Minimizing Drug Adverse Events by Informing About the Nocebo Effect-An Experimental Study

Individual difference factors that predict evaluations and acceptance of authorized concealment for the reduction of nocebo side effects

OBJECTIVES

Authorized concealment is a shared decision-making technique in which a clinician asks a patient if they would prefer not to be informed about all possible treatment side effects, so as to minimize nocebo effects. The present research assessed individual difference variables that predict evaluations and receptivity of authorized concealment.

METHODS

A demographically diverse national community US sample of 1012 adults (ages ranging from 18 to 94; M=43.2) learned about nocebo effects and then evaluated and estimated their likelihood of consenting to four possible methods of authorized concealment. A range of self-reported psychological, health, and demographic variables were tested as predictor variables.

RESULTS

The strongest and most reliable outcomes were that greater trust in doctors and a greater desire to avoid side effect knowledge predicted positive evaluations of authorized concealment and estimated personal use of authorized concealment. There was some evidence that women, those of older age, reporting better health, and using medicine more regularly, had a more positive response to authorized concealment, but these effects were dependent upon the specific method of authorized concealment described.

CONCLUSIONS

Individual difference variables can predict openness to authorized concealment.

PRACTICE IMPLICATIONS

This knowledge may benefit clinicians who consider employing this shared decision-making technique with patients.

Does health anxiety and vaccine concern predict self-reported adverse events following COVID-19 vaccination?-A Danish national cohort study

OBJECTIVES

The nocebo effect refers to an expectation of sickness that leads to sickness in the expectant. Studies have found COVID-19 vaccines to be associated with the nocebo effect. However, the literature in this field is sparse yet important with the continuation of booster vaccines.

STUDY DESIGN

National cohort study.

METHODS

This study used data from the Danish national cohort "BiCoVac", which contains self-reported information on both health anxiety and specific COVID-19 vaccine concern, as well as 19 systemic AEs following COVID-19 vaccination. Simple and multiple logistic regression was used to estimate the association between health anxiety and specific COVID-19 vaccine concern with having one or more systemic AEs following COVID-19 vaccination. Inverse probability weights were used to compensate for the initial dropout and loss to follow-up.

RESULTS

Of the 85,080 participants in the study, 4 % reported health anxiety, 30 % reported specific COVID-19 vaccine concern, and 26 % one or more systemic AEs following vaccination. After adjusting for covariates, participants with health anxiety had higher odds of reporting one or more systemic AEs following vaccination compared to those without (OR, 1·21 CI 95 % [1·10; 1·33]). For specific COVID-19 vaccine concern, the OR was 1·51 CI 95 % [1·45; 1·58].

CONCLUSIONS

Participants with specific COVID-19 vaccine concern had higher odds of reporting one or more systemic AEs following vaccination compared with those who had no specific COVID-19 vaccine concern. There might be a potential to reduce AEs, with positive framing of AEs and information about nocebo. Reporting of AEs was also associated with health anxiety, but to a lesser degree.

Identifying the psychological effects of nocebo education: results from two pre-registered experiments

Providing treatment side effect information to patients increases the risk of harm due to the nocebo effect. Nocebo education, in which patients learn about nocebo effects, is a novel strategy that can be used across a variety of situations and individuals to decrease unpleasant treatment side effects. It is currently unclear which psychological changes are induced by nocebo education, which is information required to maximize this intervention. Two pre-registered studies investigated the effects of nocebo education on side effect expectations, side effect control beliefs, feelings toward treatments, intentions to avoid or seek side effect information, and perceptions of treatment efficacy. In Study 1 (N = 220), adult participants either watched or did not watch a nocebo education intervention video prior to reading vignettes about receiving a surgical treatment for pain and a medication for pain. Study 2 (N = 252) was similar to Study 1, with the inclusion of a health behavior video control group and participants only reading about a medication treatment for pain. In both experiments, nocebo education reduced global side effect expectations and increased side effect self-efficacy beliefs. Nocebo education also increased intentions to avoid side effect information and decreased intentions to seek more side effect information. Evidence was inconclusive on whether nocebo education changes affective associations with the treatments. The findings demonstrate that nocebo education has a multi-faceted influence with the potential to change patient behavior. The results can be used to improve the management of adverse treatment side effects.

Modifiable factors for somatic symptom persistence in patients with somatic symptom disorder: study protocol for a longitudinal cohort with an embedded ecologically momentary assessment (SOMA.SSD)

INTRODUCTION

Somatic symptom disorder (SSD) is a distressing mental disorder characterised by the presence of at least one persistent somatic symptom and a significant psychological burden due to the symptom(s), as well as excessive thoughts, feelings or behaviours related to them or associated health concerns. The primary aim of our study is to deepen the understanding of risk factors and mechanisms for somatic symptom persistence. Specifically, we will investigate the role of patients' expectations and somatic comorbidity regarding symptom persistence.

METHODS AND ANALYSIS

In a prospective 12-month cohort study, n=240 patients with SSD will be recruited from the outpatient clinics of the Department of Psychosomatic Medicine and Psychotherapy at the University Medical Center Hamburg-Eppendorf. The roles of two hypothesised predictors (ie, expectations and comorbidity) will be analysed together with known predisposing and maintaining factors of persistent somatic symptoms. The study entails macrolevel and microlevel assessments to investigate symptom severity over different timespans. Assessments at the macrolevel take place at baseline, 6 and 12 months. At the microlevel, a 10-day ecological momentary assessment study will be implemented to elucidate patients' dynamic experience with somatic symptoms in their natural environments. In order to elicit possible framing effects on the 10-day course of symptom severity, participants are randomised to either a positive or a negative expectation framing group. Cross-lagged panel models will be used to analyse data at the macrolevel. At the microlevel, multivariate latent growth curve models will be conducted to relate temporal changes in predictor and outcome variables to one another.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the Medical Associations Hamburg, Germany (2020-10197-BO-ff). The results will enable us to draw conclusions regarding the role of expectations for future targeted treatment options and regarding the utility of somatic comorbidity as a potential diagnostic specifier of SSD. Dissemination of our results will be achieved through scientific publications, and lay summaries for study participants, patient advocacy groups and the general public.

