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The Placebo Effect in Clinical Practice One-Click Ebook Download

The document discusses the placebo effect in clinical practice, emphasizing its significant role in patient recovery and treatment outcomes. It highlights that many widely used medical treatments lack proven effectiveness and often derive their benefits from the placebo effect rather than intrinsic therapeutic value. The author argues that both patients and clinicians frequently misattribute healing to treatments that are essentially inert, underscoring the importance of understanding the placebo phenomenon in medicine.

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311 views14 pages

The Placebo Effect in Clinical Practice One-Click Ebook Download

The document discusses the placebo effect in clinical practice, emphasizing its significant role in patient recovery and treatment outcomes. It highlights that many widely used medical treatments lack proven effectiveness and often derive their benefits from the placebo effect rather than intrinsic therapeutic value. The author argues that both patients and clinicians frequently misattribute healing to treatments that are essentially inert, underscoring the importance of understanding the placebo phenomenon in medicine.

Uploaded by

huyenquoang.phongngiet
Copyright
© © All Rights Reserved
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The Placebo Effect in Clinical Practice

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✦

THE PLACEBO EFFECT


IN CLINICAL PRACTICE

WA LT E R A . B R OW N , M D

Clinical Professor of Psychiatry


The Warren Alpert Medical School of
Brown University
Providence, RI
and
Clinical Professor of Psychiatry
Tufts University School of Medicine
Boston, MA

1
3
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and education by publishing worldwide.

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countries.

Published in the United States of America by


Oxford University Press
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© Walter A Brown, MD 2013

All rights reserved. No part of this publication may be reproduced, stored


in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise,
without the prior permission of Oxford University Press.

Library of Congress Cataloging-in-Publication Data


Brown, Walter Armin.
The placebo effect in clinical practice / Walter A. Brown.
p.; cm.
Includes bibliographical references.
ISBN: 978–0–19–993385–3 (hardcover: alk. paper)
I. Title.
[DNLM: 1. Placebos—therapeutic use. 2. Placebo Effect. WB 330]
LC classification not assigned
615.5—dc23
2012020306

The science of medicine is a rapidly changing field. As new research and clinical experience
broaden our knowledge, changes in treatment and drug therapy occur. The author and pub-
lisher of this work have checked with sources believed to be reliable in their efforts to provide
information that is accurate and complete, and in accordance with the standards accepted
at the time of publication. However, in light of the possibility of human error or changes in
the practice of medicine, neither the author, nor the publisher, nor any other party who has
been involved in the preparation or publication of this work warrants that the information
contained herein is in every respect accurate or complete. Readers are encouraged to confirm
the information contained herein with other reliable sources, and are strongly advised to check
the product information sheet provided by the pharmaceutical company for each drug they
plan to administer.

9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper
CONTENTS

Acknowledgments vii

1. Introduction 01
2. Variations in Placebo Response 23
3. How Does Placebo Differ from No Treatment? 45
4. The Treatment Situation 56
5. Expectation 65
6. Conditioning and the Placebo Response 82
7. Psychotherapy and Placebo 97
8. The Ethics of Placebo Use in Research
with Michaella Jamiel 112
9. Using the Placebo Response 127

References 157
Index 167
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ACKNOWLEDGMENTS

I thank Michaella Jamiel for her help in tracking down the


studies described in this book and in preparing the manu-
script. Over the past several decades I have discussed many
of the ideas in this book with Arif Khan, a fine friend and
long time research collaborator. He sparked much of the
research depicted here on the placebo response in depres-
sion. Richard Stamelman, unwavering in his friendship and
support for 5 decades, went the extra mile and translated
the Aulas and Rosner paper from French to English during
a vacation weekend. Norman Moss alerted me to the work
of the Franklin Commission and regularly supplied me with
tidbits about the placebo response. Edward Shorter provided
much appreciated guidance. The editorial staff at Oxford
University Press were invariably competent, helpful and con-
siderate. Gordon Brown, Matthew Brown and Susan Brown
were steadfast in their encouragement. Christine Ryan kept
me on task by deftly wielding a combination of carrots and
sticks. I sought her counsel at every turn and she always came
through.
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THE PLACEBO EFFECT

IN CLINICAL PRACTICE
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1
✦
INTRODUCTION

THIS FEBRUARY A BOUT OF the flu left me with a cough that


wouldn’t go away. I was miserable. Talking was difficult—I
would start hacking midsentence—and the cough woke me
up throughout the night, ruining my sleep. Lozenges didn’t
help. As the cough persisted into March, uncertainty as to
how long it would last added to my discomfort.
Finally, discouraged and a little worried, I called my
internist. As soon as I picked up the phone I began to feel
better. He was, as usual, thorough, upbeat, and authoritative.
After asking about my symptoms, he told me that a persis-
tent cough was common following the recent flu strain and
that in most cases it gradually cleared within 6 weeks. He
prescribed a cough suppressant, told me I should feel much
better within a week, and added that if I didn’t, I should call
him back.
When I hung up the phone, my cough hadn’t improved
but I had. Relief was a possibility; for the first time in a month
I was in charge of my condition, not the other way around.
For the rest of the day the cough seemed less troublesome,
even though I probably hacked as often as I had for the previ-
ous few weeks. Certainly I brooded about it less. That night I
slept better than I had in a month. Within 3 days the cough
was barely noticeable, and in a week it was gone.
2 | T H E P L AC E B O E F F E C T I N C L I N IC A L P R AC T IC E

