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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 25. This is the beginning of the thread.
Posted by alexandra_k on February 15, 2015, at 21:14:47
so placebo is pretty effective. i mean, placebos are surprisingly helpful. much better than no treatment at all and as good, or nearly as good as a lot of treatments out there. and less side effects. i mean... i don't think you would have much trouble getting FDA approval for placebo...
anyway, i'm wondering whether placebos are effective if people are informed they are being given placebos. i mean, if you are all, like, 'hey! it is time for your placebo! aren't you glad you are on placebo with all the evidence about it's efficacy and relative safety?' i mean, it does have some pretty serious side-effects... but nothing that can't be treated by a different kind of placebo...
this is because i'm drinking decaf... and i think it is making me feel buzzy / anxious... which is why i'm drinking decaf instead of coffee. i KNOW i'm drinking decaf. that is why i'm drinking decaf. so it doesn't make me feel buzzy / anxious the way i've been feeling lately with drinking coffee...
sigh. should i drink water and pretend it is chamomile tea?
maybe it is like the heroin people who OD because their body has a preparatory response to their ritual... maybe the smell of coffee is enough... or the taste of coffee...
Posted by alexandra_k on February 15, 2015, at 21:14:47
In reply to placebo, posted by alexandra_k on November 21, 2014, at 15:14:38
i actually meant that for the med board. thought i thought you might move it to alternative... i thought i might get more responses on the med board...
are you very busy, dr bob?
Posted by Damos on February 15, 2015, at 21:14:48
In reply to placebo, posted by alexandra_k on November 21, 2014, at 15:14:38
The answer to your question about whether they work if you know it's a placebo, would appear surprisingly to be yes. There was a BBC doco late last year or early this year 'The Power of the Placebo' I think it was, that was incredibly interesting even down to how the colour of tablets or capsules can effect peoples perceptions of their effectiveness.
Posted by alexandra_k on February 15, 2015, at 21:14:48
In reply to Re: placebo » alexandra_k, posted by Damos on November 29, 2014, at 0:17:50
> The answer to your question about whether they work if you know it's a placebo, would appear surprisingly to be yes. There was a BBC doco late last year or early this year 'The Power of the Placebo' I think it was, that was incredibly interesting even down to how the colour of tablets or capsules can effect peoples perceptions of their effectiveness.
Hey dude!!!
I always remember this episode of M*A*S*H... Where they ran out of pain pills so they gave this guy a placebo, because they didn't have anything else...
And there was some discussion about the ethics of that. Informed consent etc etc.
And ever since... I've wondered about whether people actually can give informed consent for placebo. Whether deception is a necessary component, I mean. Or whether the placebo effect is sub-conscious... Like how some emotions can't be restructured away... Maybe placebo effect is like that, too. Try and you might not want to belive in the power of placebo... It works!
Which strikes me as funny.
Mostly strange. But a little bit haha.
Posted by alexandra_k on February 15, 2015, at 21:14:48
In reply to Re: placebo, posted by alexandra_k on November 29, 2014, at 17:38:42
i think i have a confusion about this. i probably just need to learn a bit more about trials etc... i'm confused about the role of double blinding... why that would make a difference if placebo effect was impervious to knowledge. but then, on the other hand... i was pretty sure that it was impervious to knowledge. maybe... more must be said about the extent of the knowledge or the nature of the belief or whatever...
Posted by ed_uk2010 on February 16, 2015, at 6:39:31
In reply to placebo, posted by alexandra_k on February 15, 2015, at 21:14:47
>this is because i'm drinking decaf... and i think it is making me feel buzzy / anxious...
I think it could indeed be the association that has developed in your mind between the taste and smell of coffee, and certain symptoms. On the other hand, decaf does contain a tiny dose of caffeine, but not enough to cause side effects.
