Respectful Insolence

Let’s face it. The vast majority of “complementary and alternative medicine” (CAM) or “integrative medicine” (IM) therapies are nothing more than placebo medicine. This should be so abundantly clear to readers who have followed this blog, Science-Based Medicine, and/or Neurologica Blog more than a few weeks that I shouldn’t have to repeat it yet again, but I feel that it bears repeating today as an introduction to today’s subject matter. CAM/IM is almost all placebo medicine, and placebos effects are poorly understood (or even misunderstood), even among physicians. It is this misunderstanding that has provided the opening for CAM apologists, faced with the failure of their favorite woo to demonstrate efficacy over and above that of placebo time and time again in well-designed randomized clinical trials, to “rebrand” their methods as “harnessing the power of the placebo.” In doing so, they like to ascribe magical powers to placebos, implying that it can do more than just decrease the perception of pain or other subjective symptoms but in fact can lead to objective improvements in a whole host of diseases and conditions. Some even go so far as to claim that there can be placebo effects without deception, citing a paper in which the investigators–you guessed it!–used deception to convince their patients that their placebos would relieve their symptoms.

I was reminded of just how badly placebos are misunderstood by a recent article in the Wall Street Journal by Shirley S. Wang entitled Why Placebos Work Wonders: From Weight Loss To Fertility, New Legitimacy For ‘Fake’ Treatments. If you want a primer on how not to write about placebos as a journalist, I’d be hard pressed to find a better example for you to study than this article. Wang falls for all the CAM/IM tropes that they like to use to demonstrate that their methods are anything more than ineffective methods that can provoke a placebo response. In fact, jumping ahead in her article a bit, I know she has no understanding of the issues involved–or even an active misunderstanding–when she writes a passage like this:

Ted Kaptchuk, director of Harvard’s Program in Placebo Studies and the Therapeutic Encounter, and colleagues demonstrated that deception isn’t necessary for the placebo effect to work. Eighty patients with irritable bowel syndrome, a chronic gastrointestinal disorder, were assigned either a placebo or no treatment. Patients in the placebo group got pills described to them as being made with an inert substance and showing in studies to improve symptoms via “mind-body self-healing processes.” Participants were told they didn’t have to believe in the placebo effect but should take the pills anyway, Dr. Kaptchuk says. After three weeks, placebo-group patients reported feelings of relief, significant reduction in some symptoms and some improvement in quality of life.

Wang so completely fell for the spin that Kaptchuk put on this study and so obviously doesn’t understand what she’s writing about that it makes me instantly question the rest of her article, particularly the parts where she cites studies. As an aside, let me just complain, as well, about how Wang and the WSJ do not post links to the actual studies mentioned in the article. I can understand why studies aren’t listed by name in dead tree editions of newspapers and magazines designed for a lay audience, but there is no excuse whatsoever anymore for journalists, newspapers, and magazines not to include PubMed links to the actual studies in online versions of articles on medical and scientific topics that mention scientific studies. This would allow readers to look at at least the abstracts and make it possible bloggers like me, who have access to university accounts, to look up the actual articles themselves if we’re so inclined without having to do PubMed searches ourselves and guess which articles are being referred to. In fact, in this very article in a couple of cases I had a hard time figuring out exactly which articles Wang was referencing.

Fortunately, in this case, I had already blogged about the actual primary article in depth and explained exactly why Kaptchuk’s spin that the study indicated that it was possible to induce placebo responses without deception. The long version is in this link. The short version is the observation that subjects were recruited for this study by ads touting a “novel mind-body management study of IBS [irritable bowel syndrome], which introduced selection bias for people prone to be interested in “mind-body” interactions. Moreover, while it is true that Kaptchuk and his team told subjects that they would be receiving placebos, but they also told subjects that the sugar pills used “have been shown in rigorous clinical testing to produce significant mind-body self-healing processes,” which is, to put it kindly, an exaggeration. Add to all this the way outcomes were measured were custom-designed to exaggerate. The no-treatment arm demonstrated an IBS Global Improvement Score of 4 (no change) compared to the Open Placebo arm, which averaged 5 (slightly improved). This is highly unlikely to be clinically significant. Despite all these problems, this study was widely touted as somehow being slam-dunk evidence that placebo effects can be invoked without deception when it is anything but. The best possible spin that could be put on this study is that it is consistent with previous work that expectation effects are important in placebo effects. In other words, if you expect an effect, even if you know you’re taking a placebo, you’re more likely to feel better.

