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Ijaz N, Hunter J, Grant S, Templeman K. Protocol for a scoping review of traditional medicine research methods, methodologies, frameworks and strategies. Front Med (Lausanne) 2024; 11:1409392. [PMID: 39050530 PMCID: PMC11267516 DOI: 10.3389/fmed.2024.1409392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 06/11/2024] [Indexed: 07/27/2024] Open
Abstract
Background The World Health Organization (WHO) has called for the evidence-informed integration of traditional medicine (TM) into health systems. Research rigor requires a good "fit" between research designs and what is being studied. The expectation that TM research fully adheres to biomedical evidentiary norms potentially creates tensions, as TM paradigms have their own distinct features. A scoping review will be conducted to describe and characterize the research approaches used in TM and their paradigmatic alignment with the TM being studied. Methods This scoping review protocol was informed by Joanna Briggs Institute (JBI) methods. This protocol outlines an a priori conceptual framework, provisionally termed "paradigmatic alignment." The review will include all populations, TM types, research approaches (i.e., methods, methodologies, frameworks, strategies), cultural contexts, and health care settings. Up to 38 English and non-English language databases will be searched sequentially for both published and gray literature until reaching data saturation across relevant concepts and contexts. Analysis will begin deductively, using a pre-piloted data extraction template to describe the TM research approaches. A basic qualitative content analysis of a sample of evidence sources will explore how research approaches are applied or modified to align with the TM therapeutic paradigm, and the manner in which they co-exist, contrast, complement or align with established biomedical research approaches. The findings will be narrated and summarized in charting tables and figures. The review will be reported according to the PRISMA scoping review extension. Consultative engagement with knowledge users across all review stages is planned. Discussion Aligned with the principle of Two-Eyed Seeing (Etuaptmumk), wherein Indigenous/traditional and biomedical knowledges may equitably co-exist, this review promises to advance scholarly insights of critical value in an increasingly pluralistic, globalized world.Clinical trial registration: https://clinicaltrials.gov/, identifier INPLASY2023110071.
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Affiliation(s)
- Nadine Ijaz
- Department of Law and Legal Studies, Faculty of Public Affairs, Carleton University, Ottawa, ON, Canada
| | - Jennifer Hunter
- Health Research Group, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Suzanne Grant
- NICM Health Research Institute, Western Sydney University, Penrith, NSW, Australia
- Chris O'Brien Lifehouse, Sydney, NSW, Australia
| | - Kate Templeman
- Health Research Group, Sydney, NSW, Australia
- NICM Health Research Institute, Western Sydney University, Penrith, NSW, Australia
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Maddox GA, Bodner GE, Christian MW, Williamson P. On the Effectiveness of Visual Arts Therapy for Traumatic Experiences: A Systematic Review and Meta-Analysis. Clin Psychol Psychother 2024; 31:e3041. [PMID: 39120099 DOI: 10.1002/cpp.3041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/18/2024] [Accepted: 07/19/2024] [Indexed: 08/10/2024]
Abstract
Arts therapy is a popular intervention used to work through the effects of traumatic experience. We evaluate previous reviews and report a meta-analysis of the effectiveness of arts therapy following trauma for reducing symptoms of PTSD, enhancing positive outcomes (e.g., quality of life) and decreasing negative outcomes (e.g., depression). Database searches identified 21 (N = 868) randomised controlled trials (RCTs). Outcomes were categorised as PTSD specific, positive non-PTSD specific and negative non-PTSD specific. Several moderators were tested: age, diagnosis type, trauma type, intervention instruction, control type, therapy mode and therapy duration. Overall, random-effects analysis indicated that arts therapy was favoured relative to control for positive non-PTSD-specific outcomes (g = 1.53, p < 0.001), but not for negative non-PTSD-specific (p = 0.069) or PTSD-specific outcomes (g = 0.89, p = 0.052). Regression analyses indicated that arts therapy was effective in reducing PTSD-specific outcomes in children (Z = 2.81, df = 1, p = 0.005), positive non-PTSD-specific outcomes in group-based arts therapy (Z = -2.40, df = 1, p = 0.016, I2 = 57.33) and for reducing negative non-PTSD outcomes following acute traumas (e.g., combat-related trauma or sexual abuse) (Q = 10.70, df = 3, p = 0.013, I2 = 77.09). We highlight the need for additional RCTs and standardised protocols to address heterogeneity. Our review provides an important benchmark for gauging the effectiveness of arts therapy in the treatment of trauma.
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Affiliation(s)
- Georgina A Maddox
- College of Education, Psychology and Social WorkBedford Park, Flinders University, Adelaide, South Australia, Australia
| | - Glen E Bodner
- College of Education, Psychology and Social WorkBedford Park, Flinders University, Adelaide, South Australia, Australia
| | - Matthew W Christian
- College of Education, Psychology and Social WorkBedford Park, Flinders University, Adelaide, South Australia, Australia
| | - Paul Williamson
- College of Education, Psychology and Social WorkBedford Park, Flinders University, Adelaide, South Australia, Australia
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Reis G, Savassi LCM, Ferreira TS, Reis LLF, Simplicio MIC, Ribeiro LB, Silva EADSM, Lat PK, Harari O, Forrest JI, Dron L, Park JJH, Thorlund K, Mills EJ. Matched vs Nonmatched Placebos in a Randomized Trial of COVID-19 Treatments. JAMA Netw Open 2024; 7:e2410335. [PMID: 38767921 PMCID: PMC11107303 DOI: 10.1001/jamanetworkopen.2024.10335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/07/2024] [Indexed: 05/22/2024] Open
Abstract
Importance Matched placebo interventions are complex and resource intensive. Recent evidence suggests matched placebos may not always be necessary. Previous studies have predominantly evaluated potential bias of nonmatched placebos (ie, differing on dose, frequency of administration, or formulation) in pain and mental health, but to date no systematic examination has been conducted in infectious disease. Objective To test for differences between nonmatched and matched placebo arms with respect to clinical outcome measures across multiple therapeutics for COVID-19. Design, Setting, and Participants In a comparative effectiveness research study, a post hoc analysis was conducted of data on individual patients enrolled in a large, multiarm, platform randomized clinical trial in symptomatic adult outpatients with COVID-19 between January 15, 2021, to September 28, 2023, in which the outcomes of both matched and nonmatched placebo groups were reported. Bayesian and frequentist covariate-adjusted techniques were compared with 7 intervention-placebo pairs. Exposures Seven matched and nonmatched placebo pairs (for a total of 7 comparisons) were evaluated throughout the primary platform trial. Comparisons were made between treatment and its associated matched (concurrent) placebo, as well as with nonmatched placebo (alone and in combination) assessed at a similar time point. Main Outcomes and Measures Outcomes assessed included hospitalizations, EuroQol 5-Dimension 5-level scores, and PROMIS Global-10 scores. Results A total of 7 intervention-control pairs (N = 2684) were assessed, including 1620 (60.4%) women, with mean (SD) age, 47 (15.2) years; the most common comorbidities were obesity (41.9%) and hypertension (37.9%). In a meta-analysis with decoupled SEs, accounting for overlapping placebo patients, the overall odds ratio (OR) of nonmatched compared with matched placebo was 1.01 (95% credible interval, 0.77-1.32), with posterior probability of equivalence, defined as 0.8 ≤ OR ≤ 1.2 (a deviation from perfect equivalence ie, OR = 1, by no more than 0.2) of 85.4%, implying no significant difference. Unadjusted analysis of the event rate difference between all nonmatched and matched placebo groups did not identify any notable differences across all 7 treatment-placebo combinations assessed. Similar analysis that was conducted for patient-reported quality of life outcomes did not yield statistically significant differences. Conclusions and Relevance In this post hoc study of a randomized clinical platform trial, pooling matched and nonmatched placebo patient data did not lead to inconsistencies in treatment effect estimation for any of the investigational drugs. These findings may have significant implications for future platform trials, as the use of nonmatched placebo may improve statistical power, or reduce barriers to placebo implementation.
