Psycho-Babble Medication Thread 64120

Shown: posts 1 to 13 of 13. This is the beginning of the thread.

 

NEJM Article says placebo effect small

Posted by Jane D on May 24, 2001, at 11:31:51

The NEJM just published an article claiming that the placebo effect, where you get better only because you believe you will, is actually very small.

If I understand it correctly, the authors looked at a number of studies that included a control group that knew they were not being treated as well as the placebo group and found no difference in measurable things like blood pressure and only a small difference in things like pain that depended on the subjects report. Subjects that were not treated did get better but it happened whether or not they thought they were being treated meaning it was caused by random ups and downs of the illness, not power of suggestion.

This fits with my experience. I have believed very strongly in drugs that did not work and gotten great relief from one that I expected nothing from. I've also been slightly offended by the implied suggestion that I couldn't tell what worked for me and what didn't.

Any comments?

Jane

There is a description of the article on the NY Times web site at
http://www.nytimes.com/2001/05/24/health/24PLAC.html
(registration required but free and immediate)

and the abstract is at
http://www.nejm.com/content/2001/0344/0021/1594.asp
(full text only for subscribers, alas)

 

Re: NEJM Article says placebo effect small Jane D

Posted by Paige on May 26, 2001, at 6:48:40

In reply to NEJM Article says placebo effect small, posted by Jane D on May 24, 2001, at 11:31:51

Jane,
Read "Anatomy of An Illness," by Norman Cousins.
It may shed light,or specifically a glaring high
beam on the issue of placebos. Not a panacea, but amust
read I think.

Paige

 

Re: NEJM Article says placebo effect small

Posted by SLS on May 26, 2001, at 11:23:00

In reply to NEJM Article says placebo effect small, posted by Jane D on May 24, 2001, at 11:31:51

> The NEJM just published an article claiming that the placebo effect, where you get better only because you believe you will, is actually very small.
>
> If I understand it correctly, the authors looked at a number of studies that included a control group that knew they were not being treated as well as the placebo group and found no difference in measurable things like blood pressure and only a small difference in things like pain that depended on the subjects report. Subjects that were not treated did get better but it happened whether or not they thought they were being treated meaning it was caused by random ups and downs of the illness, not power of suggestion.
>
> This fits with my experience. I have believed very strongly in drugs that did not work and gotten great relief from one that I expected nothing from. I've also been slightly offended by the implied suggestion that I couldn't tell what worked for me and what didn't.
>
> Any comments?
>
> Jane
>
> There is a description of the article on the NY Times web site at
> http://www.nytimes.com/2001/05/24/health/24PLAC.html
> (registration required but free and immediate)
>
> and the abstract is at
> http://www.nejm.com/content/2001/0344/0021/1594.asp
> (full text only for subscribers, alas)

Hi Jane.

Thanks for the citation links.

It has always seemed to me that the placebo response rate of 30% reported for clinical trials of antidepressants was higher than I would expect intuitively given the way I personally experience depression and drug responses. Such a high response rate to placebo tends to make the active treatment seem less significant somehow.

Of great significance is the observation that the placebo response rate for the more severe or treatment-resistant depressions is very low; perhaps less than 10%.

I think that there are several contributing factors to the placebo "response" when dealing with depression.

1. The objective measurement of a subjective experience such as depression is difficult to quantify, and can involve bias on the part of both the patient and the investigator.

2. The nosological classification of depressive disorders is inexact. The criteria for choosing patients for inclusion in a study can differ from investigation to investigation, and is often overly broad or liberal.

3. Depressions more often have a fluctuating or episodic course. Some of those people who improve during a trial of placebo would have done so anyway, as this was the natural course of their illness.

4. A patient may experience great relief at the thought that they are receiving medical treatment that will end their pain.

5. One study I came across demonstrated that patients recruited through advertisements rather than consultation referrals tend to show a higher rate of early placebo response and are less depressed to start with. Many of the investigations published use recruits.


