Irish Independent: The Power of Placebo
There is a radical medical treatment that is gaining popularity worldwide. It costs next to nothing to produce and has proven in quality medical studies to be effective against symptoms of an incredibly wide range of unrelated conditions: Ulcers, Irritable Bowel Syndrome, angina, arthritis, and even Parkinson’s Disease. Half of all doctors in America[1] and Germany[2] have used it to treat their patients; yet Irish doctors refuse to have anything to do with it. Why? Because it’s based on a lie.
You’ve probably heard of ‘the placebo effect’. For decades, doctors have known that a patient’s response to treatment can vary largely according to their level of expectation. If we’re told a pill will make us better, we often do get better, regardless of the medicine involved. What we’re just discovering now though, is just how curious the placebo effect can be.
For example, did you know that two dummy pills will trigger a bigger placebo effect than if a patient just takes one? Or that placebos can cause side effects including, would you believe, withdrawal symptoms? Well, that’s just for starters. A study published in the Irish Journal of Psychological Medicine showed that the size, cost and even country of origin of a placebo can have a significant effect on a patient’s response[3]. Even something as inconsequential as the colour of a pill can have a measurable effect on a patient’s experience.
One researcher, Daniel Moerman from the University of Michigan-Dearborn, found that people associate colours with moods and transfer these feelings onto their medication. On taking a red pill, most patients will report a response of stimulation and energy. A blue pill induces feelings of relaxation or drowsiness, except in Italy, where blue pills have the same arousing effects as red. Moerman has a theory that might explain this statistical anomaly: blue is the colour of the national football team, the Azurri[4].
Of course, placebos don’t just come in a bottle. A saltwater injection is seemingly more pills and fake operations are better still. Dr Fabrizio Benedetti’s lifetime of work on Parkinson’s Disease (PD) has shown that “sham surgery” can have a measurable effect on a patient’s symptoms. In one study, he implanted a device called a ‘stimulator’ into the brain of a patient suffering from Parkinson’s. It’s a procedure that is known to be very effective in reducing the amount of shake in a patient’s hands.
Sure enough, when the surgery was complete Benedetti recorded a notable reduction in movement. What the subject in question didn’t know was that the implant hadn’t even been turned on yet[5]. Weirdly, this effect can also work in reverse. When Benedetti lied to the patient saying that the stimulator had been turned off, the shaking got worse again.
The most remarkable thing about all this is that the effects are not just psychological. Changes in the body happen too. Placebo responses have led to measurable increases in hormone levels, reduced heart rates and the release of the body’s natural painkillers opioids. MRI Scans of the brain on placebo show an increased activity in what’s called the “frontal cortex”. This is the part of the brain that helps us evaluate the meaning of an event and develop emotional responses to it, which explains why our reaction to placebo can vary wildly.[6] The placebo effect has nothing to do with the pill itself, we’re really responding to a series of meaningful events. This is why placebo response rates vary from culture to culture. For example, compared to Brazilians, Germans suffering from ulcers are eight times more likely to respond positively to placebo[7].
How all this works physiologically is still a grey area, but some researchers think it has to do with what’s called “classic conditioning”. Professor Irving Kirsch at the University of Hull has worked on the placebo effect for many years. “The famous example of this procedure is Pavlov’s dog. Just as a dog will start to salivate unconsciously because they hear the dinner bell ring, so might humans’ response systems kick in when they swallow a pill from a man in a white coat. People who have experience of real medicine have learnt to automatically respond not just to the medication, but to the ritual, to the taking of the pill, the receiving of an injection. Where this becomes really useful is in situations where we still don’t have very good medication, like IBS or depression.”
It’s fair to say Kirsch has a thing about medicating for depression. He is perhaps most famous for his highly controversial analysis of nearly fifty separate commercial trials of SSRI-class anti-depressants (Prozac, Paxil, Lustral). In each trial, he compared the response of the patient on placebo to the responses to the SSRI. The results of the study were shocking. It claims that 82% of the benefit seen in these studies could be attributed to placebo. In other words, patients were responding almost as well to placebo as they were to the actual medication.
Earlier this year, another study came to a similar conclusion: that the effectiveness of SSRIs over placebo “may be minimal or nonexistent, on average, in patients with mild or moderate symptoms”[8]. It’s important to be clear here: everyone agrees that SSRIs do work, but it in many cases, so does a breath mint.
So why don’t Irish doctors use placebo? Dr Dermot Cox from the Royal College of Surgeons replies with his own question: “Well, in the first case, why not just give the patient real medicine? The patient gets the benefit of any positive placebo response because the expectation that the drug will work is still there, but they also get the additional benefit of actual, proper medicine. There’s nothing stopping your doctor from prescribing a placebo, but by administering an active drug you get both benefits.”