TRIAL REGISTRATION NUMBER

ISRCTN36251388.

Nocebo belief and attitudes towards side effect disclosure: A general population-based online survey in Europe and North America

BACKGROUND

With evidence for large nocebo effects in pain, guidelines for nocebo-minimizing strategies regarding side effect disclosure are emerging. While the ethical implications and effectiveness of such strategies have been the subject of investigations, the perspective of healthcare users are missing despite the stakes for patient autonomy.

METHODS

In an online survey, 2766 adults (≥18 years) from a general population sample in Europe and North America responded to questions related to nocebo familiarity, nocebo beliefs and attitudes towards side effect disclosure.

RESULTS

Only 474 (17%) were familiar with nocebo terminology, while 1379 (50%) were familiar with the concept of nocebo side effects. Belief in nocebo side effects was not well-established; 738 (31%) agreed that side effect information could increase side effect occurrence. Nocebo belief was associated with more negative attitudes towards side effect disclosure and 1962 (73%) indicated that positive framing was an acceptable way of disclosing side effect information. In general, the majority of participants (65-76%) held positive attitudes towards the disclosure of all potential side effects and 2309 (84%) favoured patient autonomy over nonmaleficence. Although the general patterns were similar in the European and North American sample, the latter showed stronger nocebo belief and stronger positive attitudes towards side effect disclosure.

CONCLUSIONS

The study found a consistent, moderate association between nocebo belief and attitudes towards nondisclosure, alongside positive attitudes towards the use of framing. Together with the discovered discrepancy between nocebo familiarity and nocebo belief, these findings have implications for the implementation of nocebo education and risk framing strategies.

SIGNIFICANCE STATEMENT

This is the first large-scale, general population-based study to contribute to the scientific discussion about nocebo side effects from the perspective of healthcare users. The findings have implications for the discussion on how to handle the medical and ethical problem of nocebo side effects in clinical practice.

Assessing the longevity of attribute framing in attenuating the nocebo effect to brand and generic medication

The perception of taking a generic, relative to brand, medication has been demonstrated to exacerbate the nocebo effect. Conversely, positive attribute framing has been shown to attenuate the nocebo effect. However, little is known about the longevity of positive attribute framing nor how it interacts with generic versus brand treatment cues. Healthy participants (N = 205) were randomised to receive either sham-modafinil capsules with a brand or generic appearance, in conjunction with standard negative side effect framing (brand-negative: N = 42; generic-negative: N = 41) or positive side effect framing (brand-positive: N = 40; generic-positive: N = 40). The remainder were randomised to a no-treatment control (N = 42). Participants were informed that modafinil could enhance alertness and cognitive performance and reduce fatigue. Critically, modafinil was described as having several potential side effects. Treatment-related side effects, alertness, fatigue and cognitive performance were measured at baseline, 30-min post-treatment and 24 h later. Nocebo and placebo effects were observed across modafinil-treated participants relative to control. Positive framing significantly reduced warned side effects for 24 h. Perceived side effect likelihood, severity, and worry mediated the nocebo, but not framing, effect. Results have important implications for the presentation of side effect information, providing a potential route to reduce unwanted negative effects of generic medication.

Mitigating the Nocebo Effect in Biosimilar Use and Switching: A Systematic Review

BACKGROUND

In the context of biosimilar use and switching, a patient's negative perception of a biosimilar might trigger a nocebo effect, where negative expectations unrelated to its pharmacologic action may lead to worsened symptoms, resulting in less perceived therapeutic benefit or worsened adverse events. Considering the crucial role biosimilars have in reducing health care costs and expanding access to safe biologics globally, it is essential to develop and implement effective strategies to mitigate the possible occurrence of such nocebo effects.

OBJECTIVE

The aim of this systematic literature review was two-fold: (i) to review strategies that have been applied and/or tested for minimising the nocebo effect in clinical practice, within and outside the context of biosimilar switching, and (ii) to propose recommendations on useful mitigation strategies to minimise the occurrence of the nocebo effect in the context of biosimilar switching.

METHODS

Biomedical databases PubMed and Embase were screened up until the end of April 2023 with a search string consisting of the following search terms "nocebo", "biosimilar", "mitigation", "strategy", and "prevention" and related synonyms. The search strategy was supplemented by snowballing of the included studies. The quality of the studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses, the Scale for the Assessment of Narrative Review Articles, and the Mixed Methods Appraisal Tool.

RESULTS

Of the 1617 identified and screened records, 60 met the inclusion criteria. Among these, 10 (17%) were conducted within the context of biosimilar switching, 7 of which specifically tested strategies to mitigate the nocebo effect. Among the remaining 50 studies conducted outside the biosimilar switching context, 46 tested mitigation strategies. Across the included studies, 13 distinct mitigation strategies were identified, which can be employed within the context of biosimilar switching: (i) open non-verbal communication, (ii) positive framing, (iii) empathic communication, (iv) validating communication, (v) shared decision making, (vi) self-affirmation, (vii) education of patients and health care professionals about the nocebo effect, (viii) education of patients and health care professionals about biosimilars, (ix) soft-skills training for health care professionals, (x) personalised information, (xi) supporting information, (xii) multidisciplinary approach, (xiii) organisation of the switch.

