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Horan WP, Sachs G, Velligan DI, Davis M, Keefe RS, Khin NA, Butlen-Ducuing F, Harvey PD. Current and Emerging Technologies to Address the Placebo Response Challenge in CNS Clinical Trials: Promise, Pitfalls, and Pathways Forward. INNOVATIONS IN CLINICAL NEUROSCIENCE 2024; 21:19-30. [PMID: 38495609 PMCID: PMC10941857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Excessive placebo response rates have long been a major challenge for central nervous system (CNS) drug discovery. As CNS trials progressively shift toward digitalization, decentralization, and novel remote assessment approaches, questions are emerging about whether innovative technologies can help mitigate the placebo response. This article begins with a conceptual framework for understanding placebo response. We then critically evaluate the potential of a range of innovative technologies and associated research designs that might help mitigate the placebo response and enhance detection of treatment signals. These include technologies developed to directly address placebo response; technology-based approaches focused on recruitment, retention, and data collection with potential relevance to placebo response; and novel remote digital phenotyping technologies. Finally, we describe key scientific and regulatory considerations when evaluating and selecting innovative strategies to mitigate placebo response. While a range of technological innovations shows potential for helping to address the placebo response in CNS trials, much work remains to carefully evaluate their risks and benefits.
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Affiliation(s)
- William P. Horan
- Dr. Horan is with Karuna Therapeutics in Boston, Massachusetts, and University of California in Los Angeles, California
| | - Gary Sachs
- Dr. Sachs is with Signant Health in Boston, Massachusetts, and Harvard Medical School in Boston, Massachusetts
| | - Dawn I. Velligan
- Dr. Velligan is with University of Texas Health Science Center at San Antonio in San Antonio, Texas
| | - Michael Davis
- Dr. Davis is with Usona Institute in Madison, Wisconsin
| | - Richard S.E. Keefe
- Dr. Keefe is with Duke University Medical Center in Durham, North Carolina
| | - Ni A. Khin
- Dr. Khin is with Neurocrine Biosciences, Inc. in San Diego, California
| | - Florence Butlen-Ducuing
- Dr. Butlen-Ducuing is with Office for Neurological and Psychiatric Disorders, European Medicines Agency in Amsterdam, The Netherlands
| | - Philip D. Harvey
- Dr. Harvey is with University of Miami Miller School of Medicine in Miami, Florida
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Itskovich E, Bowling DL, Garner JP, Parker KJ. Oxytocin and the social facilitation of placebo effects. Mol Psychiatry 2022; 27:2640-2649. [PMID: 35338314 PMCID: PMC9167259 DOI: 10.1038/s41380-022-01515-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 02/16/2022] [Accepted: 02/25/2022] [Indexed: 01/30/2023]
Abstract
Significant clinical improvement is often observed in patients who receive placebo treatment in randomized double-blind placebo-controlled trials. While a proportion of this "improvement" reflects experimental design limitations (e.g., reliance on subjective outcomes, unbalanced groups, reporting biases), some of it reflects genuine improvement corroborated by physiological change. Converging evidence across diverse medical conditions suggests that clinically-relevant benefits from placebo treatment are associated with the activation of brain reward circuits. In parallel, evidence has accumulated showing that such benefits are facilitated by clinicians that demonstrate warmth and proficiency during interactions with patients. Here, we integrate research on these neural and social aspects of placebo effects with evidence linking oxytocin and social reward to advance a neurobiological account for the social facilitation of placebo effects. This account frames oxytocin as a key mediator of treatment success across a wide-spectrum of interventions that increase social connectedness, thereby providing a biological basis for assessing this fundamental non-specific element of medical care.