>FDA
The FDA require new psych drugs to be tested against identical appearing placebos. It would be difficult to show one placebo was better than an identical placebo! :)
Posted by ed_uk2010 on February 16, 2015, at 7:06:05
In reply to Re: placebo, posted by alexandra_k on February 15, 2015, at 21:14:47
What makes a placebo more or less effective in psychiatric drug trials? Quite a lot of things actually:
Placebo injections have particularly marked effects. There is an expectation that injections are powerful.
Branded placebos are more effective than generic placebo tablets. Perception *is* important.
Coloured capsules are more effective that little white tablets.
In serious illness, any placebo responses may be short-lived.
Placebo response is high when recruiting pts with mild-moderate depression. Spontaneous remission is frequent is this group.
Placebo response is high is trials where a lot of contact with services is provided. The more care and visits provided, the higher the placebo effect.
Placebo response is higher in trials where there is the knowledge that most patients are receiving the active drug and a smaller proportion are receiving placebo. Again, perception is important.
Placebos which cause side effects may be more effective than true placebos. For example, if a non-psych drug which causes dry mouth is chosen instead of an inactive placebo, pts will perceive that they are definitely on an active drug, and will respond better.
Two different placebos in combination can be better than one.
People report side effects with placebos. Several different mechanisms may operate here: the tendency to attribute all symptoms which occur when taking a med to that med - even when actually unrelated, the expectation of certain symptoms will produce them 'this drug will cause nausea = pt experiences nausea', and possibly anxiety-type symptoms due to fear of medication.
Active drugs may appear to be effective in trials entirely due to side effects. For example, a drug which sedates may improve depression rating scales entirely through increased sleep, even in the absence of mood improvement.
There is a tendency for most of those recruited into trials to improve. This is because pts are often included at the point of acute illness, from which some improvement is likely to occur over time, even without treatment. This is true even in severe depression, due to fluctuations in severity over time. Regression towards the mean operates here.
Posted by ed_uk2010 on February 16, 2015, at 8:00:05
In reply to placebo, posted by alexandra_k on February 15, 2015, at 21:14:47
>should i drink water and pretend it is chamomile tea?
:) It would probably need to taste and smell similar, at the very least. Do you like chamomile tea?
Scientific study has hardly been extensive, but German Chamomile does seem possibly useful in anxiety and depression. Most chamomile teas use the German variety. Look for Matricaria recutita.
One of the little studies...
http://www.ncbi.nlm.nih.gov/pubmed/19593179
Personally, I would not be fooled by a placebo chamomile capsule. I would immediately know what it was by smelling it. I suppose alternative practitioners might argue that the smell is potentially as important as the other features of the herb. Aromatherapists would have something to say.
I find this abstract interesting, but confused:
http://www.ncbi.nlm.nih.gov/pubmed/22894890
Perhaps we should be promoting to chamomile to those on antipsychotics (think elevated blood sugar). In our rodent friends, chamomile appears anti-diabetic!
Posted by ed_uk2010 on February 16, 2015, at 8:26:08
In reply to Re: placebo, posted by alexandra_k on February 15, 2015, at 21:14:48
> i think i have a confusion about this. i probably just need to learn a bit more about trials etc... i'm confused about the role of double blinding... why that would make a difference if placebo effect was impervious to knowledge.
Placebo effects do depend at least partially on expectation. Double blind trials are the most reliable because they reduce the ability of both patients and investigators to have expectations.
Posted by ed_uk2010 on February 16, 2015, at 8:35:40
In reply to Interesting things which affect the placebo effect, posted by ed_uk2010 on February 16, 2015, at 7:06:05
As well as being double blind, I think it's important for trials to minimise the placebo response. It's difficult to find out whether a drug works if a high proportion of participants are responding whatever they are given. Maximising the placebo response in very useful in the clinic, but problematic in trials.
To minimise the placebo response in trials, companies should:
Use plain white tablets for the active and placebo group. The packaging should always be plain. The dose should be given using as few tablets as possible. Creating the impression of receiving a high dose may increase the placebo response.
