works, or worse, if there’s proof that it doesn’t, because that money could be spent on treatments we know to work beyond their placebo effect.
In short, it is not that I have a problem with anyone benefitting from the placebo effect, in fact I hope they get every benefit they can from any treatment we provide. But I do not think it is ethical to spend very limited NHS resources on the myriad of potions who’s effects we know to be the same as a dust pill, or for doctors to be dishing them out and implying they will work.
I mean, look what has happened to paracetamol! A very safe drug if taken within the recommended dosage, and a genuinely effective painkiller (as someone who rarely gets headaches, when I do, a couple of paracetamol are usually all that is needed). And yet because of their cheapness and availability, I would say at least half of the patients I see swear that “paracetamol doesn’t do anything for me, doctor”. Really? Paracetamol has stopped having any pharmacological effect on them? Or psychologically, do they feel their problem is now so severe or intractable that they need “something more powerful”, beyond the help of what they have come to see as a weak analgesic that normal people with lesser pains can use?
So then, even in the world of placebos, inflation takes place. And we would rapidly get to the point where we are required to outright lie to patients (I.e. give them paracetamol in a different colour and tell them it’s a new super pain killer) which won’t be allowed to happen I hope, or providing more exotic (and expensive) semi-placebo drugs, no proven pharmacological benefit, but are hyped up enough that people believe they will work.