- Scott

 

Re: NEJM Article says placebo effect small SLS

Posted by Jane D on May 26, 2001, at 19:38:35

In reply to Re: NEJM Article says placebo effect small, posted by SLS on May 26, 2001, at 11:23:00

>It has always seemed to me that the placebo response rate of 30% reported for clinical trials of antidepressants was higher than I would expect intuitively given the way I personally experience depression and drug responses. Such a high response rate to placebo tends to make the active treatment seem less significant somehow.

Scott -

I've never been able to fit it into my experience either.


>Of great significance is the observation that the placebo response rate for the more severe or treatment-resistant depressions is very low; perhaps less than 10%.

>3. Depressions more often have a fluctuating or episodic course. Some of those people who improve during a trial of placebo would have done so anyway, as this was the natural course of their illness.

Those 2 points together make sense. In my own experience less depression means more fluctuation of mood. Also the way severe depression is defined is going to select for this. The more symptons you have most of the time for the last 2 weeks the higher you score on the rating scale. If your mood is fluctuating already you are probably going to meet that most of the time criteria for fewer items and by definition will be considered less severely depressed.


>4. A patient may experience great relief at the thought that they are receiving medical treatment that will end their pain.

This last is what the study challenged. They compared studies that had 3 groups, treatment, placebo and no treatment. This way any difference between the placebo and no treatment groups should be due to the patients belief in their treatment not random variation in the course of the illness. They found very little difference. Their conclusion is that placebo is justified in clinical trials but not as a treatment.

I've seen articles arguing that because of the supposed placebo effect it could be justifiable to lie to patients. So if you don't have a cure for something hand out a pill, promise it will work, and maybe the patient's belief will make something happen. I wonder how many ntidepressants are prescribed with that in mind and whether its different than for other types of drugs.


>5. One study I came across demonstrated that patients recruited through advertisements rather than consultation referrals tend to show a higher rate of early placebo response and are less depressed to start with. Many of the investigations published use recruits.

That's really interesting. I wonder why. The placebo article mentioned excluding studies with paid subjects. Maybe for the same reason?

Jane


 

Norman Cousins on Placebos Paige

Posted by Jane D on May 26, 2001, at 22:57:54

In reply to Re: NEJM Article says placebo effect small Jane D, posted by Paige on May 26, 2001, at 6:48:40

>
>
> Jane,
> Read "Anatomy of An Illness," by Norman Cousins.
> It may shed light,or specifically a glaring high
> beam on the issue of placebos. Not a panacea, but amust
> read I think.
>
> Paige

Paige

Thank you for the recommendation. I'm finding the book interesting. It has also given me a new favorite image.

"No greater popular fallacy exists about medicine than that a drug is like an arrow that can be shot at a particularized target. Its actual effect is more like a shower of porcupine quills."
(Norman Cousins, Anatomy of an Illness)

Ouch.

I think he's a bit sneaky in the placebo chapter. He starts by stating that most illness go away all by themselves even if you do nothing. He then argues that placebos cure and supports it with a long list of studies. Here he assumes that everytime a patient in the placebo group got better AFTER they received a placebo it means that they got bettter BECAUSE of the placebo.

The current article says that those patients are the ones who would have gotten better anyway and it seems to be able to prove it. If this is true then all the theories on why placebos cure go out the window.

Jane

PS. There is an editorial about this in the same edition of the journal. The editorial is available online for free. And it does have some criticisms of the study. It is at:
http://www.nejm.org/content/2001/0344/0021/1630.asp

 

Re: Norman Cousins on Placebos Jane D

Posted by Paige on May 27, 2001, at 7:02:22

In reply to Norman Cousins on Placebos Paige, posted by Jane D on May 26, 2001, at 22:57:54

> >
> >
Hi jane,

I think the most profound comment that remained
in my mind regarding Norman Cousins was his
statement that we tend to separate the mind and
the body an they are both run by the same blood
stream.

I wouldn't say his book is gospel, but in 1979 when it was
written I would to venture say there was not a whole
lot of interest in his alternative based thinking
and way of healing. Maybe in the 60s, but certainly not
approaching the 80s.

I am glad the book appealed to you in some way.