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Affiliation(s)
- Gilmar Reis
- Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa, Belo Horizonte, Brazil
- Department of Medicine, Pontifícia Universidade Católica de Minas Gerais, Belo Horizonte, Brazil
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- David Sackett Research Institute, Belo Horizonte, Brazil
| | - Leonardo Cançado Monteiro Savassi
- Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa, Belo Horizonte, Brazil
- David Sackett Research Institute, Belo Horizonte, Brazil
- Public Health, Mental and Family Medicine Department, Ouro Preto Federal University, Ouro Preto, Brazil
| | - Thiago Santiago Ferreira
- Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa, Belo Horizonte, Brazil
- David Sackett Research Institute, Belo Horizonte, Brazil
| | - Luiza Lanna França Reis
- Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa, Belo Horizonte, Brazil
- David Sackett Research Institute, Belo Horizonte, Brazil
| | - Maria Izabel Campos Simplicio
- Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa, Belo Horizonte, Brazil
- David Sackett Research Institute, Belo Horizonte, Brazil
| | - Luciene Barra Ribeiro
- Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa, Belo Horizonte, Brazil
- David Sackett Research Institute, Belo Horizonte, Brazil
| | | | | | - Ofir Harari
- Core Clinical Sciences, Vancouver, British Columbia, Canada
| | | | - Louis Dron
- Cascade Outcomes Research, Vancouver, British Columbia, Canada
| | - Jay J. H. Park
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Core Clinical Sciences, Vancouver, British Columbia, Canada
| | - Kristian Thorlund
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Edward J. Mills
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Purpose Life Sciences, Vancouver, British Columbia, Canada
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Druart L, Graham Longsworth SE, Terrisse H, Locher C, Blease C, Rolland C, Pinsault N. If only they knew! A non-inferiority randomized controlled trial comparing deceptive and open-label placebo in healthy individuals. Eur J Pain 2024; 28:491-501. [PMID: 37965922 DOI: 10.1002/ejp.2204] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 09/26/2023] [Accepted: 11/03/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Placebo use is widespread in clinical practice. However, they are most often administered deceptively rather than openly. It is often suggested that open-label placebos (OLP) are less effective than deceptive placebos (DP). This study aimed to compare the use of DP and OLP treatments to reduce pain in healthy volunteers. METHODS We conducted a non-inferiority, parallel, randomized, controlled trial, which also included a nested cross-over no-treatment condition. This study was conducted at a university clinic in France. RESULTS We included 60 subjects and the main result shows that the OLP was not inferior to the DP by a margin of 10 mm. The mean difference between both groups regarding intensity of pain was 0.7 mm with a 95% compatibility interval (95% CI) of ]-∞; 5.4], and 97.5% CI of ]-∞; 6.3]. Secondary outcomes require cautious interpretation of the effect of placebo versus no treatment due to a time-treatment interaction. CONCLUSION The study indicates that OLP may perform just as well as DP and could provide support for the use of OLP as an ethical alternative to DP when they are to be used in a clinical setting. If only patients knew about the placebo nature of some treatments they are receiving, unnecessary lies could be avoided while maintaining similar placebo effects. SIGNIFICANCE This study is the first to show non-inferiority of placebos administered honestly, also called OLP, compared to DP in reducing pain. This suggests that OLP could be as effective as their deceptive counterparts while having the ethical advantage of not being required to lie. If deception is not a necessary condition for efficacy, OLP should be preferred over DP.
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Affiliation(s)
- L Druart
- Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, Grenoble, France
- Department of Physiotherapy, University Grenoble Alpes, Grenoble, France
| | - S E Graham Longsworth
- Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, Grenoble, France
- Department of Physiotherapy, University Grenoble Alpes, Grenoble, France
| | - H Terrisse
- Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, Grenoble, France
| | - C Locher
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
| | - C Blease
- Department of Psychiatry, Digital Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - C Rolland
- Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, Grenoble, France
| | - N Pinsault
- Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, Grenoble, France
- Department of Physiotherapy, University Grenoble Alpes, Grenoble, France
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Ballard R, Parkhurst JT, Gadek LK, Julian KM, Yang A, Pasetes LN, Goel N, Sit DK. Bright Light Therapy for Major Depressive Disorder in Adolescent Outpatients: A Preliminary Study. Clocks Sleep 2024; 6:56-71. [PMID: 38390946 PMCID: PMC10885037 DOI: 10.3390/clockssleep6010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Bright light therapy (BLT) has not been well-studied in adolescents with major depressive disorder, particularly in outpatient settings. METHODS We conducted an 8-week clinical trial of BLT in adolescents recruited from a primary care practice with moderate to severe major depression. Acceptability and feasibility were defined by daily use of the light box and integration into daily routines. To assess treatment effects, we utilized the Short Mood and Feelings Questionnaire (SMFQ) and actigraphic sleep variables. RESULTS Of the nine enrolled adolescents, the rate of daily use of the light therapy box was 100% at week 2, 78% at week 4 (n = 7), and 67% at weeks 6 and 8 (n = 6). Participants were better able to integrate midday BLT compared to morning BLT into their day-to-day routines. Mean depression scores improved during the 2-week placebo lead-in (dim red light-DRL) and continued to show significant improvement through 6 weeks of BLT. Sleep efficiency increased significantly (p = 0.046), and sleep onset latency showed a trend toward a significant decrease (p = 0.075) in the BLT phase compared to the DRL phase. CONCLUSION Bright light treatment that was self-administered at home was feasible, acceptable, and effective for adolescent outpatients with depression. Findings support the development of larger, well-powered, controlled clinical trials of BLT in coordination with primary care.
