Placebos, placebo effect, and the response to the healing situation: the evolution of a concept

A novel technology for preparing the placebos of vortioxetine hydrobromide tablets using LCD 3D printing

This study aimed to describe the use of liquid crystal display (LCD) three-dimensional (3D) printing technology to prepare moulds for vortioxetine hydrobromide (VOR) tablet placebos and provide an economical, convenient, and flexible method for the small-batch preparation of special-shaped, scored, and coated placebo tablets. First, LCD 3D printing was used to generate different placebo moulds of VOR tablets based on VOR tablet digital models subtracted from the digital models of cuboid moulds by Boolean operation to optimise the structures of moulds. The better placebo mould had a parting surface located at the 7/10 height of the packing cavities and the positioning columns and slots were three pairs, and the efflux space had slender efflux channels combined with wide efflux tanks. Next, the placebo mould was corrected by the dimensional compensation method due to the shrinkage rates of the packing cavities (2.42%) and placebo prescription (1.12%) and the thickness of the film coating (25.08 μm). The placebo prescription was 8% hydroxypropyl methylcellulose (SH K15M) hydroalcoholic gel, and its mass ratio to lactose was 0.8:2. The placebos were coated with 13% gastric-soluble film coating solution for 30 min and polished with the 30% PEG 4000 solution. The National Bureau of Standards value between the VOR tablets and their placebos was 1.22 ± 0.10 (less than1.5). Finally, the mass of the placebos was similar to that of the VOR tablets. Their dimensional differences were less than 0.1 mm. Their mass, colour, odour, shape, and texture were all similar, which were assessed by manual evaluation. In conclusion, the preparations of VOR tablet placebos can be applied in placebo-controlled trials, and LCD 3D printing has an extensive application value in preparing placebo tablets.

Spontaneous regression rates of actinic keratosis: a systematic review and pooled analysis of randomized controlled trials

Actinic keratosis (AK) are precancerous lesions of the skin which may progress to invasive squamous cell carcinoma. However, single lesions may also persist or even regress and heal spontaneously. Until now, evidence on the natural course of AK including spontaneous regression is limited. We aimed to synthesize regression rates of AK. We performed a systematic literature research in Medline, Embase, and CENTRAL for eligible trials until 3rd March 2020. Spontaneous regression rates were pooled using a random-effects model to calculate pooled proportions of participant-specific and lesion-specific complete clearance rates reported for the placebo arms of randomized controlled trials. Subgroup analyses were performed to dissect differences according to the type of placebo, immunocompetence of the participants, and localization of the lesions. Data from 38 records was included. The pooled participant-specific clearance rate was 8% (95% CI 6–10%, I² = 71%) while the lesion-specific clearance rate was 23% (95% CI 16–31%, I² = 97%). The highest participant- and lesion-specific clearance rates were achieved 12 weeks after the end of treatment (12% and 33%, respectively). Subgroup analysis revealed participant- as well as lesion-specific clearance rates of 0% for organ transplant recipients (OTR). We conclude that only a few participants achieve complete regression of their AK without any active treatment. Besides, the results underline that lesion clearance without active treatment is unlikely in OTR. Thus, early and consequent treatment of AK is recommended. Special attention should be paid when treating AK of OTR.

Rethinking Clinical Trials and Personalized Medicine with Placebogenomics and Placebo Dose