Not being an avid reader of NEJM and being just
a lay person with depression, my offerings are
minimal at best, but it was a thought that dawned
on me. In college I did a term on the Placebo
Effect for my Psych class and Cousins was just
the tip of the iceberg upon my research. There
were thousands of cases of placebo response and
also non-placebo. The most fascinating to me was
sham surgery with heart patients. The list goes on.

I think our minds have powerful input over every aspect
of our bodies and certainly our way of thinking.

Thank you for your information from NEJM. It has helped
me also.

Take care, Jane.

Best,

Paige

 

Re: Norman Cousins on Placebos Paige

Posted by Jane D on May 27, 2001, at 11:11:08

In reply to Re: Norman Cousins on Placebos Jane D, posted by Paige on May 27, 2001, at 7:02:22

> > >
> > >
> Hi jane,
>
> I think the most profound comment that remained
> in my mind regarding Norman Cousins was his
> statement that we tend to separate the mind and
> the body an they are both run by the same blood
> stream.
>
> I wouldn't say his book is gospel, but in 1979 when it was
> written I would to venture say there was not a whole
> lot of interest in his alternative based thinking
> and way of healing. Maybe in the 60s, but certainly not
> approaching the 80s.
>

Paige,

That's part of what I found interesting. I really can't believe I never read it before. I kept realizing that this was the book that had influenced all these other people that I've read. I'm sorry if I seemed too critical. I really was greatful for the recommendation. I'm still in the middle of the book and finding it very hard to keep in mind both what we know today and what we knew then.

>
> Not being an avid reader of NEJM and being just
> a lay person with depression, my offerings are
> minimal at best, but it was a thought that dawned
> on me. In college I did a term on the Placebo
> Effect for my Psych class and Cousins was just
> the tip of the iceberg upon my research. There
> were thousands of cases of placebo response and
> also non-placebo. The most fascinating to me was
> sham surgery with heart patients. The list goes on.

I've always thought the idea of placebos would be interesting to read up on but never followed through. I'm not a medical journal reader either but the word placebo caught my eye. I really think I want to learn more. Any other suggestions? I remember sham surgery was controversial because it wasn't entirely harmless (anesthesia). Cousins specifically talks about the ideal placebo that is completely harmless.

I do wonder if antidepressants sometimes get prescribed by doctors to patients who don't need them with the mistaken idea that they are that ideal harmless placebo. People have posted here that they were prescribed antidepressants for very minor reasons. They are outraged at any side effects that they experience and I think they have a point. I wonder too if I accidentally mislead my doctor. I rarely report side effects because I think it goes without saying that I experience more good than harm. Maybe it should be said. Maybe I should try to make sure that my doctor doesn't think that "no important side effects to me when compared to my life without drugs" really means "no side effects at all when prescribed to anybody" and then go merrily prescribing the same thing for everyone who walks in the door.


> I think our minds have powerful input over every aspect
> of our bodies and certainly our way of thinking.

And vice versa. I think we now accept this as a given compared to 1979. Cousins probably has something to do with that.

Jane

 

Re: NEJM Article says placebo effect small Jane D

Posted by SLS on May 27, 2001, at 11:16:05

In reply to Re: NEJM Article says placebo effect small SLS, posted by Jane D on May 26, 2001, at 19:38:35

Hi Jane.

> > 4. A patient may experience great relief at the thought that they are receiving medical treatment that will end their pain.

> This last is what the study challenged. They compared studies that had 3 groups, treatment, placebo and no treatment. This way any difference between the placebo and no treatment groups should be due to the patients belief in their treatment not random variation in the course of the illness. They found very little difference. Their conclusion is that placebo is justified in clinical trials but not as a treatment.

I find this observation to be reassuring. Other studies attacking the issue from other directions have concluded the same thing; that a placebo-control designed into study protocols is both valid and often necessary to produce meaningful results. Interestingly, one study concluded that there was little advantage to using an active placebo.

I see now that I took unjustified liberties in my portrayal of point #4. I included it because of my personal experience when I first entered the NIMH research program and the statements made by members of the research staff there. They noted that a great proportion of their subjects evidenced a mildly brighter mood during the first two weeks, whereafter, their mood settled down to their original baseline. However, I made the mistake of assigning to their observations a causitive explanation. I recall that no statements were made to explain why or how this phenomenon occurred. I must also add that I am not aware of any study protocol developed to quantify or validate what they thought they witnessed anecdotally.