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Affiliation(s)
- Rachel Ballard
- Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Box 10, Chicago, IL 60611, USA
| | - John T Parkhurst
- Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Box 10, Chicago, IL 60611, USA
| | - Lisa K Gadek
- Lake Forest Pediatrics, Lake Bluff, IL 60044, USA
| | - Kelsey M Julian
- Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Box 10, Chicago, IL 60611, USA
| | - Amy Yang
- Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 676 N. St. Clair St., Suite 1000, Chicago, IL 60611, USA
| | - Lauren N Pasetes
- Biological Rhythms Research Laboratory, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, 1645 W. Jackson Blvd., Suite 425, Chicago, IL 60612, USA
| | - Namni Goel
- Biological Rhythms Research Laboratory, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, 1645 W. Jackson Blvd., Suite 425, Chicago, IL 60612, USA
| | - Dorothy K Sit
- Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 676 N. St. Clair St., Suite 1000, Chicago, IL 60611, USA
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Blease C, Colagiuri B, Locher C. Replication crisis and placebo studies: rebooting the bioethical debate. JOURNAL OF MEDICAL ETHICS 2023; 49:663-669. [PMID: 36609361 DOI: 10.1136/jme-2022-108672] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/30/2022] [Indexed: 06/17/2023]
Abstract
A growing body of cross-cultural survey research shows high percentages of clinicians report using placebos in clinical settings. One motivation for clinicians using placebos is to help patients by capitalising on the placebo effect's reported health benefits. This is not surprising, given that placebo studies are burgeoning, with increasing calls by researchers to ethically harness placebo effects among patients. These calls propose placebos/placebo effects offer clinically significant benefits to patients. In this paper, we argue many findings in this highly cited and 'hot' field have not been independently replicated. Evaluating the ethicality of placebo use in clinical practice involves first understanding whether placebos are efficacious clinically. Therefore, it is crucial to consider placebo research in the context of the replication crisis and what can be learnt to advance evidence-based knowledge of placebos/placebo effects and their clinical relevance (or lack thereof). In doing so, our goal in this paper is to motivate both increased awareness of replication issues and to help pave the way for advances in scientific research in the field of placebo studies to better inform ethical evidence-based practice. We argue that, only by developing a rigorous evidence base can we better understand how, if at all, placebos/placebo effects can be harnessed ethically in clinical settings.
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Affiliation(s)
- Charlotte Blease
- General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Digital Psychiatry, Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ben Colagiuri
- School of Psychology, University of Sydney, Sydney, New South Wales, Australia
| | - Cosima Locher
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
- Psychology, Plymouth University, Plymouth, UK
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Blasco-Magraner JS, Bernabé-Valero G, Marín-Liébana P, Botella-Nicolás AM. Changing positive and negative affects through music experiences: a study with university students. BMC Psychol 2023; 11:76. [PMID: 36944996 PMCID: PMC10031901 DOI: 10.1186/s40359-023-01110-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 03/06/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Currently, there are few empirical studies that demonstrate the effects of music on specific emotions, especially in the educational context. For this reason, this study was carried out to examine the impact of music to identify affective changes after exposure to three musical stimuli. METHODS The participants were 71 university students engaged in a music education course and none of them were musicians. Changes in the affective state of non-musical student teachers were studied after listening to three pieces of music. An inter-subject repeated measures ANOVA test was carried out using the Positive and Negative Affect Schedule (PANAS) to measure their affective state. RESULTS The results revealed that: (i) the three musical experiences were beneficial in increasing positive affects and reducing negative affects, with significant differences between the interaction of Music Experiences × Moment (pre-post); (ii) listening to Mahler's sad fifth symphony reduced more negative affects than the other experimental conditions; (iii) performing the blues had the highest positive effects. CONCLUSIONS These findings provide applied keys aspects for music education and research, as they show empirical evidence on how music can modify specific affects of personal experience.
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Affiliation(s)
| | - Gloria Bernabé-Valero
- Department of Occupational Sciences, Speech Therapy, Evolutionary and Educational Psychology, Catholic University of Valencia San Vicente Mártir, Av. De La Ilustración, 2, 46100, Burjassot, Valencia, Spain
| | - Pablo Marín-Liébana
- Department of Music Education, University of Valencia, Av. Dels Tarongers, 4, 46022, Valencia, Spain
| | - Ana María Botella-Nicolás
- Department of Music Education, University of Valencia, Av. Dels Tarongers, 4, 46022, Valencia, Spain
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Donohue C, Carnaby G, Focht Garand KL. A Clinician's Guide to Critically Appraising Randomized Controlled Trials in the Field of Speech-Language Pathology. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023; 32:411-425. [PMID: 36749981 DOI: 10.1044/2022_ajslp-22-00180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
PURPOSE When considering original research articles, randomized controlled trials (RCTs) provide the highest level of research evidence. Given this, RCTS are often used by clinicians performing evidence-based practice to determine the most effective intervention for a specific patient or patient population. Although RCTs represent a high level of research evidence, it is important for clinicians to critically appraise RCTs to determine the validity of the study methods deployed, the statistical and clinical significance of treatment effects, and whether or not the results generalize to a particular patient, patient population, and/or clinical setting. Therefore, this tutorial will provide clinicians with an overview of what an RCT is, the various types of RCTs, when RCTs are appropriate to conduct and/or use to inform clinical practice, and the advantages and limitations of RCTs. Additionally, this tutorial will provide clinicians with practical tools to employ when reading an RCT, including checklists with questions, definitions of important terminology frequently used in RCTs, and demonstrations of how to critically appraise RCTs using literature examples from the speech-language pathology literature. CONCLUSIONS Learning how to interpret and apply the results from RCTs to inform clinical practice for purposes of improving patient care is a critical evidence-based practice skill for clinicians to develop. This tutorial will assist clinicians in the field of speech-language pathology by furthering their fundamental knowledge of RCTs and by providing them with pragmatic tools to critically appraise RCTs to inform their clinical practice.
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Affiliation(s)
- Cara Donohue
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Breathing Research and Therapeutics Center, University of Florida, Gainesville
- Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Giselle Carnaby
- Department of Health Sciences, School of Health Professions, University of Texas Health Science Center, San Antonio
| | - Kendrea L Focht Garand
- Department of Speech Pathology and Audiology, College of Allied Health Professions, University of South Alabama, Mobile
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Smith KA, Blease C, Faurholt-Jepsen M, Firth J, Van Daele T, Moreno C, Carlbring P, Ebner-Priemer UW, Koutsouleris N, Riper H, Mouchabac S, Torous J, Cipriani A. Digital mental health: challenges and next steps. BMJ MENTAL HEALTH 2023; 26:e300670. [PMID: 37197797 PMCID: PMC10231442 DOI: 10.1136/bmjment-2023-300670] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/28/2023] [Indexed: 05/19/2023]
Abstract
Digital innovations in mental health offer great potential, but present unique challenges. Using a consensus development panel approach, an expert, international, cross-disciplinary panel met to provide a framework to conceptualise digital mental health innovations, research into mechanisms and effectiveness and approaches for clinical implementation. Key questions and outputs from the group were agreed by consensus, and are presented and discussed in the text and supported by case examples in an accompanying appendix. A number of key themes emerged. (1) Digital approaches may work best across traditional diagnostic systems: we do not have effective ontologies of mental illness and transdiagnostic/symptom-based approaches may be more fruitful. (2) Approaches in clinical implementation of digital tools/interventions need to be creative and require organisational change: not only do clinicians and patients need training and education to be more confident and skilled in using digital technologies to support shared care decision-making, but traditional roles need to be extended, with clinicians working alongside digital navigators and non-clinicians who are delivering protocolised treatments. (3) Designing appropriate studies to measure the effectiveness of implementation is also key: including digital data raises unique ethical issues, and measurement of potential harms is only just beginning. (4) Accessibility and codesign are needed to ensure innovations are long lasting. (5) Standardised guidelines for reporting would ensure effective synthesis of the evidence to inform clinical implementation. COVID-19 and the transition to virtual consultations have shown us the potential for digital innovations to improve access and quality of care in mental health: now is the ideal time to act.