Pharmacogenomics, nutrigenomics, vaccinomics, and the nascent field of plant omics are examples of variability science. They are embedded within an overarching framework of personalized medicine. Across these public health specialties, the significance and biology of the placebo response have been historically neglected. A placebo is any substance such as a sugar pill administered in the guise of medication, but one that does not have pharmacological activity. Placebos do have clinical effects, however, that can be substantive in magnitude and vary markedly from person-to-person depending, for example, on the type of disease, symptoms, or clinical trial design. Research over the past several decades attests to a genuine neurobiological basis for placebo effects. All drugs have placebo components that contribute to their overall treatment effect. Placebos are used in clinical trials as control groups to ascertain the net pharmacological effect of a drug candidate. Not only less well known but also relevant to rational therapeutics and personalized medicine is the nocebo. A nocebo effect occurs when an inert substance is administered in a context that induces negative expectations, worsening patients' symptoms. With the COVID-19 pandemic, there are high public expectations for new vaccines and medicines to end the contagion, while at the same time antiscience, post-truth, and antivaccine movements are worrisomely on the rise. These social movements, changes in public health cultures, and conditioned behavioral responses can trigger both placebo and nocebo effects. Hence, in clinical trials, forecasting and explaining placebo and nocebo variability are more important than ever for robust science and personalized health care. Against this overarching context, this article provides (1) a brief history of placebo and (2) a discussion on biology, mechanisms, and variability of placebo effects, and (3) discusses three emerging new concepts: placebogenomics, nocebogenomics, and augmented placebo, that is, the notion of a "placebo dose." We conclude with a roadmap for placebogenomics, its synergies with the nascent field of social pharmacology, and the ways in which a new taxonomy of drug and placebo variability can be anticipated in the next decade.

Repositioning Individualized Homeopathy as a Psychotherapeutic Technique With Resolvable Ethical Dilemmas

The author puts forth the argument that the complementary and alternative medicine community should endorse specific aspects of the entire individualized homeopathic process, including its unique holistic consultation process, having dedicated lengths of time to enumerate the complete illness context, and the prescribing of homeopathic remedies, to reposition this modality as a psychotherapeutic technique. Moreover, placebo effects derived from homeopathic remedies could be used to further exploit favorable therapeutic effects that have accrued from the entirety of the homeopathic consultation process. The overall aim of this bold shift is to sustain the clinical practice of homeopathy from an ethical and clinically responsible (and plausible) framework that is properly evidence-informed.

Predictors of Erectile Function Normalization in Men With Erectile Dysfunction Treated With Placebo

BACKGROUND

Clinical study and practice data have shown sildenafil improves sexual function in men with erectile dysfunction (ED). However, some men treated with placebo in double-blind, placebo-controlled sildenafil studies also report improved erectile function as measured by International Index of Erectile Function (IIEF)-Erectile Function Domain (EFD) scores.

AIM

This analysis estimated the relationship between post-baseline IIEF-EFD scores and demographic variables, including co-morbidities, in men with ED receiving placebo in flexible-dose sildenafil studies.

METHODS

Placebo-treated participants in the intent-to-treat population of 42 double-blind, placebo-controlled, flexible-dose, sildenafil studies were included. A participant was classified as a placebo responder if the IIEF-EFD score was ≥26 at the last visit.

OUTCOMES

Variables assessed were age (<45, 45-64, ≥65 years), race, body mass index, co-morbidities (cardiovascular disease/hypertension, diabetes mellitus, depression), date the last study dose was taken, study completion date, ED etiology (psychogenic, organic, mixed), history of cigarette smoking, ED duration, baseline IIEF-EFD score (≤10, 11-16, ≥17), and treatment duration. Stepwise multivariate logistic regression models assessed the odds of being a responder vs a non-responder for each variable.

RESULTS

A total of 4,360 men were included; 13.5% were responders. Odds estimates indicated the largest likelihood of placebo response occurred in men who were black (odds = 20.2, P < .0001), were younger than 45 years (odds = 7.3, P < .0001), had mild ED (baseline IIEF-EFD ≥17; odds >100, P < .0001), and did not have diabetes (odds = 4.5, P < .0001). The likelihood of a placebo response decreased as ED duration increased (odds = 0.74, P < .0001). The frequency of common adverse events was similar between placebo responders and non-responders.

CLINICAL TRANSLATION

These findings contribute to the improved understanding of predictors of placebo response in sildenafil clinical studies. Elucidation of these factors may contribute to the development of further interventions and treatment strategies and best practices for clinical trials.

STRENGTHS AND CONCLUSIONS

Strengths of this analysis include the large and diverse population and the duration of follow-up. Limitations include those associated with retrospective analyses and the inability to ascertain to what extent other demographic factors might have contributed to the placebo responses or how these placebo responses might be related to the natural course of ED.