Thanks for amplifying the point.


- Scott

 

Re: NEJM Article says placebo effect small

Posted by Cam W. on May 27, 2001, at 12:19:50

In reply to Re: NEJM Article says placebo effect small Jane D, posted by SLS on May 27, 2001, at 11:16:05

There has been some very good research on placebo effect of late. In particular:

Stefano GB, Fricchione GL, Slingsby BT, & Benson H. The placebo effect and relaxation response: neural processes and their coupling to constituitive nitric oxide. Brain Research Reviews; 35 (2001): 1 - 19.

This review concludes "...that enough scientific information exists to support these phenomena as actual physical processes that can be harnessed to provide better patient care."

The show, using 166 references, how placebo and relaxation response have similar peripheral and central nervous system mechanisms. "Central to our hypothesis, is the significance of norepinephrine, nitric oxide and opiod signaling both in the central and peripheral nervous systems. In this regard, we find that nitric oxide controls norepinephrine processes on many levels, including synthesis, release and actions."

Also: "With regard to human history, we have always been aware of this innate protective response. For example, in Greek culture, 2000 years ago, it was believed that the healthy mind and the healthy body went hand-in-hand, establishing a link between mind-body experiences. This type of association can be found in many societies/cultures throughout human history, and it even exists in present day society. Anecdotally, we have perceived that there may be more to health maintenance than just a particular pathologic situation, suggesting that the mind's cognitive as well as non-cognitive link to the body may be involved in a proactive manner with promoting our health. Additionally, given the evolution of cognition, we propose that we may be able to initiate this innate proactive health-oriented process at will. Furthermre, the existence of such a protective process can be surmised from human longevity; mechanisms must exist to promote our health for this extended period of time. In this regard, the mind-body link can be viewed as an antibiosenescent process."

The authors show the similarities between placebo effect and relaxation response seen in some types of psychological therapies. They also give mechanisms why placebo effect does not work under all pathological circumstances and show that the placebo processes are organically based. They finish with:

"This speculative review has not been designed to answer all questions in regard to the relaxation response or the placebo effect. However, it does attempt to access these phenomena in light of current knowledge. In this regard, we conclude that there is a scientific basis for their presence. We further predict that an even greater number of physiological and biochemical processes will be found that will offer an even greater understanding of their operation. Finally, it is by way of this research, that we may be able to harness the body's own 'healthy' processes, allowing us to live longer and healthier lives."

Three of the authors (Stefano, Fricchione, and Benson) work at The Mind/Body Institute, CareGroup, Department of Medicine, Beth Isreal Deaconess Medical Center, Harvard Medical School, Boston, MA, so they can do have some credible credentials.

- Cam

 

Re: Placebo in depression SLS

Posted by Jane D on May 27, 2001, at 13:29:48

In reply to Re: NEJM Article says placebo effect small Jane D, posted by SLS on May 27, 2001, at 11:16:05

> Hi Jane.
>
> > > 4. A patient may experience great relief at the thought that they are receiving medical treatment that will end their pain.
>
> > This last is what the study challenged. They compared studies that had 3 groups, treatment, placebo and no treatment. This way any difference between the placebo and no treatment groups should be due to the patients belief in their treatment not random variation in the course of the illness. They found very little difference. Their conclusion is that placebo is justified in clinical trials but not as a treatment.
>
> I find this observation to be reassuring. Other studies attacking the issue from other directions have concluded the same thing; that a placebo-control designed into study protocols is both valid and often necessary to produce meaningful results. Interestingly, one study concluded that there was little advantage to using an active placebo.
>
> I see now that I took unjustified liberties in my portrayal of point #4. I included it because of my personal experience when I first entered the NIMH research program and the statements made by members of the research staff there. They noted that a great proportion of their subjects evidenced a mildly brighter mood during the first two weeks, whereafter, their mood settled down to their original baseline. However, I made the mistake of assigning to their observations a causitive explanation. I recall that no statements were made to explain why or how this phenomenon occurred. I must also add that I am not aware of any study protocol developed to quantify or validate what they thought they witnessed anecdotally.
>
Scott,

It may still turn out to be real. I found an editorial accompanying the article (which IS available online) after I made my first post. It points out some problems with the study. One I think was that these studies weren't designed to look for placebo effect and would miss small changes. I don't think we can ignore gut feeling even if we can't trust it either. I've experienced a temporary lift at the start of treatment too. How about the following scenario?