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Affiliation(s)
- Katharine A Smith
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
| | - Charlotte Blease
- Division of Digital Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Participatory eHealth and Health Data Research Group, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Maria Faurholt-Jepsen
- Copenhagen Affective Disorder Research Center (CADIC), Psychiatric Center Copenhagen, Frederiksberg, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Joseph Firth
- Division of Psychology and Mental Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Tom Van Daele
- Expertise Unit Psychology, Technology and Society, Thomas More University of Applied Sciences, Mechelen, Belgium
| | - Carmen Moreno
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, IiSGM, CIBERSAM, ISCIII, Universidad Complutense de Madrid Facultad de Medicina, Madrid, Spain
| | - Per Carlbring
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Ulrich W Ebner-Priemer
- Mental mHealth Lab, Institute of Sports and Sports Science, Karlsruhe Institute of Technology, Karlsruhe, Germany
- mHealth Methods in Psychiatry, Department of Psychiatry and Psychotherapy, Medical Faculty Mannheim, Central Institute of Mental Health, Heidelberg University, Heidelberg, Germany
| | - Nikolaos Koutsouleris
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University of Munich, München, Germany
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Max-Planck Institute of Psychiatry, Munich, Germany
| | - Heleen Riper
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Department of Psychiatry, Amsterdam Public Health Research Institute, Amsterdam University Medical Centre, Duivendrecht, Netherlands
- Department of Psychiatry, University of Turku, Turku, Finland
| | - Stephane Mouchabac
- Department of Psychiatry, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
- Infrastructure for Clinical Research in Neurosciences (iCRIN), Brain Institute (ICM), INSERM, CNRS, Hôpital de la Pitié Salpêtrière, Sorbonne Université, Paris, France
| | - John Torous
- Division of Digital Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
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Gukasyan N, Nayak SM. Psychedelics, placebo effects, and set and setting: Insights from common factors theory of psychotherapy. Transcult Psychiatry 2022; 59:652-664. [PMID: 33499762 DOI: 10.1177/1363461520983684] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Psychedelic-assisted treatment is at first glance markedly different in structure and approach from mainstream forms of psychotherapy in the West. A major criticism of clinical psychedelic research rests on the difficulty of executing placebo-controlled studies and distinguishing drug effects from those of the psychotherapeutic container in which psychedelics are typically presented. Detractors also tend to find fault in spiritual or mystical themes that often arise in the context of psychedelic use. Common factors theory of psychotherapy is a useful and extensively studied framework that can help make sense of these issues, and has much to contribute to our understanding of contextual effects that are often discussed in psychedelic literature as "set and setting." In this article, we examine four major contextual "common factors" shared by various healing traditions: 1) the therapeutic relationship; 2) the healing setting; 3) the rationale, conceptual scheme, or myth; and 4) the ritual. We explain how these factors show up in psychedelic-assisted treatment and how they may contribute to therapeutic effects. Lastly, we discuss the implications of these factors for the concept of placebo, and for future research.
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Affiliation(s)
| | - Sandeep M Nayak
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Faltinsen E, Todorovac A, Staxen Bruun L, Hróbjartsson A, Gluud C, Kongerslev MT, Simonsen E, Storebø OJ. Control interventions in randomised trials among people with mental health disorders. Cochrane Database Syst Rev 2022; 4:MR000050. [PMID: 35377466 PMCID: PMC8979177 DOI: 10.1002/14651858.mr000050.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Control interventions in randomised trials provide a frame of reference for the experimental interventions and enable estimations of causality. In the case of randomised trials assessing patients with mental health disorders, many different control interventions are used, and the choice of control intervention may have considerable impact on the estimated effects of the treatments being evaluated. OBJECTIVES To assess the benefits and harms of typical control interventions in randomised trials with patients with mental health disorders. The difference in effects between control interventions translates directly to the impact a control group has on the estimated effect of an experimental intervention. We aimed primarily to assess the difference in effects between (i) wait-list versus no-treatment, (ii) usual care versus wait-list or no-treatment, and (iii) placebo interventions (all placebo interventions combined or psychological, pharmacological, and physical placebos individually) versus wait-list or no-treatment. Wait-list patients are offered the experimental intervention by the researchers after the trial has been finalised if it offers more benefits than harms, while no-treatment participants are not offered the experimental intervention by the researchers. SEARCH METHODS In March 2018, we searched MEDLINE, PsycInfo, Embase, CENTRAL, and seven other databases and six trials registers. SELECTION CRITERIA We included randomised trials assessing patients with a mental health disorder that compared wait-list, usual care, or placebo interventions with wait-list or no-treatment . DATA COLLECTION AND ANALYSIS Titles, abstracts, and full texts were reviewed for eligibility. Review authors independently extracted data and assessed risk of bias using Cochrane's risk of bias tool. GRADE was used to assess the quality of the evidence. We contacted researchers working in the field to ask for data from additional published and unpublished trials. A pre-planned decision hierarchy was used to select one benefit and one harm outcome from each trial. For the assessment of benefits, we summarised continuous data as standardised mean differences (SMDs) and dichotomous data as risk ratios (RRs). We used risk differences (RDs) for the assessment of adverse events. We used random-effects models for all statistical analyses. We used subgroup analysis to explore potential causes for heterogeneity (e.g. type of placebo) and sensitivity analyses to explore the robustness of the primary analyses (e.g. fixed-effect model). MAIN RESULTS We included 96 randomised trials (4200 participants), ranging from 8 to 393 participants in each trial. 83 trials (3614 participants) provided usable data. The trials included 15 different mental health disorders, the most common being anxiety (25 trials), depression (16 trials), and sleep-wake disorders (11 trials). All 96 trials were assessed as high risk of bias partly because of the inability to blind participants and personnel in trials with two control interventions. The quality of evidence was rated low to very low, mostly due to risk of bias, imprecision in estimates, and heterogeneity. Only one trial compared wait-list versus no-treatment directly but the authors were not able to provide us with any usable data on the comparison. Five trials compared usual care versus wait-list or no-treatment and found a SMD -0.33 (95% CI -0.83 to 0.16, I² = 86%, 523 participants) on benefits. The difference between all placebo interventions combined versus wait-list or no-treatment was SMD -0.37 (95% CI -0.49 to -0.25, I² = 41%, 65 trials, 2446 participants) on benefits. There was evidence of some asymmetry in the funnel plot (Egger's test P value of 0.087). Almost all the trials were small. Subgroup analysis found a moderate effect in favour of psychological placebos SMD -0.49 (95% CI -0.64 to -0.30; I² = 53%, 39 trials, 1656 participants). The effect of pharmacological placebos versus wait-list or no-treatment on benefits was SMD -0.14 (95% CI -0.39 to 0.11, 9 trials, 279 participants) and the effect of physical placebos was SMD -0.21 (95% CI -0.35 to -0.08, I² = 0%, 17 trials, 896 participants). We found large variations in effect sizes in the psychological and pharmacological placebo comparisons. For specific mental health disorders, we found significant differences in favour of all placebos for sleep-wake disorders, major depressive disorder, and anxiety disorders, but the analyses were imprecise due to sparse data. We found no significant differences in harms for any of the comparisons but the analyses suffered from sparse data. When using a fixed-effect model in a sensitivity analysis on the comparison for usual care versus wait-list and no-treatment, the results were significant with an SMD of -0.46 (95 % CI -0.64 to -0.28). We reported an alternative risk of bias model where we excluded the blinding domains seeing how issues with blinding may be seen as part of the review investigation itself. However, this did not markedly change the overall risk of bias profile as most of the trials still included one or more unclear bias domains. AUTHORS' CONCLUSIONS We found marked variations in effects between placebo versus no-treatment and wait-list and between subtypes of placebo with the same comparisons. Almost all the trials were small with considerable methodological and clinical variability in factors such as mental health population, contents of the included control interventions, and outcome domains. All trials were assessed as high risk of bias and the evidence quality was low to very low. When researchers decide to use placebos or usual care control interventions in trials with people with mental health disorders it will often lead to lower estimated effects of the experimental intervention than when using wait-list or no-treatment controls. The choice of a control intervention therefore has considerable impact on how effective a mental health treatment appears to be. Methodological guideline development is needed to reach a consensus on future standards for the design and reporting of control interventions in mental health intervention research.