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Affiliation(s)
- Elena Itskovich
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94305
| | - Daniel L. Bowling
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94305
| | - Joseph P. Garner
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94305.,Department of Comparative Medicine, Stanford University School of Medicine, Stanford, CA 94305
| | - Karen J. Parker
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94305.,Department of Comparative Medicine, Stanford University School of Medicine, Stanford, CA 94305
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Shen Z, Xu Q, Jin L. Structured procedures promote placebo effects. JOURNAL OF EXPERIMENTAL SOCIAL PSYCHOLOGY 2020. [DOI: 10.1016/j.jesp.2020.104029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Meeuwis SH, van Middendorp H, van Laarhoven AIM, van Leijenhorst C, Pacheco-Lopez G, Lavrijsen APM, Veldhuijzen DS, Evers AWM. Placebo and nocebo effects for itch and itch-related immune outcomes: A systematic review of animal and human studies. Neurosci Biobehav Rev 2020; 113:325-337. [PMID: 32240668 DOI: 10.1016/j.neubiorev.2020.03.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/24/2020] [Indexed: 12/19/2022]
Abstract
Placebo and nocebo effects can influence somatic symptoms such as pain. For itch and other dermatological symptoms these effects have been far less investigated. This review systematically integrates evidence from both animal (mainly rodents) and human trials on placebo and nocebo effects in itch, itch-related symptoms and conditions of the skin and mucous membranes, and related immune outcomes (e.g., histamine). Thirty-one animal studies, and fifty-five human studies (k = 21 healthy participants, k = 34 patients) were included. Overall, studies consistently show that placebo and nocebo effects can be induced by various methods (e.g., suggestions, conditioning and social cues), despite high heterogeneity across studies. Effects of suggestions were found consistently across subjective and behavioral parameters (e.g., itch and scratching in humans), whereas conditioning was likely to impact physiological parameters under certain conditions (e.g., conditioning of histamine levels in stressed rodents). Brain areas responsible for itch processing were associated with nocebo effects. Future research may investigate how variations in methods impact placebo and nocebo effects, and whether all symptoms and conditions can be influenced equally.
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Affiliation(s)
- Stefanie H Meeuwis
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Faculty of Social and Behavioral Sciences, Leiden University, P.O. Box 9555, 2300RB, Leiden, the Netherlands; Leiden Institute for Brain and Cognition, P.O. Box 9600, 2300RC, Leiden University Medical Center, Leiden, the Netherlands.
| | - Henriët van Middendorp
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Faculty of Social and Behavioral Sciences, Leiden University, P.O. Box 9555, 2300RB, Leiden, the Netherlands; Leiden Institute for Brain and Cognition, P.O. Box 9600, 2300RC, Leiden University Medical Center, Leiden, the Netherlands
| | - Antoinette I M van Laarhoven
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Faculty of Social and Behavioral Sciences, Leiden University, P.O. Box 9555, 2300RB, Leiden, the Netherlands; Leiden Institute for Brain and Cognition, P.O. Box 9600, 2300RC, Leiden University Medical Center, Leiden, the Netherlands; Department of Psychiatry, Leiden University Medical Center, P.O. Box 9600, 2300RC, Leiden, the Netherlands
| | - Cora van Leijenhorst
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Faculty of Social and Behavioral Sciences, Leiden University, P.O. Box 9555, 2300RB, Leiden, the Netherlands
| | - Gustavo Pacheco-Lopez
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Faculty of Social and Behavioral Sciences, Leiden University, P.O. Box 9555, 2300RB, Leiden, the Netherlands; Metropolitan Autonomous University (UAM), Campus Lerma, Health Sciences Department, Lerma, 52005, Edo Mex, Mexico
| | - Adriana P M Lavrijsen
- Department of Dermatology, Leiden University Medical Center, P.O. Box 9600, 2300RC, Leiden, the Netherlands
| | - Dieuwke S Veldhuijzen
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Faculty of Social and Behavioral Sciences, Leiden University, P.O. Box 9555, 2300RB, Leiden, the Netherlands; Leiden Institute for Brain and Cognition, P.O. Box 9600, 2300RC, Leiden University Medical Center, Leiden, the Netherlands
| | - Andrea W M Evers
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Faculty of Social and Behavioral Sciences, Leiden University, P.O. Box 9555, 2300RB, Leiden, the Netherlands; Leiden Institute for Brain and Cognition, P.O. Box 9600, 2300RC, Leiden University Medical Center, Leiden, the Netherlands; Department of Psychiatry, Leiden University Medical Center, P.O. Box 9600, 2300RC, Leiden, the Netherlands