CONCLUSION

This review has identified a set of strategies that have been tested to mitigate the nocebo effect, which can be applied by health care professionals in the context of biosimilar switching with the aim of mitigating the occurrence of a nocebo effect. We recommend implementing a combination of mitigation strategies for patients and health care professionals to utilise before, during, and after a switch. It should be noted that given the limited number of studies specifically testing nocebo mitigation strategies within the biosimilar switching context to date, it is not yet possible to draw definite conclusions about the effect size of each mitigation strategy individually or in combination.

Practitioner warmth and empathy attenuates the nocebo effect and enhances the placebo effect

Augmented patient-practitioner interactions that enhance therapeutic alliance can increase the placebo effect to sham treatment. Little is known, however, about the effect of these interactions on maladaptive health outcomes (i.e., the nocebo effect). Healthy participants (N = 84) were randomised to a 3-day course of Oxytocin nasal drops (actually, sham treatment) in conjunction with a high-warmth interaction (Oxy-HW: N = 28), a low-warmth interaction (Oxy-LW: N = 28) or to a no treatment control group (NT: N = 28). All participants were informed that the Oxytocin treatment could increase psychological well-being but was associated with several potential side effects. Treatment-related side effects, unwarned symptoms, and psychological well-being were measured at baseline and all post-treatment days. Side effect reporting was increased in the Oxy-LW condition compared to the other groups across all days. Conversely, increased psychological well-being was observed in the Oxy-HW condition, relative to the other conditions, but only on Day 1. Among those receiving treatment, positive and negative expectations, and treatment-related worry, did not vary by interaction-style, while psychological well-being and side effect reporting were inversely associated at the level of the individual. Results have important implications for practice, suggesting poorer quality interactions may not only reduce beneficial health outcomes but also exacerbate those that are maladaptive.

Temporal Dynamics of Adverse Effects across Five Sessions of Transcranial Direct Current Stimulation

(1) Background: Transcranial direct current stimulation (tDCS) is a safe intervention, only producing mild and transient adverse effects (AEs). However, there is no detailed analysis of the pattern of adverse effects in an application transferable to the clinic. Therefore, our objective is to describe the AEs produced by tDCS and its temporal evolution. (2) Methods: A total of 33 young volunteers were randomized into a tDCS or sham group. Participants performed a hand dexterity task while receiving the tDCS or sham intervention (20 min and 1 mA), for five consecutive days. AEs were assessed daily after each intervention and classified as somatosensory, pain, or other effects. (3) Results: The number of AEs was generally increased by tDCS intervention. Specifically, tDCS led to more frequent somatosensory discomfort, characterized by sensations like itching and tingling, alongside painful sensations such as burning, compared to the sham intervention. Additionally, certain adverse events, including neck and arm pain, as well as dizziness and blurry vision, were exclusive to the tDCS group. Interestingly, tDCS produced similar AEs across the days; meanwhile, the somatosensory AEs in the sham group showed a trend to decrease. (4) Conclusions: tDCS produces mild and temporary somatosensory and pain AEs during and across sessions. The different evolution of the AEs between the tDCS and sham protocol could unmask the blinding protocol most used in tDCS studies. Potential solutions for improving blinding protocols for future studies are discussed.

The desire for side-effect information in pain treatment: an experimental analysis of contextual and individual difference factors

ABSTRACT

Informing patients about potential side effects of pain treatment is a requirement that protects patients and aids decision making, but it increases the likelihood of unwanted nocebo side effects. If patients do not desire all side-effect information, it may be possible to ethically reduce nocebo effects through authorized concealment of side effects, whereby patients and clinicians engage in shared decision-making to regulate the disclosure of side-effect information. Currently, there is no experimental data clarifying the factors that causally influence desire for side-effect information in pain treatment. In 2 cross-sectional, between-subjects scenario experiments (experiment 1 N = 498, experiment 2 N = 501), 18 to 79-year-old community adults learned about a lower back pain treatment, and potential side-effect severity, frequency, and duration were manipulated. Individual differences in information avoidance were also recorded. In both experiments, participants reported high desire for side-effect information, but the desire was reduced when side effects were described as less severe, less frequent, and participants scored high in information avoidance. Results were not moderated by participants' level of contact with the health care system, chronic health condition, or clinical pain history. Additional analyses indicated that low side-effect severity and frequency lessen desire for side-effect information because these variables reduce belief that side-effect information will be needed in the future and lower feelings of anticipated regret. The experiments identify situational and individual-difference factors that decrease the desire for side-effect information and provide evidence on when and for whom it may be useful for physicians to engage in shared medical decision-making with the goal of reducing nocebo side effects.

The relationship between expectancy, anxiety, and the nocebo effect: a systematic review and meta-analysis with recommendations for future research

Despite the theoretical prominence of expectancy and anxiety as potential mechanisms of the nocebo effect, not all studies measure expectancy and/or anxiety, and there are inconsistent findings among those that do. The present study sought to systematically review and meta-analyse available data to evaluate the relationship between expectancy, anxiety and the nocebo effect. The two key questions were: (1) whether nocebo manipulations influence expectancy and anxiety; and (2) whether expectancy and anxiety are associated with the subsequent nocebo effect. Fifty-nine independent studies (n = 3129) were identified via database searches to 1st August 2021. Nocebo manipulations reliably increased negative expectancy with a large effect (g = .837) and state anxiety with a small effect (g = .312). Changes in expectancy and state anxiety due to the nocebo manipulation were associated with larger nocebo effects (r = .376 and .234, respectively). However, there was no significant association between dispositional anxiety and the nocebo effect. These findings support theories that rely on situationally-induced expectancy and anxiety, but not dispositional anxiety, to explain nocebo effects. Importantly, being malleable, these findings suggest that interventions that target maladaptive negative expectancies and state anxiety could be beneficial for reducing the harm nocebo effects cause across health settings. Recommendations for future research are discussed.