CONCLUSIONS

Certain demographics, co-morbidities, and condition characteristics predicted the odds of a placebo response in sildenafil clinical studies of ED. Underlying reasons behind a placebo response warrant further evaluation. Mulhall JP, Carlsson M, Stecher V, et al. Predictors of Erectile Function Normalization in Men With Erectile Dysfunction Treated With Placebo. J Sex Med 2018;15:866-872.

Rethinking placebo in psychiatry: the range of placebo effects

This article, the first of two on placebo effects, provides a broad overview of placebo in the field of medicine. A brief conceptual history is followed by some basic facts about placebos. Problems of definition are identified. Additive and non-additive models of treatment effects, and problems of measurement of placebo effects are described. The role of placebo in the pharmacotherapy of depression and complementary and alternative medicine is discussed. The ‘efficacy paradox’ (that placebo treatments can have larger effects than ‘evidence-based treatments’) is introduced. Finally, ethical issues are discussed.

Effects of Scheduled Waiting for Psychotherapy in Patients With Major Depression

The role of nonspecific factors in the outcome of psychotherapy is poorly understood. To study the effects of pretreatment expectancy of scheduled psychotherapy, we examined the effects of an agreed waiting time on the outcome of psychodynamic psychotherapy. Thirty-three treatment-naive outpatients with major depressive disorder were randomly selected to start psychotherapy either directly (DG; n = 17) or after waiting for 6 months (WG; n = 16). In WG, 18% to 60% of the total decline in symptoms took place during the waiting time. After 1 year of active psychotherapy, the anxiety score declined significantly only in WG, and the total length of treatment needed was shorter in WG. No other outcome differences between WG and DG were found. We conclude that scheduled waiting associates with a significant decline in depressive symptoms. Scheduled waiting should be regarded as a preparatory treatment and not as an inert nontreatment control.

Measuring Multiple Dimensions of Religion and Spirituality for Health Research

Progress in studying the relationship between religion and health has been hampered by the absence of an adequate measure of religiousness and spirituality. This article reports on the conceptual and empirical development of an instrument to measure religiousness and spirituality, intended explicitly for studies of health. It is multidimensional to allow investigation of multiple possible mechanisms of effect, brief enough to be included in clinical or epidemiological surveys, inclusive of both traditional religiousness and noninstitutionally based spirituality, and appropriate for diverse Judeo-Christian populations. The measure may be particularly useful for studies of health in elderly populations in which religious involvement is higher. The measure was tested in the nationally representative 1998 General Social Survey ( N = 1,445). Nine dimensions have indices with moderate-to-good internal consistency, and there are three single-item domains. Analysis by age and sex shows that elderly respondents report higher levels of religiousness in virtually every domain of the measure.

Treatment expectations among adolescents with chronic musculoskeletal pain and their parents before an initial pain clinic evaluation

OBJECTIVES

To understand expectations regarding treatment recommendations among treatment-seeking adolescents with chronic musculoskeletal pain and their parents.

METHODS

A total of 102 adolescent-parent dyads were recruited at the time of initial contact with a multidisciplinary pain management clinic. Each participant completed reports of adolescent pain intensity and disability, biopsychosocial perspective of pain, and treatment expectations related to recommendations and feedback for a vignette description of an adolescent presenting at an initial multidisciplinary pain clinic evaluation.

RESULTS

Descriptive findings for individual treatment expectations and adolescent-parent dyad agreement statistics were examined. Slight to fair levels of agreement occurred for 50% of the expectations assessed. The strongest shared expectations were for recommendations to return to school, pursue psychological counseling, and pursue PT/OT treatment. Stronger agreement occurred for items reflecting alternative, emotional, behavioral, and activity recommendations with weaker agreement for medical interventions (eg, medication and surgery). Correlations emerged between individual expectations and adolescent pain intensity, disability, with the greatest number of significant relationships found for adolescent and parent expectations and biopsychosocial perspectives of pain.

DISCUSSION

Our results document that adolescents and parents show modest levels of agreement on expectations for treatment at the time of an initial pain clinic evaluation. This may relate to expectations being internal perspectives not clearly expressed within families; thus, the initial treatment consultation may provide an important opportunity to create and align appropriate expectations. Implications of our findings are considered with respect to education, treatment, and future research to understand factors that contribute to treatment adherence and outcomes.