I don’t know if the suppressant helped heal my cough


or if it would have gone away on its own. I do know that the
act of seeking and receiving medical care—in other words,
the treatment situation—made me feel better: less distressed,
less disabled, more hopeful. The benefit I got from the treat-
ment situation is called, often derisively, the placebo effect. A
powerful part of healing, it contributes to the success of all
treatments; often, it is the only benefit.

C H E R I S H E D T R E AT M E N T S

The history of medical treatment is largely a chronicle of pla-


cebos. When subjected to scientific scrutiny, the overwhelm-
ing majority of treatments have turned out to be devoid of
intrinsic therapeutic effectiveness; they derived their benefits
from the placebo effect. It is easy for us to accept that the
treatments of antiquity—potions, brews, and incantations—
did not provide the benefits ascribed to them. After all, truly
effective treatments were in short supply; the healers of
the past cannot be faulted for offering something they and
their patients believed might be helpful. But it is less widely
acknowledged that more than a bit of today’s medicine—the
treatments offered in technologically sophisticated hospitals
and doctors’ offices—continues to be an amalgam of faith,
magic, and ritual. Yes, medical treatment is now more scien-
tific. New treatments often undergo rigorous testing to prove
their effectiveness. And both the healing professions and
managed care providers are demanding that treatment be
based on evidence. Even so, some experts estimate that less
than 50% of the treatments routinely used by physicians have
actually been proven effective in careful studies. Doctors and
1 . I N T R O DU C T IO N | 3

their patients continue to ascribe healing powers to pills,


psychotherapies, and surgical procedures that may be essen-
tially inert.
Part of the reason for the pervasive tendency on the part
of both doctors and patients to believe that treatments in
common use are of value when in fact they have no real ther-
apeutic effectiveness is that these treatments almost always
come with convincing therapeutic rationales. Internal mam-
mary artery ligation was widely used to treat angina pectoris
in the mid-1950s. The procedure was thought to increase cor-
onary flow through collateral vessels proximal to the ligation
(Benson and McCallie, 1979). Scores of patients underwent
this procedure and most, according to the reports of enthusi-
astic surgeons, showed both symptomatic improvement and
improvement on electrocardiography. Nonetheless, many
cardiologists were skeptical of both the proposed physi-
ologic basis for the procedure and the high rates of reported
improvement. In the late 1950s two double-blind trials were
conducted in which a sham procedure (skin incision only)
was compared to internal mammary artery ligation. In both
studies the majority of patients who received both the real
and sham (placebo) surgery reported symptomatic improve-
ment. There was no difference in outcome between the
two procedures. Following these studies, the treatment was
abandoned.
Medical history abounds in widely used treatments that
had compelling rationales and strong advocates—psychoanal-
ysis for schizophrenia, radical mastectomy for breast cancer,
prophylactic tonsillectomy, and the ulcer diet, to name just
a few—but which, following years of clinical experience and
the scrutiny of controlled trials, turned out to offer no real
benefit. The story continues. Vertebroplasty, the injection of
4 | T H E P L AC E B O E F F E C T I N C L I N IC A L P R AC T IC E

a cement directly into a vertebral fracture, was proposed as


a treatment for vertebral fractures in the late 1980s. It was
thought to stabilize the fractured vertebra and thus reduce
pain and disability. And indeed, some patients who under-
went the procedure did report less pain and better function.
By 2009, this procedure had become an important, widely
used treatment option for patients with vertebral fractures,
but no controlled trials had been conducted. When two con-
trolled trials were finally undertaken in which vertebroplasty
was compared to a sham (placebo) procedure (no cement
injected), it turned out that the sham and real procedures
produced equivalent benefit (Buchbinder, Osborne, Ebeling,
et al., 2009; Kallmes, Comstock, Heagerty, et al., 2009).
The doctors who advocate for and administer procedures
that have no proven value have all sorts of reasons for doing
so. For the most part they are convinced by the therapeutic
rationale and want to help their patients. Financial incentives
are also at play and can bias the assessment of a treatment’s
effectiveness. But, arguably, the most significant factor con-
tributing to an inert treatment’s endurance is that—whether
the treatment involves bleeding or vertebroplasty—some
patients given the treatment get better. Clinicians tend to
remember their successes and attribute them to the treat-
ment. And both clinicians and medical researchers are
subject to a natural tendency that distorts the accuracy of
all perceptions. We see what we expect to see and what we
wish for. As Yogi Berra supposedly said: “If I didn’t believe it
I wouldn’t have seen it.”
So it isn’t that these unproven treatments don’t work;
most do. Patients benefit from them. The catch is, the treat-
ment itself is of no particular value. The healing comes from
the placebo effect.

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