Socially Acquired Nocebo Effects Generalize but Are Not Attenuated by Choice

BACKGROUND

Socially observing a negative treatment-related experience has been shown to modulate our own experience with the same intervention, leading to worsened health outcomes. However, whether this social learning generalizes to similar but distinct interventions has not been explored nor what manipulations can reduce these effects.

PURPOSE

To determine whether socially acquired nocebo effects can be generated by observing a negative experience with a similar, but distinct intervention, and whether choice can reduce these effects.

METHODS

Across three experiments, a community sample of healthy adults (N = 336) either watched a confederate report cybersickness to the same Virtual Reality (VR) activity they were assigned to (Social Modeling: Consistent); a similar, but different VR activity (Social Modeling: Inconsistent); or did not view the confederate (No Social Modeling). Participants were either given choice over the VR (Choice) or assigned by the experimenter (No Choice).

RESULTS

Across the experiments, there was significantly greater cybersickness in both Social Modeling groups relative to No Social Modeling, while the two Social Modeling groups did not differ. There was no significant effect of Choice or a Choice by Social Modeling interaction. Social Modeling elicited greater anxiety and expectancies for cybersickness. Furthermore, these mechanisms mediated the association between social modeling and cybersickness.

CONCLUSIONS

Socially acquired side-effects were demonstrated to generalize to similar, but distinct interventions, highlighting the diffuse and robust effect social modeling can have on our experiences. However, choice did not attenuate the experience of cybersickness, highlighting the need for alternative methods to counteract the effect of social modeling.

Nocebo response in dentistry: A systematic review and meta-analysis of adverse events in analgesic trials of third molar removal

BACKGROUND

The nocebo response refers to the phenomenon where non-specific factors, including negative verbal suggestion and treatment expectations, cause adverse events (AE) following a placebo treatment. Non-specific factors are also likely to influence AE occurrence following administration of active pharmacological treatments.

OBJECTIVE

This meta-analysis aimed to estimate the nocebo response in dentistry by assessing the AEs prevalence in placebo- and active arms of randomised controlled trials (RCTs) assessing analgesic treatment following third molar (M3) surgery.

METHODS

A systematic search was performed in PubMed, Embase, Scopus, Web of Science and the Cochrane Central Register of Controlled Trials. Eligible studies had to report the number of patients experiencing at least one drug-related AE (patients with AE ≥ 1) separately for the active and placebo arms. The proportion of patients with AE ≥ 1 and drug-related dropouts were pooled, and risk differences (RDs) between patients in the placebo- and active arm were calculated.

RESULTS

In 50 independent RCTs of 47 identified articles, the pooled rates of patients with AE ≥ 1 were 22.8% in the placebo arm and 20.6% in the active arm. The pooled rates of drug-related dropout were 0.24% in the placebo arm and 0.08% in the active arm. There were no significant RDs in patients with AE ≥ 1 and drug-related dropouts.

CONCLUSION

These results show that patients in the placebo arm reported AEs to the same extent as patients receiving active treatment, suggesting that most AEs in analgesic medication following M3 surgery may be attributed to the nocebo phenomenon.

Expectations and Prior Experiences Associated With Adverse Effects of COVID-19 Vaccination

Importance

Uptake of vaccination against COVID-19 is strongly affected by concerns about adverse effects. Research on nocebo effects suggests that these concerns can amplify symptom burden.

Objective

To investigate whether positive and negative expectations prior to COVID-19 vaccination are associated with systemic adverse effects.

Design, Setting, and Participants

This prospective cohort study analyzed the association of expected benefits and risks of vaccination, adverse effects at first vaccination, and observed adverse effects in close contacts with severity of systemic adverse effects among adults receiving a second dose of messenger RNA (mRNA)-based vaccines between August 16 and 28, 2021. A total of 7771 individuals receiving the second dose at a state vaccination center in Hamburg, Germany, were invited to participate; of these, 5370 did not respond, 535 provided incomplete information, and 188 were excluded retrospectively. The mobile application m-Path was used for data collection.

Main Outcomes and Measures

Primary outcome was a composite severity index of systemic adverse effects in 12 symptom areas measured once daily with an electronic symptom diary over 7 consecutive days. Data were analyzed by mixed-effects multivariable ordered logistic regression adjusted for prevaccine symptom levels and observation times.

Results

A total of 10 447 observations from 1678 individuals receiving vaccinations (BNT162b2 [Pfizer BioNTech] in 1297 [77.3%] and mRNA-1273 [Moderna] in 381 [22.7%]) were collected. The participants' median age was 34 (IQR, 27-44) years, and 862 (51.4%) were women. The risk for more severe adverse effects was higher for persons expecting a lower benefit of vaccination (odds ratio [OR] for higher expectations, 0.72 [95% CI, 0.63-0.83]; P < .001), expecting higher adverse effects of vaccination (OR, 1.39 [95% CI, 1.23-1.58]; P < .001), having experienced higher symptom burden at the first vaccination (OR, 1.60 [95% CI, 1.42-1.82]; P < .001), scoring higher on the Somatosensory Amplification Scale (OR, 1.21 [95% CI, 1.06-1.38]; P = .004), and if the vaccine mRNA-1273 was given rather than BNT162b2 (OR, 2.45 [95% CI, 2.01-2.99]; P < .001). No associations were seen for observed experiences.