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Leibowitz KA, Hardebeck EJ, Goyer JP, Crum AJ. The role of patient beliefs in open-label placebo effects. Health Psychol 2019; 38:613-622. [PMID: 31021124 DOI: 10.1037/hea0000751] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Recent research on open-label placebos, or placebos administered without deception or concealment, suggests that they can be effective in a variety of conditions. The current research sought to unpack the mechanisms underlying the treatment efficacy of open-label placebos. METHOD A health care provider induced an allergic reaction in 148 participants via a histamine skin prick test. Participants were then exposed to 1 of 4 conditions additively leveraging various mechanisms of open-label placebo treatments: a supportive patient-provider relationship, a medical ritual, positive expectations, and a rationale about the power of placebos. RESULTS There were no main effects of condition on allergic responses. However, participant beliefs about placebos moderated the effect of open-label placebo treatment condition on physiological allergic reactions: the condition including all 4 components of open-label placebos (a supportive patient-provider relationship, a medical ritual, positive expectations, and a rationale about the power of placebos) significantly reduced physiological allergic reaction among participants with a strong belief in placebos compared with participants in the control group. CONCLUSION Participants' beliefs about placebos interact with information from the provider to reduce physiological allergic reactions in response to an open-label placebo treatment. This study underscores the importance of measuring and understanding how participants' beliefs influence outcomes of treatment, and furthers our understanding of when and how open-label placebo treatments work. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Faasse K, Martin LR. The Power of Labeling in Nocebo Effects. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2018; 139:379-406. [PMID: 30146055 DOI: 10.1016/bs.irn.2018.07.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Nocebo effects comprise two broad types: primary nocebo effects, in which overall treatment efficacy is reduced; and nocebo side effects, which result in the increased experience of unpleasant secondary side effects. An important factor in generating nocebo effects of both types is the patient's expectations of how well a treatment will work, and how likely it is to cause side effects. One source of negative expectations is the presence of generic-as opposed to brand name-labeling. A medicine's labeling is likely to be one of the first aspects of a treatment that is encountered by a patient, and perhaps the most common labeling information on pharmaceuticals is the labeling that identifies the drug as being made by the originator brand manufacturer, or as a generic copy. Although generic medicines are pharmaceutically equivalent to their brand name counterparts, generics are often viewed with distrust and perceived to be inferior to branded medicines. Negative perceptions of generic pharmaceuticals may contribute to reduced treatment efficacy via enhanced primary nocebo effects, and increased nocebo side effects. This chapter reviews evidence for the role of brand and generic labeling in treatment outcomes across a range of contexts-most often laboratory research assessing pain outcomes, as well as the influence of related factors including price, familiarity, and treatment switches. Although increasing evidence suggests that labeling of medicines can shape nocebo effects, interventions to improve perceptions of generics do not necessarily translate into more positive treatment outcomes.
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Affiliation(s)
- Kate Faasse
- School of Psychology, University of New South Wales, Sydney, NSW, Australia.
| | - Leslie R Martin
- Department of Psychology and Neuroscience, La Sierra University, Riverside, CA, United States
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Boissoneault J, Letzen J, Robinson M. Treating patients rather than their functional neuroimages. Comment on Br J Anaesth 2018; 120: 299-307. Br J Anaesth 2018; 121:969-971. [PMID: 30236260 DOI: 10.1016/j.bja.2018.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 03/21/2018] [Accepted: 03/29/2018] [Indexed: 11/16/2022] Open
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Geuter S, Koban L, Wager TD. The Cognitive Neuroscience of Placebo Effects: Concepts, Predictions, and Physiology. Annu Rev Neurosci 2017; 40:167-188. [PMID: 28399689 DOI: 10.1146/annurev-neuro-072116-031132] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Placebos have been used ubiquitously throughout the history of medicine. Expectations and associative learning processes are important psychological determinants of placebo effects, but their underlying brain mechanisms are only beginning to be understood. We examine the brain systems underlying placebo effects on pain, autonomic, and immune responses. The ventromedial prefrontal cortex (vmPFC), insula, amygdala, hypothalamus, and periaqueductal gray emerge as central brain structures underlying placebo effects. We argue that the vmPFC is a core element of a network that represents structured relationships among concepts, providing a substrate for expectations and a conception of the situation-the self in context-that is crucial for placebo effects. Such situational representations enable multidimensional predictions, or priors, that are combined with incoming sensory information to construct percepts and shape motivated behavior. They influence experience and physiology via descending pathways to physiological effector systems, including the spinal cord and other peripheral organs.