The medical alliance: from placebo response to alliance effect

The natural human response to illness is to seek to understand what is happening and to look for help from others. In all cultures, one finds healers, who provide explanations and offer care. Their interventions often have a placebo effect through activation of natural healing processes in the patient. Although placebo effects are relatively large and robust, physicians generally consider placebo treatment prescientific and deceptive. We review the determinants of the placebo response and show how a particular professional alliance between a patient and a caregiver is apt to equally affect treatment outcome. We distinguish the alliance effect from the placebo effect. We develop a comprehensive model of the medical alliance, on the basis of the concept of concordance, and review its relevance for clinical practice and medical education. The alliance effect represents a professional and ethical way of activating a patient's natural healing mechanisms.

The effect of oral evening primrose oil on menopausal hot flashes: a randomized clinical trial

PURPOSE

Hot flashes are common experience for menopausal women, and for many, are severe enough to significantly compromise their overall sense of well being and quality of life. The aim of this study was to compare the efficacy of evening primrose with placebo in improvement of menopausal hot flashes.

METHODS

In a 6-week randomized clinical trial, a total of 56 menopausal women aged 45-59 years were participated in this study. The patients were asked for their hot flashes characteristics and responded to HFRDIS (hot flash related daily interference scale) questionnaire before and after the intervention. The participants were randomly assigned to take two capsules per day (totally 90 capsules for 6 weeks) of placebo or evening primrose (500 mg) for continuous 6 weeks. Then, the improvement in hot flashes was compared between two groups.

RESULTS

The percent of improvement in hot flash frequency, severity and duration were 39, 42 and 19 %, in evening primrose group compared with 32, 32 and 18 % in placebo group, respectively. Although all three characters of hot flash was ameliorated in evening primrose arm, only its severity was significantly better in this arm compared with placebo group (P < 0.05). All HFRDIS score were significantly improved in two groups, but the percentage of improvement in social activities, relations with others, and sexuality was significantly superior to placebo group (P < 0.05).

CONCLUSIONS

The application of oral evening primrose oil compared with placebo for controlling hot flashes may decrease more the intensity of attacks as well as ameliorating the HFRDIS score.

Energy healing and the placebo effect. An anthropological perspective on the placebo effect

The paper deals with a classical anthropological issue, the working mechanisms of rituals and the relation between healing rituals and the placebo effect. The point of departure of the paper is MUS (medically unexplained symptoms) patients' experiences of Danish healing rituals. The aim of the paper is to develop an understanding of how bodily experienced images of body and self work to transform the patient during a healing ritual. It is argued that a bodily founded symbolic re-editing of body- and self-image is an essential skill in healing rituals. In conclusion, it is argued that the placebo is nothing but the effectiveness of bodily experienced symbols.

Behavior and symptom change among women treated with placebo for sexual dysfunction

INTRODUCTION

In clinical trials of drug treatments for women's sexual dysfunction, placebo responses have often been substantial. However, little is known about the clinical significance, specificity, predictors, and potential mechanisms of placebo response in sexual dysfunction.

AIM

We aimed to determine the nature and predictors of sexual function outcomes in women treated with placebo for female sexual arousal disorder (FSAD).

METHODS

We conducted a secondary analysis of data from the placebo arm of a 12-week, multisite, randomized controlled pharmaceutical trial for FSAD (N=50). We analyzed the magnitude, domain specificity, and clinical significance of sexual function scores at baseline, 4, 8, and 12 weeks (post-treatment). We examined longitudinal change in sexual function outcomes as a function of several baseline variables (e.g., age, symptom-related distress) and in relation to changes in sexual behavior frequency during the trial.

MAIN OUTCOME MEASURE

Female Sexual Function Index total score.

RESULTS

The magnitude of change at post-treatment was clinically significant in approximately one-third of placebo recipients. Effect sizes were similar across multiple aspects of sexual function. Symptom improvement was strongly related to the frequency of satisfying sexual encounters during treatment. However, the relationship between sexual encounter frequency and outcome varied significantly between participants.