Conclusions and Relevance

In this cohort study, several nocebo effects occurred in the first week after COVID-19 vaccination. The severity of systemic adverse effects was associated not only with vaccine-specific reactogenicity but also more negative prior experiences with adverse effects from the first COVID-19 vaccination, more negative expectations regarding vaccination, and tendency to catastrophize instead of normalize benign bodily sensations. Clinician-patient interactions and public vaccine campaigns may both benefit from these insights by optimizing and contextualizing information provided about COVID-19 vaccines.

Really just a little prick? A meta-analysis on adverse events in placebo control groups of seasonal influenza vaccination RCTs

BACKGROUND

The Corona pandemic and ongoing mass vaccinations raise the question of the nocebo mechanisms involved. Since immunization is usually administered to healthy people as a preventive health measure, adverse events (AE) following immunization are less accepted and could contribute to vaccine hesitancy. Assuming that vaccinees experience nocebo responses, the aim of this meta-analysis was to investigate the effect sizes of solicited adverse events (or assumed reactogenicity) reported in placebo groups in RCTs on seasonal influenza vaccination.

METHODS

Literature search via PubMed, Web of Science, and CENTRAL was conducted considering gray literature. Only RCTs with placebo groups using pharmacologically inert substances (like saline) were included. Quality was assessed using Cochrane Collaboration's Risk of Bias Tool. Effect sizes were estimated using a random mixed effects model based on k = 31 studies covering 14,326 participants in placebo groups.

RESULTS

Reported solicited AEs in placebo groups showed significant effect sizes of proportions (ES_p). In k = 13 analyzed placebo groups, 35 % of the participants reported at least one solicited systemic AE (p = 0.007). The most common particular solicited systemic AEs were headache (k = 27; 17 %; p = 0.001), malaise (k = 13; 12 %; p = 0.004), and hyperhidrosis (k = 4; 12 %; p < 0.001) within one week after vaccination.

CONCLUSION

The results show significant solicited AEs in placebo groups, indicating substantial nocebo responses after vaccination. Based on the fact that most vaccination programs include similar groups of healthy people, we expect that comparable nocebo effects occur during other campaigns. Health care professionals should be aware of the nocebo response and take action to prevent or decrease the burden of adverse events following immunization. Fear of side effects must be addressed early in order to diminish vaccine hesitancy. Prospero identifier: CRD42020156287, October 2019.

What Is the Benefit of Adding Placebo Side-Effect Information to Positively Framed Patient Leaflets?

Abstract. Background: Positively framing side-effect risk in patient information leaflets (PILs) can reduce side-effect expectations and resulting nocebo effects (nonspecific medication side effects unrelated to the drug’s pharmacological action). There is scope to educate patients about nocebo effects in PILs to minimize their occurrence further. Aims: To investigate if incorporating information on placebo-reported side effects reduces side-effect expectations compared to a positively framed-only or standard PIL. Methods: Participants ( N = 443) completed an online study and were randomized to read one of three PILs for a hypothetical antibiotic: standard PIL ( n = 140), positively framed PIL ( n = 151), or positively framed PIL with placebo side-effect information ( n = 152). Participants’ side-effect expectations, absolute risk perceptions, and intended adherence were recorded. Results: The standard PIL resulted in significantly higher side-effect expectations compared to the positively framed + placebo side-effect information PIL. Including the placebo side-effect results had no effect on side-effect expectations compared to the positive framing only PIL, however, there was a significant interaction between health literacy and PIL condition on side-effect expectations. Both positively framed PILs produced more accurate risk estimates for the more common side effects. There was no difference in intended adherence between the three PILs. Limitations: Our findings are limited by the highly educated sample and hypothetical context. Conclusions: There was no benefit of adding placebo side-effect information, however alternative ways of explaining nocebo effects in PILs should be explored utilizing clinical contexts and samples with a wider range of participant ages, and health literacy.

Social communication pathways to COVID-19 vaccine side-effect expectations and experience

OBJECTIVE

Negative beliefs about medication and vaccine side-effects can spread rapidly through social communication. This has been recently documented with the potential side-effects from the COVID-19 vaccines. We tested if pre-vaccination social communications about side-effects from personal acquaintances, news reports, and social media predict post-vaccination side-effect experiences. Further, as previous research suggests that side-effects can be exacerbated by negative expectations, we assessed if personal expectations mediate the relationships between social communication and side-effect experience.

METHOD

In a prospective longitudinal survey (N = 551), COVID-19 vaccine side-effect information from three sources-social media posts, news reports, and first-hand accounts from personal acquaintances-as well as side-effect expectations, were self-reported pre-vaccination. Vaccination side-effect experience was assessed post-vaccination.

RESULTS

In multivariate regression analyses, the number of pre-vaccination social media post views (β = 0.17) and impressions of severity conveyed from personal acquaintances (β = 0.42) significantly predicted an increase in pre-vaccination side-effect expectations, and the same variables (βs = 0.11, 0.14, respectively) predicted post-vaccination side-effect experiences. Moreover, pre-vaccination side-effect expectations mediated the relationship between both sources of social communication and experienced side-effects from a COVID-19 vaccination.

CONCLUSIONS

This study identifies links between personal acquaintance and social media communications and vaccine side-effect experiences and provides evidence that pre-vaccination expectations account for these relationships. The results suggest that modifying side-effect expectations through these channels may change the side-effects following a COVID-19 vaccination as well as other publicly discussed vaccinations and medications.