One symptom of depression is an irrational feeling of hopelessness about everything. Experiencing this and believing that it may never go away (which is not at all irrational) is also depressing in the less technical sense of the word. Depression causing situational depression? Starting a new treatment makes you believe again that there may be a cure so you can reason your way out of the rational part of your hopelessness. This makes you feel better even though the irrational part of the hopelessness remains until the depression is actively treated. Eventually, if the treatment fails, the rational hopelessness returns also.

This fits with the observation that placebo improvements are temporary and doesn't assume that they are unrelated to the placebo. I have no idea how this could be tested. Maybe it can't be.

Jane

 

Re: Placebos effective Cam W.

Posted by Jane D on May 27, 2001, at 13:49:38

In reply to Re: NEJM Article says placebo effect small, posted by Cam W. on May 27, 2001, at 12:19:50

> There has been some very good research on placebo effect of late. In particular:
>
> Stefano GB, Fricchione GL, Slingsby BT, & Benson H. The placebo effect and relaxation response: neural processes and their coupling to constituitive nitric oxide. Brain Research Reviews; 35 (2001): 1 - 19.
>
> This review concludes "...that enough scientific information exists to support these phenomena as actual physical processes that can be harnessed to provide better patient care."
>
> The show, using 166 references, how placebo and relaxation response have similar peripheral and central nervous system mechanisms. "Central to our hypothesis, is the significance of norepinephrine, nitric oxide and opiod signaling both in the central and peripheral nervous systems. In this regard, we find that nitric oxide controls norepinephrine processes on many levels, including synthesis, release and actions."
>

Thanks. That will be next weeks reading if I can find it. (I'm still struggling through cytochrome p450 stuff which was set off by Scott's and your posts of a week ago.)

 

Re: Placebos effective

Posted by AMenz on May 28, 2001, at 22:48:09

In reply to Re: Placebos effective Cam W., posted by Jane D on May 27, 2001, at 13:49:38

Where can you find publication cited below?

> > There has been some very good research on placebo effect of late. In particular:
> >
> > Stefano GB, Fricchione GL, Slingsby BT, & Benson H. The placebo effect and relaxation response: neural processes and their coupling to constituitive nitric oxide. Brain Research Reviews; 35 (2001): 1 - 19.
> >
> > This review concludes "...that enough scientific information exists to support these phenomena as actual physical processes that can be harnessed to provide better patient care."
> >
> > The show, using 166 references, how placebo and relaxation response have similar peripheral and central nervous system mechanisms. "Central to our hypothesis, is the significance of norepinephrine, nitric oxide and opiod signaling both in the central and peripheral nervous systems. In this regard, we find that nitric oxide controls norepinephrine processes on many levels, including synthesis, release and actions."
> >
>
> Thanks. That will be next weeks reading if I can find it. (I'm still struggling through cytochrome p450 stuff which was set off by Scott's and your posts of a week ago.)

 

Re: Placebos effective AMenz

Posted by Cam W. on May 28, 2001, at 23:12:50

In reply to Re: Placebos effective, posted by AMenz on May 28, 2001, at 22:48:09

> Where can you find publication cited below?

Stefano GB, Fricchione GL, Slingsby BT, & Benson H. The placebo effect and relaxation response: neural processes and their coupling to constituitive nitric oxide. Brain Research Reviews; 35 (2001): 1 - 19.

AMenz - You can find this journal article in the archives on the Neuroscion website. You have to sign up, but it's worth it.

http://www.neuroscion.com

- Cam


This is the end of the thread.


Show another thread

URL of post in thread:


Psycho-Babble Medication | Extras | FAQ


[dr. bob] Dr. Bob is Robert Hsiung, MD, bob@dr-bob.org

Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.