CONCLUSIONS

A substantial number of women experienced clinically significant improvement in sexual function during treatment with placebo. Changes in sexual behavior during the trial, more so than participant age or symptom severity at baseline, appeared to be an important determinant of outcome. Contextual and procedural aspects of the clinical trial may have influenced outcomes in the absence of an active drug treatment.

The potential of a placebo/nocebo effect in pharmacogenetics

Pharmacogenetic testing holds great promise to improve health outcomes and reduce adverse drug responses through enhanced selection of therapeutic agents. Since drug responses can be manipulated by verbal suggestions, it is of particular interest to understand the potential impact of pharmacogenetic test results on drug response. Placebo and nocebo-like effects may be possible due to the suggestive nature of pharmacogenetic information that a drug will or will not likely lead to improved health outcomes. For example, pharmacogenetic testing could provide further reassurance to patients that a given drug will be effective and/or cause minimal side effects. However, pharmacogenetic information could adversely affect drug response through negative expectations that a drug will be less than optimally effective or cause an adverse response, known as a nocebo-like effect. Therefore, a patient's perceived value of testing, their understanding of the test results, and the manner in which they are communicated may influence therapeutic outcome. As such, physicians should consider the potential effect of pharmacogenetic test results on therapeutic outcome when communicating results to patients. Studies are needed to investigate the impact of pharmacogenetic information of therapeutic outcome.

Use of 'sham' radiotherapy in randomized clinical trials

The objective of this systematic review was to identify quality trials that use sham radiotherapy in their design and review them to determine its potential value. The Cochrane Library, Pubmed and a Reference Search served as data sources. Trials were included if they met a minimum quality score of 3 on a validated assessment instrument (which assesses randomization, control and blinding) and if they compared sham radiotherapy to active treatment. External beam therapy and brachytherapy trials were considered. Twenty-six trials were identified, collectively including 2663 participants in the period of 1970-2004. All the trials studied the value of radiotherapy for treatment or prevention of benign diseases, including multiple sclerosis, coronary artery restenosis, age-related macular degeneration and Graves' ophthalmopathy. There were no trials relating to the use of radiotherapy in the treatment of malignancy. This review showed that it is possible to carry out sham radiotherapy with due regard for ethical concerns, with effective blinding and high levels of patient acceptance. Large sample sizes with multicentre trial designs were achievable. Although the statistical philosophy for using sham radiotherapy in trials is legitimate, it is no longer routinely used.

Symbolic healing of early psychosis: psychoeducation and sociocultural processes of recovery

This article analyzes sociocultural processes of recovery in a Danish mental health service providing two years of integrated biopsychosocial treatment following first-episode psychosis. The study is based on ethnographic research in the service and person-centered involvement with 15 clients. The analysis applies Dow's [1986 American Anthropologist 88:56-69] model of universal components of symbolic healing to elucidate sociocultural aspects of therapeutic efficacy that are alternatively disregarded as placebo or nonspecific effects. It is demonstrated how staff engaged with clients to deliver "psychoeducation" that provided scientific and biomedical theories about mental illness, constituting a shared "mythic world" that was accepted as an experiential truth and used to explain clients' illness experiences. The analysis highlights the need to supplement attention in Dow's model to the healing procedure with consideration of variability in the healing process. Depending on individual responses to the intervention, the staff's professional backgrounds and staff-client relationships different recovery models were applied. One suggested "episodic psychosis" and full recovery, and the other suggested "chronic schizophrenia" and the necessity of comprehensive life adjustments to the mental illness. The recovery models influenced clients' perspectives on illness and self as they engaged in identity work, negotiating future plans and individual life projects by including also alternative systems of explanation from the wider cultural repertoire.