[Consensus statement of the migraine and headache societies (DMKG, ÖKSG, and SKG) on the duration of pharmacological migraine prophylaxis]

Migraine is the most common neurological disorder and can be associated with a high degree of disability. In addition to non-pharmacological approaches to reduce migraine frequency, pharmacological migraine preventatives are available. Evidence-based guidelines from the German Migraine and Headache Society (DMKG), and German Society for Neurology (DGN), Austrian Headache Society (ÖKSG), and Swiss Headache Society (SKG) are available for indication and application. For therapy-relevant questions such as the duration of a pharmacological migraine prevention, no conclusions can be drawn from currently available study data. The aim of this review is to present a therapy consensus statement that integrates the current data situation and, where data are lacking, expert opinions. The resulting current recommendations on the duration of therapy for pharmacological migraine prophylaxis are shown here.

Placebo and nocebo effects: from observation to harnessing and clinical application

Placebo and nocebo effects are salubrious benefits and negative outcomes attributable to non-specific symbolic components. Leveraging advanced experimental and analytical approaches, recent studies have elucidated complicated neural mechanisms that may serve as a solid basis for harnessing the powerful self-healing and self-harming capacities and applying these findings to improve medical practice and minimize the unintended exacerbation of symptoms in medical practice. We review advances in employing psychosocial, pharmacological, and neuromodulation approaches to modulate/harness placebo and nocebo effects. While these approaches show promising potential, translating these research findings into clinical settings still requires careful methodological, technical, and ethical considerations.

[Consensus statement of the migraine and headache societies (DMKG, ÖKSG, and SKG) on the duration of pharmacological migraine prophylaxis]

Migraine is the most common neurological disorder and can be associated with a high degree of disability. In addition to non-pharmacological approaches to reduce migraine frequency, pharmacological migraine preventatives are available. Evidence-based guidelines from the German Migraine and Headache Society (DMKG), and German Society for Neurology (DGN), Austrian Headache Society (ÖKSG), and Swiss Headache Society (SKG) are available for indication and application. For therapy-relevant questions such as the duration of a pharmacological migraine prevention, no conclusions can be drawn from currently available study data. The aim of this review is to present a therapy consensus statement that integrates the current data situation and, where data are lacking, expert opinions. The resulting current recommendations on the duration of therapy for pharmacological migraine prophylaxis are shown here.

Impact of Vaccine Hesitancy on Onset, Severity and Type of Self-reported Adverse Events: A French Cross-Sectional Survey

INTRODUCTION

Little is known about the impact of mandatory vaccination on people who are reluctant to be vaccinated, despite the potential importance in terms of public health policy.

OBJECTIVE

We aimed to explore the relationship between vaccine hesitancy and onset, severity and characteristics of self-reported adverse events.

METHODS

We used a cross-sectional online survey conducted in 2021 among a representative sample of the French population aged 18 years and older (n = 1593). All reported adverse events were analyzed and categorized by trained experts in drug safety and pharmacovigilance. Multivariate binomial regressions on the onset of self-reported adverse events, vaccine hesitancy categories and predefined responders' characteristics were performed.

RESULTS

Overall, 590 (37.0%) participants reported at least one adverse event, with 121 (20.5%) considered it to be severe. Proportions of reported adverse events, ranging from 18% (in non-reluctant responders) to 65% (in very reluctant responders), and their severity, ranging from 5% (non-reluctant responders) to 41% (very reluctant responders), depended highly on attitudes toward vaccination. The adverse events profile remained similar between groups. In the multivariate regression model, beyond attitude toward vaccination, younger age and female gender were significantly associated with higher reporting of vaccine adverse events.

CONCLUSIONS

Our results suggest that vaccine hesitancy could be a major driver of patient-reported vaccine-related adverse events and their perceived severity. In this context, vaccinators must pay special attention to reluctant patients and inform them on the possible nocebo nature of these adverse events so as to prevent them.

Possible alleviation of symptoms and side effects through clinicians' nocebo information and empathy in an experimental video vignette study

To alleviate anti-cancer treatment burden in advanced breast cancer, patient-clinician communication strategies based on nocebo-effect mechanisms are promising. We assessed distinct/combined effects on psychological outcomes (e.g. anxiety; main outcome) and side-effect expectations of (1) nocebo information about the (non)pharmacological origin of side effects, and (2) clinician-expressed empathy through reassurance of continuing support. Furthermore, we explored whether information and empathy effects on side-effect expectations were mediated by decreased anxiety. In a two-by-two experimental video-vignette design, 160 cancer patients/survivors and healthy women watched one of four videos differing in level of nocebo information (±) and empathy (±). Regression and mediation analysis were used to determine effects of information/empathy and explore anxiety's mediating role. Anxiety was not influenced by empathy or information (Stai-state: p = 0.295; p = 0.390, VAS p = 0.399; p = 0.823). Information improved (specific) side-effect coping expectations (p < 0.01). Empathy improved side-effect intensity expectations (p < 0.01 = specific; p < 0.05 = non-specific/partial) and specific side-effect probability expectations (p < 0.01), and increased satisfaction, trust, and self-efficacy (p < 0.001). No mediating effects were found of anxiety on expectations. Mainly empathy, but also nocebo information improved psychological outcomes and-mainly specific-side-effect expectations. Exploring the power of these communication elements in clinical practice is essential to diminish the anti-cancer treatment burden in advanced breast cancer.