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Affiliation(s)
- Erlend Faltinsen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Adnan Todorovac
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | | | - Asbjørn Hróbjartsson
- Open Patient data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Mickey T Kongerslev
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Erik Simonsen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ole Jakob Storebø
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Department of Psychology, University of Southern Denmark, Odense, Denmark
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Evidence-based individual psychotherapy for complex posttraumatic stress disorder and at-risk groups for complex traumatization: A meta-review. J Affect Disord 2022; 299:610-619. [PMID: 34952116 DOI: 10.1016/j.jad.2021.12.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/05/2021] [Accepted: 12/18/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND The current meta-review of meta-analyses on psychotherapy research for complex post-traumatic stress disorder (CPTSD) and samples at risk of complex traumatization has three aims: first, to provide an overview of efficacy of individual psychotherapies; second, to compare the quality of the meta-analyses; and third, to assess statistical power. METHODS The literature search was conducted until August 2020. Meta-analyses providing individual treatment effect estimates focusing on CPTSD or samples at risk of complex traumatization (i.e., victims of childhood sexual abuse (CSA), war or torture, refugees, and veterans with PTSD) were eligible for inclusion. The effect sizes were classified according to Cohen as small, medium, or large. The "A MeaSurement Tool to Assess systematic Reviews" (AMSTAR) was applied to assess the quality of the meta-analyses, and power was assessed post-hoc. RESULTS Twenty-four meta-analyses were suitable for inclusion. The efficacy of the interventions varied (g = -0.04 (CI -0.39; 0.48), controlled, to d = 2.73 (1.69; 3.76), uncontrolled). Overall, 16 effect estimates were large. On average, the quality of the meta-analyses was good (average AMSTAR total score 7.71 points (range 3-11). Considering quality assessments and power together, nine meta-analyses were evaluated as high quality. LIMITATIONS No meta-analysis for CPTSD was eligible and the number of individuals with complex traumatization was not directly assessed in the at-risk groups. CONCLUSIONS For at-risk groups for complex traumatization, on average, good-quality empirical evidence exists. Given the limited research on CPTSD, future studies are needed to further investigate the efficacy of interventions.
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Rathschlag M, Klatt S. Open-Label Placebo Interventions With Drinking Water and Their Influence on Perceived Physical and Mental Well-Being. Front Psychol 2021; 12:658275. [PMID: 34938222 PMCID: PMC8685225 DOI: 10.3389/fpsyg.2021.658275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 10/22/2021] [Indexed: 12/12/2022] Open
Abstract
In recent years, the postulation that deception is necessary for placebos to have an effect on pain relief or increased well-being has come into question. Latest studies have shown that an openly administered mock drug works just as well as a deceptively administered placebo on certain complaints. This open-label placebo effect has primarily been used in the area of pain treatment so far. This study is the first to examine the effect of such placebos on healthy individuals with the use of drinking water. In two experiments, participants were required to use certain specified water bottles for their daily drinking water consumption. At the beginning of Experiment 1, all participants (N = 68) received one bottle of water, which they were asked to refill themselves each day during a 2-week intervention period. In Experiment 2, participants (N = 75) received a new sealed water bottle every day. In both experiments, participants were randomly assigned to one of four groups: no treatment (control group CG), open-label placebo without rationale (OPR–), open-label placebo with rationale (OPR+), and open-label placebo with additional rationale in a suggested relaxed state (group OPR++). We conducted baseline and post-treatment measurements of the subjective perceived physical and mental well-being of the participants. In Experiment 1, only the OPR++ group reported enhanced vitality at the post-treatment level compared to the other groups. In Experiment 2, post-treatment measurements showed improvements for the OPR++ group in the Physical Performance Capability, Mental Performance Capability, Emotional Balance, Overall Recovery, Negative Emotional State, and Overall Stress categories compared to the other groups. Our results support the idea that placebos with an additional rationale in a suggestive relaxed state are more effective than with just a rationale in a normal state. Furthermore, our study shows the tendency that OLP++ in the form of water with health claims may be more effective when the water is given in several sealed bottles separately than in one sealed but refillable bottle.
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Affiliation(s)
- Marco Rathschlag
- Institute of Exercise Training and Sport Informatics, German Sport University Cologne, Cologne, Germany
| | - Stefanie Klatt
- Institute of Exercise Training and Sport Informatics, German Sport University Cologne, Cologne, Germany.,Institute of Sports Science, University of Rostock, Rostock, Germany.,School of Sport and Health Sciences, University of Brighton, Brighton, United Kingdom
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Koechlin H, Kharko A, Probst T, Pradela J, Buechi S, Locher C. Placebo Responses and Their Clinical Implications in Fibromyalgia: A Meta-Analysis Using SSRI and SNRI Trials. FRONTIERS IN PAIN RESEARCH 2021; 2:750523. [PMID: 35295427 PMCID: PMC8915657 DOI: 10.3389/fpain.2021.750523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/11/2021] [Indexed: 12/21/2022] Open
Abstract
Background: Fibromyalgia (FM) is a chronic primary pain condition, associated with widespread musculoskeletal pain, disturbed sleep, fatigue, cognitive dysfunction, and a range of comorbid conditions such as irritable bowel syndrome, and depression. Despite its high prevalence of 2% in the general population, FM continues to pose scientific and clinical challenges in definition, etiology, and day-to-day management. In terms of treatment, FM can be treated with selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs). Objective: Patients with FM and other chronic primary pain syndromes are known to experience substantial and clinically relevant placebo effects. An update of the placebo responses for various outcomes in the FM population and especially a discussion about clinical implications is therefore needed. Methods: We used data from a large data pool that includes randomized controlled trials (RCTs) examining within-placebo mean change scores of baseline vs. follow-up assessments in FM trials of SSRIs and SNRIs. The primary outcomes were pain, functional disability, and depression and using different scales. We assessed heterogeneity of included trials. Results: A total of 29 RCTs with N = 8,453 patients suffering from FM were included in our analysis. Within-placebo mean change scores of baseline vs. follow-up assessments were large for pain (mean change = 2.31, 95% CI: 0.42-4.21, p = 0.017), functional disability (mean change = 3.31, 95% CI: 2.37-4.26, p < 0.000), and depression (mean change = 1.55, 95% CI: 0.92-2.18, p < 0.000). Heterogeneity was found to be large for all outcomes. Impact: Our results provide preliminary evidence that placebo responses, which also consist of non-specific effects, might play a role in the treatment of FM. Furthermore, we highlight limitations of our analyses and make suggestions for future studies.