The story of placebo effects in medicine: evidence in context

In 2005, in an article reviewing the evidence related to the placebo effect that was derived from clinical trials in medicine and psychotherapy, B. E. Wampold, T. Minami, S. C. Tierney, T. W. Baskin, and K. S. Bhati re-analyzed studies contained in A. Hróbjartsson and P. C. Gøtzsche's (2001) meta-analysis of trials that contained placebo and no-treatment conditions. Whereas Hróbjartsson and Gøtzsche (2001) concluded that the placebo effect was weak at best, Wampold et al. (2005) concluded that it was "robust." Hróbjartsson and Gøtzsche (this issue) challenged Wampold et al.'s (2005) conclusion, claiming essentially that the results of clinical trials containing placebo and no-treatment conditions are not sufficient to claim that the placebo effect exists to any substantial degree. In this article, it is shown that when properly interpreted by considering theory, method, context, and related research, the results of clinical trials support the existence of a placebo effect. In short, the placebo effect appears in those instances where it is expected.

Interpreting the magnitude of the placebo effect: mountain or Molehill?

The ambiguity involved in interpreting numbers and words is central to Hróbjartsson and Gøtzsche's (this issue) claim of "powerful spin" in the Wampold, Minami, Tierney, Baskin, and Bhati (2005) re-analysis of their meta-analytic findings on the placebo effect in medicine. Meta-analytic results reported by the two sets of authors are nearly identical, yet their conclusions differ dramatically. In our comment, we discuss the findings of the respective authors and consider options for representing and interpreting the magnitude of meta-analytic effect size estimates. We conclude that although the meta-analyses described indicate that placebo effects do exist and cannot be dismissed as unimportant, given contextual information, it is consistent with existing research to describe the obtained mean effect size for placebos in medicine as small in magnitude.

Effects of expectation and caffeine on arousal, well-being, and reaction time

The objective of this study is to determine the impact of expectation associated with placebo and caffeine ingestion. We used a three-armed, randomized, double-blind design. Two three-armed experiments varying instruction (true, false, control) investigated the role of expectations of changes in arousal (blood pressure, heart rate), subjective well-being, and reaction time (RT). In Experiment 1 (N = 45), decaffeinated coffee was administered, and expectations were produced in one group by making them believe they had ingested caffeinated coffee. In Experiment 2 (N = 45), caffeinated orange juice was given in both experimental groups, but only one was informed about the true content. In Experiment 1, a significant effect for subjective alertness was found in the placebo treatment compared to the control group. However, for RT and well-being no significant effects were found. In Experiment 2, no significant expectancy effects were found. Caffeine produced large effects for blood pressure in both treatments compared to the control group, but the effects were larger for the false information group. For subjective well-being (alertness, calmness), considerable but nonsignificant changes were found for correctly informed participants, indicating possible additivity of pharmacologic effect and expectations. The results tentatively indicate that placebo and expectancy effects primarily show through introspection.

Expectations and associations that heal: Immunomodulatory placebo effects and its neurobiology

The use of placebo may have accompanied healing and medical practices since their origins (Plato; Charmides, 155-156). Recent experimental data indicate that we would be well advised to further consider placebo effects in future therapeutic strategies, with a better knowledge of their potency, psychological basis and underlying neurobiological mechanisms. Current research in the areas of pain, depression and Parkinson's disease has uncovered some of the potential neurobiological mechanisms of placebo effects. These data indicate that conscious expectation and unconscious behavioral conditioning processes appear to be the major neurobiological mechanisms capable of releasing endogenous neurotransmitters and/or neurohormones that mimic the expected or conditioned pharmacological effects. To date, research on placebo responses affecting immune-related diseases is scarce, but there are consistent indications that skin and mucosal inflammatory diseases, in particular, are strongly modulated by placebo treatments. However, the brain's capability to modulate peripheral immune reactivity has been impressively demonstrated by paradigms of behavioral conditioning in animal experiments and human studies. Thus, placebo effects can benefit end organ functioning and the overall health of the individual through positive expectations and behavioral conditioning processes.