Avoid recruiting patients with mild illness likely to remit spontaneously. In depression trials, pts should have had fairly constant symptoms for many weeks or months.
Avoid excessively 'lush' environments for care during the trial. Consultations should be as similar to normal practice as possible.
The proportion of patients receiving the active treatment and placebo should be evenly distributed.
Posted by ed_uk2010 on February 16, 2015, at 8:39:07
In reply to Chamomile » alexandra_k, posted by ed_uk2010 on February 16, 2015, at 8:00:05
In real life, it's important to maximise the chance of a good response by whatever means. To enhance response, careful branding and packaging of medicines gives a good impression to the users of the medicine. Enhanced confidence in a medicine seems to make people feel better. Although some would argue that excessive amounts of colourings should not be used in medicines.... if it enhances response, it may be worthwhile. It also reduces confusion between tablets by making them more identifiable.
Posted by alexandra_k on February 16, 2015, at 13:23:50
In reply to Trial design, posted by ed_uk2010 on February 16, 2015, at 8:35:40
Thanks very much for responding :)
You have given me much to think about... I have an exam, soon... But I will get back to this after...
I'm shocked about all this talk of minimising placebo response in trials, honestly. Not by YOUR talk of it, because I know that you are just informing me of 'standard talk'... But, honestly... I don't want my medications to be better than those inaffective placebos. I want my medications to be better than the best placebos money can buy! I mean... Placebo's are pretty effective... Done well... Probably more effective than standard meds.
This seems... Important.
Posted by alexandra_k on February 16, 2015, at 13:24:50
In reply to Re: Trial design, posted by alexandra_k on February 16, 2015, at 13:23:50
And no, I don't like chamomile, at all. I just thought I might acquire some of the R&R by placebo if I took placebo chamomile tea. Instead of the anxiety placebo I was getting from decaf.
Posted by ed_uk2010 on February 16, 2015, at 14:36:41
In reply to Re: Trial design, posted by alexandra_k on February 16, 2015, at 13:23:50
>I'm shocked about all this talk of minimising placebo response in trials, honestly.
I do understand why, but.... part of the problem with recent drug trials in psychiatry is that they are too 'lush'. This is temporarily good for the participants, no doubt, but bad for the millions of people who then go on to take (or not take) the drug based on poor quality evidence. Minimising placebo responses in clinical trials gives a more accurate picture of what the drug itself is actually doing... or failing to do... as the case my be. Good quality trial data leads to a better understanding of the drug's effects.... very valuable information for psychiatrists and hence patients alike. The fact that participants are provided with an unusually large number of consultations appears to increase the placebo response so much that the trial is no longer of much scientific value - which is indeed a problem!
You might say that this shows we need to spend less on new drugs and more on providing a good therapeutic environment, which should include frequent consultations. That would be a good point. The problem is that patients in clinical trials are not very representative of the 'average' person visiting a psych. This is due to the complex entry criteria which clinical trials employ, sometimes out of necessity. The result may be that those selected are more responsive to placebo that the 'average' pt who has more complex problems eg. including suicidal behavior, which would normally prevent trial entry, for example. Many people visiting a pdoc have already tried several meds from their GP over a period of many months, and not improved.... this removes a lot of placebo responders from those who see pdocs. As a result, psychiatrists really do need to know which meds work better than placebos.
>But, honestly... I don't want my medications to be better than those ineffective placebos. I want my medications to be better than the best placebos money can buy! I mean... Placebo's are pretty effective... Done well... Probably more effective than standard meds.
Once trials have been done on those little weight tablets, companies can go to all the effort they like to make their products better placebos. Fancy packaging, attractive branding, advertising, nicely designed capsules (!) etc etc.
>Not by YOUR talk of it, because I know that you are just informing me of 'standard talk'...
I am, yes, but it does have a purpose for pdocs and those who see them. It's not just a case of benefiting the manufacturers! We all need accurate information of the effects of meds.