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Affiliation(s)
- Stephan Geuter
- Institute of Cognitive Science, University of Colorado, Boulder, Colorado 80309; , , .,Department of Psychology and Neuroscience, University of Colorado, Boulder, Colorado 80309
| | - Leonie Koban
- Institute of Cognitive Science, University of Colorado, Boulder, Colorado 80309; , , .,Department of Psychology and Neuroscience, University of Colorado, Boulder, Colorado 80309
| | - Tor D Wager
- Institute of Cognitive Science, University of Colorado, Boulder, Colorado 80309; , , .,Department of Psychology and Neuroscience, University of Colorado, Boulder, Colorado 80309
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Howe LC, Goyer JP, Crum AJ. Harnessing the placebo effect: Exploring the influence of physician characteristics on placebo response. Health Psychol 2017; 36:1074-1082. [PMID: 28277699 DOI: 10.1037/hea0000499] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Research on placebo/nocebo effects suggests that expectations can influence treatment outcomes, but placebo/nocebo effects are not always evident. This research demonstrates that a provider's social behavior moderates the effect of expectations on physiological outcomes. METHODS After inducing an allergic reaction in participants through a histamine skin prick test, a health care provider administered a cream with no active ingredients and set either positive expectations (cream will reduce reaction) or negative expectations (cream will increase reaction). The provider demonstrated either high or low warmth, or either high or low competence. RESULTS The impact of expectations on allergic response was enhanced when the provider acted both warmer and more competent and negated when the provider acted colder and less competent. CONCLUSION This study suggests that placebo effects should be construed not as a nuisance variable with mysterious impact but instead as a psychological phenomenon that can be understood and harnessed to improve treatment outcomes. (PsycINFO Database Record
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Affiliation(s)
| | | | - Alia J Crum
- Department of Psychology, Stanford University
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Fehse K, Maikowski L, Simmank F, Gutyrchik E, Meissner K. Placebo Responses to Original vs Generic ASA Brands During Exposure to Noxious Heat: A Pilot fMRI Study of Neurofunctional Correlates. PAIN MEDICINE 2015; 16:1967-74. [DOI: 10.1111/pme.12783] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 03/30/2015] [Accepted: 04/04/2015] [Indexed: 12/01/2022]
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The neuroscience of placebo effects: connecting context, learning and health. Nat Rev Neurosci 2015; 16:403-18. [PMID: 26087681 DOI: 10.1038/nrn3976] [Citation(s) in RCA: 438] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Placebo effects are beneficial effects that are attributable to the brain-mind responses to the context in which a treatment is delivered rather than to the specific actions of the drug. They are mediated by diverse processes--including learning, expectations and social cognition--and can influence various clinical and physiological outcomes related to health. Emerging neuroscience evidence implicates multiple brain systems and neurochemical mediators, including opioids and dopamine. We present an empirical review of the brain systems that are involved in placebo effects, focusing on placebo analgesia, and a conceptual framework linking these findings to the mind-brain processes that mediate them. This framework suggests that the neuropsychological processes that mediate placebo effects may be crucial for a wide array of therapeutic approaches, including many drugs.
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Steinkopf L. The Signaling Theory of Symptoms : An Evolutionary Explanation of the Placebo Effect. EVOLUTIONARY PSYCHOLOGY 2015; 13:1474704915600559. [PMID: 37924177 PMCID: PMC10480909 DOI: 10.1177/1474704915600559] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 07/02/2015] [Indexed: 11/06/2023] Open
Abstract
Placebo research shows that the subjective quality of care and social support, as well as the patients' expectations of treatment, influence therapeutic outcomes. However, this phenomenon, known as the placebo effect, does not usually cure the disease, but rather can provide symptomatic relief: It may soothe symptoms such as pain, swelling, or nausea that constitute part of an immune response. The function of this mechanism remains unclear. This article puts forward the Signaling Theory of Symptoms (STS) as a possible explanation. According to STS, discernible aspects of an immune response, such as pain, swelling, or nausea, not only serve a defensive and healing function but also a signaling function: symptoms signal the need for care and treatment to potential helpers. Once help and treatment are granted, the signaling function is fulfilled and the symptoms diminish. This mechanism may have been a significant advantage in preindustrial environments, when sufferers depended on extensive social support and personal treatment. Nowadays, from the point of view of modern materialist medicine, the mobilization of social support no longer seems so crucial, and thus the placebo effect has been assigned a somewhat mysterious quality.
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