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Affiliation(s)
- Helen Koechlin
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Anna Kharko
- Faculty of Health, University of Plymouth, Plymouth, United Kingdom
| | - Tamara Probst
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Julia Pradela
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Stefan Buechi
- Clinic for Psychotherapy and Psychosomatics “Hohenegg”, Meilen, Switzerland
| | - Cosima Locher
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
- Faculty of Health, University of Plymouth, Plymouth, United Kingdom
- Clinic for Psychotherapy and Psychosomatics “Hohenegg”, Meilen, Switzerland
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
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Locher C, Buergler S, Frey Nascimento A, Kost L, Blease C, Gaab J. Lay perspectives of the open-label placebo rationale: a qualitative study of participants in an experimental trial. BMJ Open 2021; 11:e053346. [PMID: 34408060 PMCID: PMC8375733 DOI: 10.1136/bmjopen-2021-053346] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES To analyse participants' concepts about the open-label placebo (OLP) effect; to explore their views about the discussion points that are applied in conventional OLP trials and to examine their experiences of taking part in an OLP trial. DESIGN A qualitative study using thematic analysis of semistructured interviews that were nested within a randomised controlled trial investigating experimental OLP analgesia (registered at ClinicalTrials.gov: NCT02578420). PARTICIPANTS 30 healthy adults who took part in the randomised controlled trial. RESULTS Participants mostly conceptualised placebo as something that is inert and requires deception in order to be effective. Interviewees used a broad definition of placebos, going beyond a conventional notion of sugar pills. In contrast to the conventional OLP rationale, participants seldom emphasised classical conditioning as a mechanism of placebo effects, stressing a variety of other well-established components through which placebos might be therapeutic, whereas the conventional OLP disclosures state that 'a positive attitude helps but is not necessary', participants in our study applied other attitudes, such as 'it's worth a try'. When asked about their experiences during the trial, the majority emphasised that the concept of OLP was completely novel to them. Participants were rather sceptical about the efficacy of the intervention. CONCLUSION Integrating lay perspectives into the scientific rationale of OLP treatments might enhance the plausibility and credibility of the rationale in ethical treatments. TRIAL REGISTRATION NUMBER NCT02578420.
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Affiliation(s)
- Cosima Locher
- Department of Consultation-Liaison Psychiatry and Psychosomatics, University Hospital Zurich, Zurich, Switzerland
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
- Faculty of Health, University of Plymouth, Plymouth, UK
| | - Sarah Buergler
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Antje Frey Nascimento
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Linda Kost
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Charlotte Blease
- General Medicine and Primary Care, Harvard Medical School, Boston, Massachusetts, USA
| | - Jens Gaab
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
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Effects of open-label placebos on test performance and psychological well-being in healthy medical students: a randomized controlled trial. Sci Rep 2021; 11:2130. [PMID: 33483552 PMCID: PMC7822842 DOI: 10.1038/s41598-021-81502-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 01/07/2021] [Indexed: 01/30/2023] Open
Abstract
Psychological distress is prevalent in students and can predispose to psychiatric disorders. Recent findings indicate that distress might be linked to impaired cognitive performance in students. Experimental findings in healthy participants suggest that placebo interventions can improve cognition. However, whether non-deceptive (i.e., open-label, OLP) placebos can enhance cognitive function and emotional well-being is unclear. Using a randomized-controlled design we demonstrate a positive impact of OLP on subjective well-being (i.e., stress, fatigue, and confusion) after a 21-day OLP application in healthy students during midterm exams. OLP did not improve test performance, but, within the OLP group, test performance was positively correlated with measures of general belief in the benefit of medication. These results show that OLP can counteract negative effects of acute stress on psychological well-being and might improve cognitive performance if supported by positive treatment expectations. Additionally, our findings in healthy volunteers warrant further investigation in exploring the potential of OLP in reducing stress-related psychological effects in patients. The trial was preregistered at the German Clinical Trials Register on December 20, 2017 (DRKS00013557).
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Blease CR, Bernstein MH, Locher C. Open-label placebo clinical trials: is it the rationale, the interaction or the pill? BMJ Evid Based Med 2020; 25:159-165. [PMID: 31243047 PMCID: PMC6930978 DOI: 10.1136/bmjebm-2019-111209] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2019] [Indexed: 12/20/2022]
Abstract
National surveys of primary care physicians demonstrate that placebo use is prevalent. Against their widespread use, until recently, it was assumed among researchers that placebos must be deceptively prescribed for beneficial effects to be elicited. However, a new programme of research in placebo studies indicates that it may be possible to harness placebo effects in clinical practice via ethical, non-deceptively prescribed 'open label placebos' ('OLPs'). To date, there have been 14 small scale clinical and experimental trials into OLPs. Results suggest therapeutic potential of these treatments for a range of conditions and symptoms. In this evidence-based Analysis we identify conceptual issues that, if not given due consideration, risk undermining research methodologies in OLP trials. Counterintuitively, owing to the nuances posed by placebo terminology, and the difficulties of designing placebos controls in OLP trials, we suggest that experimentalists reflect more deeply when formulating adequate comparison groups. Further research is needed to disentangle which specific components of OLPs are effective, such as: the rationale provided to participants; the quality of provider interaction; and/or the action of taking the pills. We conclude with recommendations for how researchers might take up the significant challenge of devising optimal placebo controls for OLP clinical trials. Although these issues are intricate, they are not merely academic: without due diligence to conceptual, and as a consequence, methodological considerations, OLP effect sizes may be over- or underestimated. We conclude that there may yet be potential to use OLPs in medical practice but clinical translation depends on rigorously controlled research.