There’s an interesting point here that probably helps to explain why placebos aren’t common even as an alternative therapy if patients, for example, are allergic to the standard medication. While a commercial drug company is only licensed to sell products for an approved purpose, there are no such restrictions governing what doctors prescribe for their patients. However, what appears to be a liberating freedom is actually a double-edged sword.
It’s true that your GP is entirely within his or her rights to recommend a dose of leeches to treat your broken foot. But when you need to be amputated at the knee you’ll have a rock-solid case for professional negligence. The same goes for a placebo. If there’s a recognised treatment for a condition and a doctor has prescribed a sugar pill or salt-water injection instead, he or she may find it very difficult to defend that decision in court.
Primarily though, the problem is not a fear of litigation, it’s an ethical question. Prescribing a placebo is fundamentally engaging in deception, something that makes doctors like Kirsch and Cox extremely uncomfortable. Morally, it’s obviously extremely shaky ground merely lying to the patient, but it’s not just about acting without consent. What if you pretend to treat a patient’s angina with a sugar pill, do you charge them for that? How much? What if you know that the more you charge them for the “medication”, the stronger the patient’s response?
So, could there be a way to get the benefits of placebo with a patient’s consent? In a recent study, Professor of Medicine at Harvard medical School Ted Kaptchuk divided eighty sufferers of Irritable Bowel Syndrome into two groups. One group received no treatment at all while the other group was told they were being given a dummy pill with no active ingredient from a bottle clearly labelled “placebo”. They were to take two of these pills twice a day for three weeks.
Even though both groups had the same amount of attention and care from the dispensing medical staff, the results were dramatically, and inexplicably different. By the end of the trial, patients from the second group not only saw a major improvement in their discomfort, they actually recorded relief levels higher than some of the best IBS medicines on the market. Even though the patients were categorically told that there was no medical benefit to the drug whatsoever, they somehow got better[9].
The question remains though: Why are doctors in other countries so ready to prescribe a placebo?[10] “I suspect to do with how you define placebo”, says Cox. “There are thousands of people in this country who have taken a homeopathic remedy and benefitted from it. Yet few of them would consider it a placebo, even though what they’ve been prescribed is essentially water”.
These words might rankle the thousands of Irish that visit homeopathic practitioners every year, but despite endorsements from figures as diverse as Madonna and MEP Marian Harkin[11], any critical study of evidence shows that “homeopathy performs no better than placebo”[12]. Indeed, even the German Medical Association (BÄK) lists homeopathy as one of the placebos that German doctors commonly prescribed in its recent study Placebo In Medicine[13].
But there is another, more subtle context in which Irish doctors may use placebo without even realising it. Cox illustrates it with a story from a few years ago. “I used to work with a physician who treated end-stage cancer patients and it involved using a lot of experimental treatments. One day, a nurse came into his office one day to report that a particular patient was clearly not responding to whatever it was she was trying. The nurse wanted to know if she should stop the treatment and tell the patient that there was no point in coming back to the clinic”.
“The doctor, realising that he had exhausted all possible avenues, told the nurse to schedule the patient’s appointment as usual. He knew the drugs were no good, but he wanted to give her the feeling that someone was looking after her. Essentially, he was giving her something to live for. He was giving her hope.”
So can we reduce all of this to something practical? Is the placebo effect really just down to the power of positive thinking? Like most things in life, it’s probably not that simple. Positive people die of cancer every day, and pessimists often survive against all odds. What we can say is that we are only beginning to understand how our brains make sense of the world. The power of the placebo effect, and its very meaning it seems, is in the eye of the beholder.
[1] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2173915/
[2] http://www.guardian.co.uk/science/2011/mar/06/half-german-doctors-prescribe-placebos
[3] http://www.ijpm.org/content/pdf/139/placebo.pdf
[4] 1. Cattaneo AD, Lucchilli PE, Filippucci G. Sedative effects of placebo treatment. European Journal of Clinical Pharmacology 1970;3:43-5.
2. Lucchelli PE, Cattaneo AD, Zattoni J. Effect of capsule colour and order of administration of hypnotic treatments. Eur J Clin Pharmacol 1978;13:153-5.
[5] http://psycnet.apa.org/index.cfm?fa=search.displayRecord&uid=2003-07872-001
[6] Interview notes – Tor Wager professor of psychology Boulder, Colorado
[7] http://www.jstor.org/pss/649462
[8] http://jama.ama-assn.org/content/303/1/47.short?home
[9] http://www.plosone.org/article/info:doi/10.1371/journal.pone.0015591
[10] http://www.time.com/time/health/article/0,8599,1700079,00.html
[11] http://www.echamp.eu/news/echamp-news-archive/2009/aprilmay/homeopathy-for-a-healthier-europe.html
[13] http://www.bundesaerztekammer.de/page.asp?his=3.71.8899.9061.9064&all=true