Posted by ed_uk2010 on February 16, 2015, at 14:39:19
In reply to Re: Trial design, posted by alexandra_k on February 16, 2015, at 13:24:50
> And no, I don't like chamomile, at all. I just thought I might acquire some of the R&R by placebo if I took placebo chamomile tea. Instead of the anxiety placebo I was getting from decaf.
Ha!
Would you get strange looks if you were spotted sniffing the herbal tea boxes in your local supermarket to find out what takes your fancy?
Posted by alexandra_k on February 16, 2015, at 16:29:49
In reply to Re: Trial design » alexandra_k, posted by ed_uk2010 on February 16, 2015, at 14:36:41
yes...
i think there is some equivocation going on with respect to 'placebo response'...
that is creating problems...
in the drug trials... we want to minimise the aspect of the response that is due to placebo. yes.
but part of how we do that is to... give the placebo group the best freaking placebo we can find...
if that makes sense...
i mean... i don't just want to know that drug x is better than plain packaged plain white pill placebo y... i want to know that drug x is better than fancy packaged colorful capsule brand name equally advertised placebo y.
otherwise... drug x hasn't been shown to be better than placebo. seems to me...
Posted by alexandra_k on February 16, 2015, at 16:31:20
In reply to Re: Trial design, posted by alexandra_k on February 16, 2015, at 16:29:49
because pharma isn't going to fund research on improving the efficacy of placebo... for obvious reasons.
so instead they use it as this thing to... restrict what they do with new meds. to plain package them etc, i mean...
but i thought the whole point was in developing the BEST TREATMENT. only... we can't do that if making better placebo's is off limits to gold standard science. yeah?
Posted by alexandra_k on February 16, 2015, at 16:34:21
In reply to Re: Trial design, posted by alexandra_k on February 16, 2015, at 16:31:20
what i mean is... instead of learning stuff about placebo (x helps and y helps and z helps) and then controlling out all the helping... so x and y and z are removed from both groups...
instead of that...
why not build placebo into all conditions. in order to improve the treatment response (for all groups) as much as possible.
isn't that the relevant control group? Placebos... everything we can throw at it no holds barred... we want to discover something *better than that*
Posted by ed_uk2010 on February 16, 2015, at 17:26:59
In reply to Re: Trial design, posted by alexandra_k on February 16, 2015, at 16:34:21
I think I see what you mean.
Someone could do a large trial of common/established drug X in a plain white tablet against posh placebo Y in a branded box....
But I think there are two issues here:
1. Who would fund this and why?
2. We already have evidence of what makes placebos more effective eg. capsules instead of tablets, coloured instead of white, branded instead of unbranded etc. What would the study attempt to prove? Even if the response appeared similar, if we knew the drug was effective from previous trials, we would know that some pts will respond better to it than placebo. Others may have side effects and prefer the colourful placebo!So, it seems to me that people would have the best chance of recovery when they receive:
a) a medication (assuming one is necessary) which is optimal for their condition
and b) the product in a), appropriately presented.Part of the reason, probably the main reason, that people often say they to respond better to branded drugs than generics is because they have more confidence in them. Confidence does not only influence the psychological response to treatment, but also the probability that the medicine will be taken at all.
Posted by ed_uk2010 on February 16, 2015, at 17:29:49
In reply to Re: Trial design, posted by alexandra_k on February 16, 2015, at 16:31:20
>because pharma isn't going to fund research on improving the efficacy of placebo... for obvious reasons...
I doubt pharma is at the forefront of this research, but we do know how to improve the power of placebos. The best way seems to be to inject them! Inject them and tell the person the are receiving something powerful.
Now a question....
How would you feel about receiving a placebo injection for a mental health problem? Ethical issues?
Posted by ed_uk2010 on February 16, 2015, at 17:39:40
In reply to Re: Trial design, posted by alexandra_k on February 16, 2015, at 16:34:21
Here is my impression of the ultimate placebo:
Injected
Administered by specialist staff in a specialist environment
Well presented
Causes some form of side effect - pts know they have 'received something' strong, creating confidence in the treatment. The public seem to expect side effects when told something is 'strong'.