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Affiliation(s)
- Charlotte R Blease
- Program in Placebo Studies, Department of General Medicine and Primary Care Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- School of Psychology, University College Dublin, Dublin, Ireland
| | - Michael H. Bernstein
- School of Public Health, Department of Behavioral and Social Sciences, Brown University, Providence, Rhode Island, USA
| | - Cosima Locher
- Department of Clinical Psychology and Psychotherapy, University of Basel, Basel, Switzerland
- School of Psychology, University of Plymouth, Plymouth, UK
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Blease C. Psychotherapy is still failing patients: revisiting informed consent-a response to Garson Leder. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2020-106865. [PMID: 32963089 DOI: 10.1136/medethics-2020-106865] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 09/05/2020] [Indexed: 06/11/2023]
Abstract
Compared with mainstream medicine and complementary and alternative therapies, the practice of psychotherapy has enjoyed a relative pass when it comes to ethical evaluation. Therefore, contributions to the, although slowly growing, body of literature on psychotherapy ethics are to be welcomed. In his paper 'Psychotherapy, placebos, and informed consent', Garson Leder takes issue with what he calls the 'go open' project in psychotherapy ethics-the idea that the so-called 'common factors' in therapy should be disclosed to prospective patients. Although Leder does not give a detailed list, the common factors include therapist characteristics (empathy, positive regard, positive expectations that therapy will succeed), patient characteristics (expectations about therapy including its plausibility, confidence in the therapist), and the working alliance (how well both therapist and patient work well together during sessions). He argues that the project advocating disclosure of these factors is flawed on two grounds: (1) that information about common factors is not necessary for informed consent; and (2) clarity about specific mechanisms of change in therapy is consistent with 'many theory-specific forms of psychotherapy'. There are multiple serious problems with Leder's critique of the recent literature, including how he represents the contours of the debate, which I list, and address in this response.
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Affiliation(s)
- Charlotte Blease
- General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Bernstein MH, Locher C, Stewart-Ferrer S, Buergler S, DesRoches CM, Dossett ML, Miller FG, Grose D, Blease CR. Primary care providers' use of and attitudes towards placebos: An exploratory focus group study with US physicians. Br J Health Psychol 2020; 25:596-614. [PMID: 32472982 DOI: 10.1111/bjhp.12429] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/24/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To examine how primary care physicians define placebo concepts, use placebos in clinical practice, and view open-label placebos (OLPs). DESIGN Semi-structured focus groups that were audio-recorded and content-coded. METHODS Two focus groups with a total of 15 primary care physicians occurred at medical centres in the New England region of the United States. Prior experience using placebo treatments and attitudes towards open-label placebos were explored. Themes were analysed using an inductive data-driven approach. RESULTS Physicians displayed a nuanced understanding of placebos and placebo effects in clinical contexts which sometimes focused on relational factors. Some respondents reported that they prescribed treatments with no known pharmacological effect for certain conditions and symptoms ('impure placebos') and that such prescriptions were more common for pain disorders, functional disorders, and medically unexplained symptoms. Opinions about OLP were mixed: Some viewed OLPs favourably or considered them 'harmless'; however, others strongly rejected OLPs as disrespectful to patients. Other issues in relation to OLPs included the following: lack of guidelines, legal and reputational concerns, and the notion that such treatments would run counter to customary medical practice. CONCLUSIONS A number of physicians reported prescribing impure placebos in clinical care. Although some primary care physicians were resistant to the possibility of recommending OLPs, others regarded OLPs more favourably, viewing them as potential treatments, albeit with restricted potential. Statement of contribution What is already known? Many physicians report prescribing drugs for the purposes of eliciting a placebo effect. Initial evidence for the efficacy of open-label placebos is promising. What does this study add? A more nuanced description of the circumstances under which primary care physicians report placebo prescribing. A qualitative account of physician attitudes about using open-label placebos in clinical practice.
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Affiliation(s)
- Michael H Bernstein
- Department of Behavioral & Social Sciences, Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Cosima Locher
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,School of Psychology, University of Plymouth, UK.,Division of Clinical Psychology & Psychotherapy, University of Basel, Switzerland
| | - Sif Stewart-Ferrer
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Sarah Buergler
- Division of Clinical Psychology & Psychotherapy, University of Basel, Switzerland
| | - Catherine M DesRoches
- General Medicine and Primary Care Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Michelle L Dossett
- Division of General Internal Medicine and Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of General Internal Medicine, Geriatrics & Bioethics, University of California, Davis, Sacramento, California, USA
| | - Franklin G Miller
- Division of Medical Ethics, Weill Cornell Medical College, New York, USA
| | - Deborah Grose
- Program in Placebo Studies, Beth Isreal Deaconess Medical Center, Boston, Massachusetts, USA
| | - Charlotte R Blease
- General Medicine and Primary Care Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,School of Psychology, University College Dublin, Ireland
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López-Pinar C, Martínez-Sanchís S, Carbonell-Vayá E, Sánchez-Meca J, Fenollar-Cortés J. Efficacy of Nonpharmacological Treatments on Comorbid Internalizing Symptoms of Adults With Attention-Deficit/Hyperactivity Disorder: A Meta-Analytic Review. J Atten Disord 2020; 24:456-478. [PMID: 31189374 DOI: 10.1177/1087054719855685] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: Attention-deficit/hyperactivity disorder (ADHD) is highly comorbid in adulthood. This meta-analysis was aimed at ascertaining the efficacy of different psychotherapies in improving comorbid internalizing symptoms in adults with ADHD. Method: Twenty randomized controlled trials and 12 uncontrolled pretest-posttest studies were included and combined using the inverse variance method. Risk of bias and heterogeneity assessment and moderator analyses were performed. Results: Cognitive-behavioral therapy (CBT) improved quality of life (QoL), emotional dysregulation (ED), depression, and anxiety symptoms, particularly at follow-up, which was predicted by core symptoms reduction. A significant between-group effect was obtained only on QoL, ED, and self-esteem for dialectical behavior therapy (DBT), mindfulness-based therapies (MBTs), and neurofeedback, respectively. Conclusion: Results support CBT efficacy for treating comorbid internalizing symptoms. More research is needed to determine the effectiveness of DBT, MBT, and neurofeedback. The small number of studies evaluating some therapies and the high risk of bias observed might limit these results.
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Bayoumy HMM, Almuwallad GE, Eissa AO. Investigating Knowledge, Attitude, and Beliefs Regarding Placebo Interventions in Clinical Practice: A Comparative Study of Nursing and Medical University Students. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2020; 11:619-635. [PMID: 32982535 PMCID: PMC7498927 DOI: 10.2147/amep.s250019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 07/16/2020] [Indexed: 05/08/2023]
Abstract
BACKGROUND Placebo interventions are commonly used in medical practice for alleviating symptoms of illnesses. Placebo is considered a pseudo-medication and its use is debatable ethically, professionally, and legally. Despite that there is also a lack of evidence on understanding of placebo interventions among health profession students. Further, no previous studies have been conducted to investigate whether future nurses and physicians differ in their knowledge, attitudes, and beliefs regarding placebo intervention. MATERIALS AND METHODS A comparative cross-sectional study was carried out for exploring knowledge, attitude, and beliefs about placebo interventions among a convenient sample of 187 medical and nursing students at King Saud bin Abdulaziz University for Health Sciences. Data were collected using a sociodemographic data sheet and a 32-item placebo knowledge, beliefs, and attitude scale, which was developed from the evidence-based literature. Validity and reliability were ensured through utilizing a panel of experts and internal consistency analysis. RESULTS Overall mean participants' knowledge score was 7.68±2.07 (out of 15). Nursing students showed significantly higher knowledge than medical students (P=0.028). More nursing than medical students believed in the effectiveness of placebo (P˂0.001). Medical students had a stronger belief that the placebo effect is mental, while nursing students reported that it is both mental and physiologic (P˂0.006). Concerning placebo attitude, medical students significantly pointed out that it should generally be prohibited and should not be permitted unless research supports its use (P˂0.001). Both groups agreed that impure placebo intervention involves deception. CONCLUSION Participants' overall placebo knowledge was low. Inconsistencies in attitude and beliefs were shown among students. Current study findings offered a unique opportunity to better study misunderstandings for placebo, which might open the gate for misuse and place patients at risk of deception. Additionally, study findings were imperative as a relevant evidence-based recommendation for nursing and medical educators could be achieved.