Factors Moderating the Link between Personal Recounts of COVID-19 Vaccine Side Effects Viewed on Social Media and Viewer Postvaccination Experience

While social media exposure is known to influence vaccine hesitancy, its impact on postvaccination experience remains relatively unknown. This retrospective cross-sectional study explored whether various psychosocial and individual factors moderate the association between social media exposure to personal recounts of COVID-19 vaccine side effects and the viewer’s subsequent postvaccination side effect experience. Adults residing in Australia, who were fully vaccinated with two COVID-19 vaccine doses (n = 280) completed an online survey. The more severe the personal recounts of post-COVID-19 vaccination side effects participants were exposed to on social media, the more severe their own postvaccination side effects were following both their first (β = 0.261, p < 0.001) and second dose (β = 0.299, p < 0.001). This association was stronger among those with greater vaccine side effect worry, elevated negative emotional states such as anxiety and stress, and a stronger proclivity for using social media over mainstream media for COVID-19 vaccine side effect information. As such, not only does social influence appear to exacerbate or trigger postvaccination side effects, but a range of psychosocial and situational factors moderate this association. Health organisations and government bodies could minimise the negative effects of social media exposure in future health outbreaks by countering treatment misperceptions on social media platforms as they arise.

Avoidance of nocebo effects by coincident naming of treatment benefits during the medical interview for informed consent—Evidence from dynamometry

Introduction

In the context of giving risk information for obtaining informed consent, it is not easy to comply with the ethical principle of “primum nihil nocere.” Carelessness, ignorance of nocebo effects and a misunderstood striving for legal certainty can lead doctors to comprehensive and brutal risk information. It is known that talking about risks and side effects can even trigger those and result in distress and nonadherence to medication or therapy.

Methods

Recently, we have reported on significant clinically relevant effects of verbal and non-verbal suggestions on maximal muscular arm strength in healthy volunteers and in patients at two time points before surgery. Maximal strength during arm abduction was measured by dynamometry of the deltoid muscle group. Suggestions from clinical everyday life were formulated as presumed negative and neutral versions.

Results

Here, we report on the effects of two versions of risk information in 45 patients. After sole mentioning risks of a puncture for the placement of a pain catheter, the maximal arm muscle strength was significantly reduced to 83% of baseline several days (T1), and to 84% the evening before surgery (T2). Strength was not significantly decreased and close to baseline at T1 and T2 when risks and benefits of a pain catheter were combined in one sentence. The difference between both versions was significant. With persistent normal distribution of values, the effect was due to uniform reactions of many patients, not to strong reactions of a few. High suggestibility and increase of anxiety with approaching surgery were identified as influencing factors for the neutralizing effect of modified wording.

Conclusion

We not only suggest an alternative formulation for risk information to avoid nocebo effects but present an objective method to quantify and compare effects of different wordings. Thereby, we provide evidence that concurrently given positive aspects can neutralize negative effects during medical interview.

Erwartungseffekte beim Absetzen von Antidepressiva

Erwartungseffekte bei Antidepressiva wurden in zahlreichen randomisierten Studien und Metaanalysen nachgewiesen. In den Placebogruppen zeigten sich sowohl relevante Verbesserungen der depressiven Erkrankungen (Ansprechraten: Placebo 40 % vs. Verum 50 %) als auch belastende Nebenwirkungen im Sinne von Noceboeffekten. Diese Befunde unterstreichen den Einfluss individueller Erwartungshaltungen auf die Wirksamkeit und Verträglichkeit von Antidepressiva und legen nahe, dass diese auch beim Absetzen relevant sind. Das Absetzen von Antidepressiva kann mit belastenden Beschwerden wie Schwindel, Schlaflosigkeit und Reizbarkeit verbunden sein. Diese sog. Absetzsymptome sind in der Mehrzahl der Fälle mild und klingen nach wenigen Tagen bis Wochen wieder ab. Sind Patient:innen allerdings nicht auf solche möglichen Beschwerden vorbereitet, kann deren Auftreten Ängste vor einem Rückfall oder einer Abhängigkeit auslösen. Insbesondere, wenn das Absetzen ohne ärztliche und psychologische Begleitung stattfindet, können Absetzsymptome leicht mit dem Wiederauftreten einer Depression verwechselt werden. In der aktuellen Versorgungspraxis finden sich zunehmend Berichte zu missglückten Absetzversuchen und entsprechend negativen Erwartungen an das Absetzen. Erwartungen lassen sich vornehmlich in der Interaktion mit Behandelnden und über die Patient:innen-Information verändern. Dieser Beitrag diskutiert therapeutische Strategien zum Umgang mit Absetzsymptomen mit dem Ziel, Erwartungen, angepasst an individuelle Vorerfahrungen, zu optimieren. Um realistische Erwartungen zu erarbeiten und den Absetzprozess durch eine therapeutische Begleitung positiv zu beeinflussen, können Strategien wie Psychoedukation, Framing, die Aufklärung über Placebo- und Noceboeffekte sowie die Erarbeitung von Coping-Strategien eingesetzt werden.

What is the nocebo effect and does it apply to dentistry? A narrative review

Background

Evidence for the nocebo effect, a phenomenon characterised by suboptimal treatment efficacy, worsening of symptoms, or the occurrence of adverse events caused by an individual’s negative treatment expectations, is growing across a multitude of medical fields. However, little attention has been paid to patients’ negative expectations and the nocebo effect within dentistry.

Aim

This review summarises essential evidence of the nocebo phenomenon especially in relation to pain and drug administration. Subsequently, an overview of the current evidence of the nocebo phenomenon in the dental field is presented.

Methods

A PubMed search was performed using keywords related to “nocebo,” “placebo,” “expectations,” and “dentistry.” In addition to the articles selected from the search, placebo/nocebo researchers and dental researchers added important references from their respective fields.

Results

Although research on the nocebo effect in dentistry is limited, available current evidence suggests that the factors, which is related to the nocebo effect are likely to play a role in dental practice.