Reviving the old sermon of medicine with the placebo effect

OBJECTIVE: The message of the importance of a caring doctor-patient relationship is now like an old sermon which does not impact anyone's mind or action. Observing the healing practice of the old time physicians, who valued their attitudes and relationship with their patients more than the actual interventions, this paper reviews the literature on their main therapeutic device - the placebo effect - as a novel way of delivering this old sermon of medicine to contemporary doctors. DISCUSSION: There are countless historical and contemporary examples of the impressive placebo effect and although contested by some, it seems real and significant. The classic conditioning theory and the expectation theory explain reasonably well the mechanisms of the placebo effect, especially in conjunction with each other. The underlying biochemical pathway, according to the limited current knowledge, involves endorphins for pain and dopamine for Parkinson's disease. Finally, human factors such as the doctor's positive attitudes and a good doctor-patient relationship seem to be more essential than the placebo itself in eliciting the placebo effect. CONCLUSIONS: Given the body of evidence supporting the existence of significant placebo effect and the importance of the doctor-patient relationship in determining it, the human factors of the medical treatment should be emphasised in order to maximise the placebo effect and consequently the overall therapeutic effect of the healing acts.

Treatment expectations for CAM interventions in pediatric chronic pain patients and their parents

Patient expectations regarding complementary and alternative medicine (CAM) interventions have important implications for treatment adherence, attrition and clinical outcome. Little is known, however, about parent and child treatment expectations regarding CAM approaches for pediatric chronic pain problems. The present study examined ratings of the expected benefits of CAM (i.e. hypnosis, massage, acupuncture, yoga and relaxation) and conventional medicine (i.e. medications, surgery) interventions in 45 children (32 girls; mean age = 13.8 years ± 2.5) and parents (39 mothers) presenting for treatment at a specialty clinic for chronic pediatric pain. Among children, medications and relaxation were expected to be significantly more helpful than the remaining approaches (P < 0.01). However, children expected the three lowest rated interventions, acupuncture, surgery and hypnosis, to be of equal benefit. Results among parents were similar to those found in children but there were fewer significant differences between ratings of the various interventions. Only surgery was expected by parents to be significantly less helpful than the other approaches (P < 0.01). When parent and child perceptions were compared, parents expected hypnosis, acupuncture and yoga, to be more beneficial than did children, whereas children expected surgery to be more helpful than did parents (P < 0.01). Overall, children expected the benefits of CAM to be fairly low with parents' expectations only somewhat more positive. The current findings suggest that educational efforts directed at enhancing treatment expectations regarding CAM, particularly among children with chronic pain, are warranted.

Placeboeffekt und Bedeutung

Zusammenfassung. Der Placeboeffekt (PE) beinhaltet bedeutsame Heilmechanismen, wenn Placebos nicht alleine als Kontrollsubstanz verwendet werden. Diese sind mit Effekten tatsächlicher Interventionen vergleichbar. Viele Fragen zu den Mechanismen sind allerdings ungelöst. Dies liegt zu einem Teil in der Reduzierung psychologischer Mechanismen auf bewusste Denkinhalte. Es wird ein funktional orientierter Ansatz vorgestellt, die Persönlichkeits-System-Interaktionen-Theorie (PSI-Theorie), die psychische Funktionen und deren Dynamik beschreibt. Ihm zufolge ist der PE an ein spezifisches System gebunden, das Extensionsgedächtnis (EG) genannt wird. Es besteht aus weitgehend impliziten Netzwerken, integriert (Selbst-)Aspekte und ist eng an somatosensorische Systeme gekoppelt. Eine Reihe von (neuro-)psychologischen Befunden steht mit dieser Auffassung in Einklang. Die vorgestellten Forschungsideen erlauben ein besseres Verständnis für psychologische Mechanismen, die im therapeutischen Kontext eine Rolle spielen, aber auch für die pharmakologische Testpraxis Konsequenzen haben.

The placebo response in the treatment of chronic fatigue syndrome: a systematic review and meta-analysis

OBJECTIVE

The placebo response is conventionally asserted to be high in chronic fatigue syndrome (CFS) because of the latter's subjective nature and obscure pathogenesis, but no systematic review of placebo responses has been undertaken. We report such a study. Patient expectation is known to be important in the placebo response. It is also known that CFS patients attending specialist clinics often have strong physical attributions regarding causation and hence skepticism about psychological or psychiatric interventions. If so, the placebo response in CFS may be influenced by the type of intervention according to its perceived rationale. We aimed to estimate the summary placebo response in clinical trials of CFS and to determine whether intervention type influences the placebo response in CFS.

