Lessons from Recent Research about the Placebo Effect – from Art to Science Brody and Miller, JAMA 306:2612-13, 2011.
There have been two thoughts regarding the placebo effect in clinical medicine. On the one hand, the placebo is disparaged as an inert and deceptive intervention intended to please or placate the patient but without any potential to produce meaningful therapeutic benefit. On the other hand, placebo effects are touted as having the power to produce substantial symptomatic relief across a wide range of medical conditions.
Until recently, scientific data that elucidate the mechanisms of placebo effects and evaluate the potential to significantly enhance patient care have been lacking. During the past decade, there have been advances in scientific research on the placebo effect, paving the way for evidence-based techniques for promoting placebo responses in clinical practice in ethically appropriate ways.
Neural imaging studies have demonstrated some of the pathways activated when study participants received placebos and then experienced therapeutic responses. Many studies have shown the release of endogenous opioids and dopamine with placebos. Nero physiology and neurochemistry suggest that there are multiple placebo effects depending on the organ system and the target illness.
Moreover, experiments comparing open administration of active medication versus hidden administration of the same medications have consistently shown a greater effect when patients knew that they were receiving a drug compared with the same dosage given by hidden means. This suggests that a substantial proportion of symptomatic relief from drugs is derived from the positive effects of the clinical encounter to augment their inherent pharmacologic properties.
In addition, a study of patients with irritable bowel syndrome showed that sham acupuncture treatment administered him personally resulted in a greater therapeutic response than no treatment, but the addition of a warm interpersonal relationship added a substantial therapeutic benefit.
Two intertwined psychological mechanisms are thought to underlie placebo effects – expectancy and conditioning.
Positive beliefs about future outcomes, especially when connected with an intervention recommended by a clinician, may trigger improved out, based upon expectancy. Moreover, much of medical practice consists of repeated rituals that make create conditioned responses that can be reactivated in the future by placing the patient in a similar environment. Conditioning overlaps with learning, thus creating positive expectancies.
A recent study with irritable bowel syndrome showed that openly prescribing sugar pills as a helpful placebo, taking advantage of the ritual of therapy (expectancy and conditioning), had a superior outcome compared to the do-nothing-watch-and-wait-and-see strategy.
Although practitioners’ interest in promoting placebo effect is heartening, some physicians appear willing to prescribe unnecessary and potentially toxic medications for their placebo effects. Appreciation of mind-body science should reassure physicians that they need not give such prescriptions in order to promote a positive outcome.
Developments in research on placebos hold the promise for bridging the long-standing gap between the scientific and humanistic orientations of modern medicine.
Dr. Albrecht’s comments:
There remains much to be discovered about taking advantage of placebo effects in clinical practice. But physicians today seem to be much more comfortable acknowledging the placebo effect as a therapeutic tool consistent with a scientific understanding of the mind-body connection. And at least some patients are eager to become active collaborators in mind-body healing practices.
I am a strong believer in the power of the mind to control a person’s life. If we believe it, hopefully it will happen; if we don’t believe it, there is a high likelihood that we won’t be disappointed and in fact it will not happen. I believe in helping each patient activate their potentially powerful inner pathways that can assist their own healing.
I believe that a good way to enhance every day patient encounters is to invite patients to ask as many questions as they wish and to carefully listen to their concerns. By expressing care and concern and communicating a positive expectation for therapeutic benefit, I hope to help each patient to feel more in control of their life circumstances and their ability to overcome their illness.
By explaining the physiology of fertility and infertility to patients and proposing positive ways to deal with it, I hope to use patient education, as well as therapy options, to set the stage for shared decision-making. I believe this pays off in enhancing patient care and positive outcomes.
I hope that you will become an active collaborator in mind-body healing practices as well as the rest of your medical care.