Conclusion

Preliminary evidence from the review warrants further investigation into the nocebo effect in dentistry. Finally, based on the general knowledge of the nocebo effect, the review indicates fruitful arrays of research into the nocebo effect in dentistry.

Frequency of Adverse Events in the Placebo Arms of COVID-19 Vaccine Trials: A Systematic Review and Meta-analysis

Importance

Adverse events (AEs) after placebo treatment are common in randomized clinical drug trials. Systematic evidence regarding these nocebo responses in vaccine trials is important for COVID-19 vaccination worldwide especially because concern about AEs is reported to be a reason for vaccination hesitancy.

Objective

To compare the frequencies of AEs reported in the placebo groups of COVID-19 vaccine trials with those reported in the vaccine groups.

Data Sources

For this systematic review and meta-analysis, the Medline (PubMed) and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched systematically using medical subheading terms and free-text keywords for trials of COVID-19 vaccines published up to July 14, 2021.

Study Selection

Randomized clinical trials of COVID-19 vaccines that investigated adults aged 16 years or older were selected if they assessed solicited AEs within 7 days of injection, included an inert placebo arm, and provided AE reports for both the vaccine and placebo groups separately. Full texts were reviewed for eligibility by 2 independent reviewers.

Data Extraction and Synthesis

Data extraction and quality assessment were performed independently by 2 reviewers, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline and using the Cochrane risk-of-bias tool. Meta-analyses were based on random-effects models.

Main Outcomes and Measures

The primary outcomes were the proportions of placebo recipients reporting overall, systemic, and local (injection-site) AEs as well as logarithmic odds ratios (ORs) to evaluate group differences. Outcomes were tested for significance using z tests with 95% CIs.

Results

Twelve articles with AE reports for 45 380 participants (22 578 placebo recipients and 22 802 vaccine recipients) were analyzed. After the first dose, 35.2% (95% CI, 26.7%-43.7%) of placebo recipients experienced systemic AEs, with headache (19.3%; 95% CI, 13.6%-25.1%) and fatigue (16.7%; 95% CI, 9.8%-23.6%) being most common. After the second dose, 31.8% (95% CI, 28.7%-35.0%) of placebo recipients reported systemic AEs. The ratio between placebo and vaccine arms showed that nocebo responses accounted for 76.0% of systemic AEs after the first COVID-19 vaccine dose and for 51.8% after the second dose. Significantly more vaccine recipients reported AEs, but the group difference for systemic AEs was small after the first dose (OR, -0.47; 95% CI, -0.54 to -0.40; P < .001; standardized mean difference, -0.26; 95% CI, -0.30 to -0.22) and large after the second dose (OR, -1.36; 95% CI, -1.86 to -0.86; P < .001; standardized mean difference, -0.75; 95% CI, -1.03 to -0.47).

Conclusions and Relevance

In this systematic review and meta-analysis, significantly more AEs were reported in vaccine groups compared with placebo groups, but the rates of reported AEs in the placebo arms were still substantial. Public vaccination programs should consider these high rates of AEs in placebo arms.

European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB): An Update on the Pediatric CEUS Registry on Behalf of the "EFSUMB Pediatric CEUS Registry Working Group"

The European Federation of Ultrasound in Medicine and Biology (EFSUMB) created the "EFSUMB Pediatric Registry" (EFSUMB EPR) with the purpose of collecting data regarding the intravenous application of pediatric contrast-enhanced ultrasound (CEUS). The primary aim was to document the current clinical practice and usefulness of the technique and secondarily to assess CEUS safety in children. We issue the preliminary results of this database and examine the overall practice of CEUS in children in Europe.

Informing About the Nocebo Effect Affects Patients' Need for Information About Antidepressants-An Experimental Online Study

Relevance: Understanding patients' informational needs and adapting drug-related information are the prerequisites for a contextualized informed consent. Current information practices might rather harm by inducing nocebo effects. Objective: To investigate whether informing about the nocebo effect using a short information sheet affects patients' need for information about antidepressants. Methods: A total of 97 patients taking recently prescribed antidepressants (≤4 months intake) were recruited over the internet and randomized to receiving either a one-page written information about the nocebo effect or a control text about the history of antidepressants. After experimental manipulation, informational needs about the side effects and mechanisms of antidepressants were assessed with 3 and 7 items on categorical and 5-point Likert scales. Group differences in informational needs were calculated with Chi-square tests and ANOVAs. Results: Patients received antidepressants for depression (84.5%) and/or anxiety disorders (42.3%). Three participants (6.0%) of the nocebo group reported previous knowledge of the nocebo effect. After the experimental manipulation, participants in the nocebo group reported a reduced desire for receiving full side effect information [X ( 4 , 97 ) 2 = 12.714, Cramer's V = 0.362, p = 0.013] and agreed more frequently to the usefulness of withholding information about possible side effects [X ( 4 , 97 ) 2 = 14.878, Cramer's V = 0.392, p = 0.005]. Furthermore, they desired more information about the mechanisms of antidepressants (F = 6.373, p = 0.013, partial η2 = 0.063) and, specifically, non-pharmacological mechanisms, such as the role of positive expectations (F = 16.857, p < 0.001, partial η2 = 0.151). Conclusions: Learning about the nocebo effect can alter patients' informational needs toward desiring less information about the potential side effects of antidepressants and more information about general mechanisms, such as expectations. The beneficial effects of including nocebo information into contextualized informed consent should be studied clinically concerning more functional information-seeking behavior, which may ultimately lead to improved treatment outcomes, such as better adherence and reduced side effect burden.