METHODS

We searched Medline, Embase, Cochrane Library, PsychInfo, and the references of the identified articles, and contacted experts for controlled trials (randomized or nonrandomized) of any intervention on CFS patients reporting the placebo response as a clinical improvement in physical or general outcomes. Data were extracted from the articles and validity assessment conducted by one reviewer and checked by a second. Meta-analysis and metaregression were performed.

RESULTS

The pooled placebo response was 19.6% (95% confidence interval, 15.4-23.7), lower than predicted and lower than in some other medical conditions. The meta-regression revealed that intervention type significantly contributed to the heterogeneity of placebo response (p = .03).

CONCLUSION

In contrast with the conventional wisdom, the placebo response in CFS is low. Psychological-psychiatric interventions were shown to have a lower placebo response, perhaps linked to patient expectations.

The placebo is powerful: Estimating placebo effects in medicine and psychotherapy from randomized clinical trials

The logic of the randomized double-blind placebo control group design is presented, and problems with using the design in psychotherapy are discussed. Placebo effects are estimated by examining clinical trials in medicine and psychotherapy. In medicine, a recent meta-analysis of clinical trials with treatment, placebo, and no treatment arms was conducted (Hróbjartsson & Gøtzsche, 2001), and it was concluded that placebos have small or no effects. A re-analysis of those studies, presented here, shows that when disorders are amenable to placebos and the design is adequate to detect the effects, the placebo effect is robust and approaches the treatment effect. For psychological disorders, particularly depression, it has been shown that pill placebos are nearly as effective as active medications whereas psychotherapies are more effective than psychological placebos. However, it is shown that when properly designed, psychological placebos are as effective as accepted psychotherapies.

Efecto nocebo: la otra cara del placebo

Administration of drugs is often followed by beneficial (placebo effects) and harmful (nocebo effects) effects that are not always related to their mechanism of action. Nocebo effects are rather unknown even when may be the source of many adverse reactions which could be erroneously attributed to drug therapy. Some mechanisms have been postulated which might be associated with the development of nocebo effects. Expectancy, learning and classical conditioning are probably important in the psychological domain. The neuropharmacological substrate is much less known yet an opioid peptide-cholecystokinin interaction has been suggested. At the clinical setting, a nocebo effect should be suspected in those patients who present common unspecific symptoms after drug administration and have a tendency to somatize. An early detection of these patients may contribute to the prevention of the nocebo effect.

Can medical hypnosis accelerate post-surgical wound healing? Results of a clinical trial

Although medical hypnosis has a long history of myriad functional applications (pain reduction, procedural preparation etc.), it has been little tested for site-specific effects on physical healing per se. In this randomized controlled trial, we compared the relative efficacy of an adjunctive hypnotic intervention, supportive attention, and usual care only on early post-surgical wound healing. Eighteen healthy women presenting consecutively for medically recommended reduction mammaplasty at an ambulatory surgery practice underwent the same surgical protocol and postoperative care following preoperative randomization (n = 6 each) to one of the three treatment conditions: usual care, 8 adjunctive supportive attention sessions, or 8 adjunctive hypnosis sessions targeting accelerated wound healing. The primary outcome data of interest were objective, observational measures of incision healing made at 1,7 weeks postoperatively by medical staff blind to the participants' group assignments. Data included clinical exams and digitized photographs that were scored using a wound assessment inventory (WAI). Secondary outcome measures included the participants' subjectively rated pain, perceived incision healing (VAS Scales), and baseline and post-surgical functional health status (SF-36). Analysis of variance showed the hypnosis group's objectively observed wound healing to be significantly greater than the other two groups', p < .001, through 7 postoperative weeks; standard care controls showed the smallest degree of healing. In addition, at both the 1 and 7 week post-surgical observation intervals, one-way analyses showed the hypnosis group to be significantly more healed than the usual care controls, p < 0.02. The mean scores of the subjective assessments of postoperative pain, incision healing and functional recovery trended similarly. Results of this preliminary trial indicate that use of a targeted hypnotic intervention can accelerate postoperative wound healing and suggest that further tests of using hypnosis to augment physical healing are warranted.