Closely monitored
.......
All this sounds a bit like the ketamine injections used for depression, which incidentally can cause acute mood changes and often euphoria! Researchers claim that the antidepressant effect of K lasts a week after the injection. My question.... is this because K is an AD, or because the placebo effect of K is more powerful than the placebo effect of saline? K causes obvious side effects and in some cases, substantial acute euphoria. This gives the impression that something very powerful has been given. Is this why mood elevation persists long after the K has been eliminated from the body? Or it is because K is truly an AD with effects lasting beyond the elimination of the drug? Given that other drugs acting at the same receptor have shown AD activity in preliminary trials without the acute mood changes, I think it's probably a bit of both.
Interesting anyway.
Posted by ed_uk2010 on February 16, 2015, at 17:42:43
In reply to The ultimate placebo, posted by ed_uk2010 on February 16, 2015, at 17:39:40
Double blind?
Ketamine trials are about as double blind as those involving chamomile tea. The effects of ketamine are hardly subtle!
I was amused by the concept of a double blind aromatherapy trial. Perhaps you could use sunflower oil versus lavender? The study population would have to be very well selected to not notice the difference...
Posted by alexandra_k on February 16, 2015, at 23:57:26
In reply to Re: The ultimate placebo, posted by ed_uk2010 on February 16, 2015, at 17:42:43
I'm thinking there might be something doctrine of double effect-y to appeal to. So... I didn't intend to kill them... I just intended to turn the switch off on the life support system and a by-product of the switch being turned off was that they died. Or... I didn't intend to kill them I just intended to increase their morphene to control their pain and an unintentional by-product was that they died of too much morphene.
I just intended to give them the best *most effective* treatment. Who wouldn't consent to that??
I don't quite know.
Maybe... Governments should fund such studies. Especially insofar as governments pay for approved treatments. You would think they would need to fund someone to check / balance pharma studies... In some countries, at least...
Because... Conning people into paying a crap ton of money for something that is no more effective than (properly jazzed up) placebo... Sounds worse. Ethically, I mean.
Posted by ed_uk2010 on February 17, 2015, at 19:11:43
In reply to Re: The ultimate placebo, posted by alexandra_k on February 16, 2015, at 23:57:26
Decades ago, it was common practice for doctors to prescribe placebos. The placebos were often low strength vitamin tablets labelled as something else 'Nerve tablets'. This hasn't been possible for a long time because all medicines have to be labelled with their precise ingredient - a legal requirement.
These days, a huge amount of placebo-like prescribing goes on, sometimes without even realising it, but the products involved are not actually placebos.
Common examples include:
Using acid-suppressants for vague abdominal symptoms not clearly related in any way to acid. Use of potent PPI drugs (omeprazole etc) in this manner is now extremely frequent.
Most use of antispasmodics and cough suppressants.
Rxing low doses of meds, often antidepressants, to 'relieve' a multitude of undiagnosable symptoms.
Prescribing vitamin supplements for a variety of purposes in those unlikely to be deficient.
Prescribing low doses of anti-emetics (esp. prochlorperazine) for symptoms of dizziness in older people, after investigation has been unrevealing and in the absence of any nausea/vomiting. Use of prochlorperazine for this purpose has been common and except in the very short term, is a very bad idea!
And unfortunately, a very high proportion of antibiotic prescribing in primary care.
The problem with this type of prescribing is that with the exception of the vitamin example, side effects can and do occur.... it would be better if most of the pts involved actually were being given placebos. The drugs are unlike to produce much pharmacological benefit....
Posted by phidippus on March 2, 2015, at 13:49:37
In reply to placebo, posted by alexandra_k on February 15, 2015, at 21:14:47
Decaf still has small amounts of caffeine.
Eric
This is the end of the thread.
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