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Affiliation(s)
- Hala Mohamed Mohamed Bayoumy
- Department of Nursing, Cairo University, Gizah, Egypt
- Department of Nursing, King Saud Bin Abdul Aziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center; King Saud Bin Abdul Aziz University for Health Sciences, Jeddah, Saudi Arabia
- Correspondence: Hala Mohamed Mohamed Bayoumy P.O.Box. 9515, Jeddah21423, Saudi ArabiaTel +966 565609919 Email
| | - Ghada Eissa Almuwallad
- Pediatric Intensive Care Unit, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Ashwag Othman Eissa
- Medical-Surgical Intensive Care Unit, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
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Blease CR, Arnott T, Kelley JM, Proctor G, Kube T, Gaab J, Locher C. Attitudes About Informed Consent: An Exploratory Qualitative Analysis of UK Psychotherapy Trainees. Front Psychiatry 2020; 11:183. [PMID: 32231601 PMCID: PMC7083167 DOI: 10.3389/fpsyt.2020.00183] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 02/25/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Ethical informed consent to psychotherapy has recently been the subject of in-depth analysis among healthcare ethicists. Objective: This study aimed to explore counseling and psychotherapy students' views and understanding about informed consent to psychological treatments. Methods: Two focus groups were conducted with a total of 10 students enrolled in a Masters course in counseling and psychotherapy at a British university. Questions concerned participants' understanding of informed consent including judgments about client capacity; the kinds of information that should be disclosed; how consent might be obtained; and their experiences of informed consent, both as a client and as a therapist. Focus groups were audio-recorded, transcribed, and analyzed using qualitative content analysis. Coding was conducted independently by three authors. Results: Comments were classified into three main themes: (1) the reasons and justifications for informed consent; (2) informed consent processes; and (3) the hidden ethics curriculum. Some trainees expressed significant doubts about the importance of informed consent. However, participants also identified the need to establish the clients' voluntariness and their right to be informed about confidentiality issues. In general, the format and processes pertaining to informed consent raised considerable questions and uncertainties. Participants were unsure about rules surrounding client capacity; expressed misgivings about describing treatment techniques; and strikingly, most trainees were skeptical about the clinical relevance of the evidence-base in psychotherapy. Finally, trainees' experiences as clients within obligatory psychotherapy sessions were suggestive of a "hidden ethics curriculum"-referring to the unintended transmission of norms and practices within training that undermine the explicit guidance expressed in formal professional ethics codes. Some students felt coerced into therapy, and some reported not undergoing informed consent processes. Reflecting on work placements, trainees expressed mixed views, with some unclear about who was responsible for informed consent. Conclusions: This qualitative study presents timely information on psychotherapy students' views about informed consent to psychotherapy. Major gaps in students' ethical, conceptual, and procedural knowledge were identified, and comments suggested the influence of a hidden curriculum in shaping norms of practice. Implications: This exploratory study raises important questions about the preparedness of psychotherapy students to fulfill their ethical obligations.
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Affiliation(s)
- Charlotte R Blease
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.,School of Psychology, University College Dublin, Dublin, Ireland
| | - Tim Arnott
- School of Healthcare, University of Leeds, Leeds, United Kingdom
| | - John M Kelley
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.,Department of Psychology, Endicott College, Beverly, MA, United States
| | - Gillian Proctor
- School of Healthcare, University of Leeds, Leeds, United Kingdom
| | - Tobias Kube
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.,Pain and Psychotherapy Lab, University of Koblenz and Landau, Landau, Germany
| | - Jens Gaab
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Cosima Locher
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland.,School of Psychology, University of Plymouth, Plymouth, United Kingdom
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Locher C, Koechlin H, Gaab J, Gerger H. The Other Side of the Coin: Nocebo Effects and Psychotherapy. Front Psychiatry 2019; 10:555. [PMID: 31440174 PMCID: PMC6694178 DOI: 10.3389/fpsyt.2019.00555] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 07/16/2019] [Indexed: 12/28/2022] Open
Abstract
Psychotherapy and placebo have a long history, and both have been shown to have significant and clinically meaningful effects. In the last 100 years and up to today, psychotherapy has been subject to an enduring and often heated debate about its mechanisms and its possible relationship to placebos and their effects. However, there is little awareness of the placebo effects' counterpart-nocebo effects (from Latin "I will harm")-in the context of psychotherapy. Embedded in the controversy of whether psychotherapy and placebo share some unwanted proximity in terms of effects and mechanisms, the question arises which role nocebo effects may play in relation to psychotherapy. By using two examples, this article analyzes and discusses two different kinds of possible associations between psychotherapy and nocebo effects. We close with possibilities of how to prevent the occurrence of nocebo effects in psychotherapy, including some specific recommendations for clinical practice.
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Affiliation(s)
- Cosima Locher
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
- School of Psychology, University of Plymounth, Plymouth, United Kingdom
| | - Helen Koechlin
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Jens Gaab
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Heike Gerger
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
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Gruszka P, Burger C, Jensen MP. Optimizing Expectations via Mobile Apps: A New Approach for Examining and Enhancing Placebo Effects. Front Psychiatry 2019; 10:365. [PMID: 31214057 PMCID: PMC6554680 DOI: 10.3389/fpsyt.2019.00365] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 05/13/2019] [Indexed: 12/12/2022] Open
Abstract
There is growing interest in interventions that enhance placebo responses in clinical practice, given the possibility that this would lead to better patient health and more effective therapy outcomes. Previous studies suggest that placebo effects can be maximized by optimizing patients' outcome expectations. However, expectancy interventions are difficult to validate because of methodological challenges, such as reliable blinding of the clinician providing the intervention. Here we propose a novel approach using mobile apps that can provide highly standardized expectancy interventions in a blinded manner, while at the same time assessing data in everyday life using experience sampling methodology (e.g., symptom severity, expectations) and data from smartphone sensors. Methodological advantages include: 1) full standardization; 2) reliable blinding and randomization; 3) disentangling expectation effects from other factors associated with face-to-face interventions; 4) assessing short-term (days), long-term (months), and cumulative effects of expectancy interventions; and 5) investigating possible mechanisms of change. Randomization and expectancy interventions can be realized by the app (e.g., after the clinic/lab visit). As a result, studies can be blinded without the possibility for the clinician to influence study outcomes. Possible app-based expectancy interventions include, for example, verbal suggestions and imagery exercises, although a large number of possible interventions (e.g., hypnosis) could be evaluated using this innovative approach.
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Affiliation(s)
- Piotr Gruszka
- Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
| | - Christoph Burger
- Department of Basic Psychological Research and Research Methods, Faculty of Psychology, University of Vienna, Vienna, Austria
- Department of Applied Psychology: Work, Education and Economy, Faculty of Psychology, University of Vienna, Vienna, Austria
| | - Mark P. Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
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