Of course, I shouldn’t be too hard on Wang, I suppose, at least not for this. After all, it apparently fooled Edzard Ernst himself into calling it “elegant.” I’ll also mention that she also discusses (and gets mostly right) another study that I’ve blogged about just last summer. In fact, it was a study that was prominently featured in the discussion panel that I participated in at TAM last summer, along with Steve Novella, Kimball Atwood, Mark Crislip, Harriet Hall, Rachael Dunlop, and Ginger Campbell. Steve even mischievously switched back and forth between two of the graphs in the paper to make a point. Yes, I’m referring to the “placebo in asthma” study, or, as I called it, dangerous placebo medicine for asthma. Wang correctly points out that only the active treatment (albuterol) improved the underlying biology but that both groups felt better. This is more or less the very definition of placebo effects: Feeling better without any actual improvement. Yet that’s not the overall impression that her article gives, as she cites a number of studies that suggest that placebo effects are more than just an effect on “how a person experiences or reacts to an illness.” She even uses an argument from popularity, pointing out how many physicians knowingly prescribe placebos based on a study from 2008 (which, I can’t help but mention, I also blogged about when it came out), as did Abel Pharmboy, Janet Stemwedel, Jake Young, revere, and Peter Lipson, who quite aptly said about this study, “Placebo—I do not think it means what you think it means.” The reason is that the authors counted many things as placebo, including pills known to have actual pharmacologic activity and how the authors defined placebo, as Peter pointed out:

In the current study, a placebo is defined as “positive clinical outcomes caused by a treatment that is not attributable to its known physical properties or mechanism of action.” This implies that the physician either knows the treatment shouldn’t work, or doesn’t understand how it works. This isn’t just semantics; we have many treatments available whose exact mechanism of action isn’t known, but whose effectiveness has been proved. If you interpret the definition less strictly, it oxymoronically defines a placebo as something that works despite it’s lack of efficacy. If I prescribe something expecting a predictable effect, and it produces that effect, by definition it isn’t a placebo. If I prescribe something I expect to work, and it doesn’t, then it isn’t a placebo. If I prescribe something expecting failure, but it works, I’m a lucky idiot. This would seem to imply that there is no such thing as a placebo (and I might agree).

The same is true of another study cited by Wang, a study by Alia and Langer from 2007 that examined the question of whether placebo effects can augment the effects of exercise:

Hotel-room attendants who were told they were getting a good workout at their jobs showed a significant decrease in weight, blood pressure and body fat after four weeks, in a study published in Psychological Science in 2007 and conducted by Alia Crum, a Yale graduate student, and Ellen Langer, a professor in the psychology department at Harvard. Employees who did the same work but weren’t told about exercise showed no change in weight. Neither group reported changes in physical activity or diet.

This is the study in question, which was not only not randomized (the hotels from which subjects were recruited were randomized to control or “informed,” not individual subjects, but tolerated a huge difference in the ages of the informed group and the control group, with the mean age of the informed group being eight years younger than that of the controls. Moreover, the reported changes in the informed group are pretty small, so much so that one wonders whether, even if they are real, they are clinically significant. For example, the change in weight in the informed group was from 145.5 lbs to 143.72 lbs, and in body mass index from 26.05 to 25.7. These are, of course, good things, but small changes, although the ten point decline in systolic blood pressure was intriguing. Does this remind you of anything? Perhaps of the IBS study I mentioned above? It should. Based on a small study finding small differences in outcomes that, while statistically significant, are probably not clinically significant (as I discussed the other day!), the authors make an overblown conclusion, in this case, that “mind set” is a powerful mediator of exercise effects, concluding:

People have mindlessly overlooked what it means that placebos are inert. Ultimately, each individual is responsible for their effects. Recognizing this suggests that it is time for us all to explore more direct means of controlling our health, such as pursuing mindfulness (see Langer, 1989) as a tool to actively and deliberately change our mind-sets.

“Mindlessly” overlooked? Who edited this paper? That’s not exactly scientific writing there. Maybe that sort of language is considered acceptable in the social sciences. I can say from my experience that such language is not acceptable in formal scientific writing for the medical sciences. Be that as it may, This study doesn’t exactly mean what its authors think it means, and they seem confused about placebos as well, defining them as “any effect that is not attributed to an actual pharmaceutical drug or remedy, but rather is attributed to the individual’s mind-set (mindless beliefs and expectations”). Oh wait. perhaps “mindless” is meant to mean “unconscious.” That would explain a lot. Clearly the editors were unconscious when this paper came through.

All too often, “placebo” seems to mean exactly what people choose it to mean, no more, no less (apologies to Lewis Carroll). In reality, a placebo is nothing more than “a substance or procedure a patient accepts as medicine or therapy, but which has no specific therapeutic activity” or, as Wikipedia now defines it, “simulated or otherwise medically ineffectual treatment for a disease or other medical condition intended to deceive the recipient.” This strikes me as a better definition than the old definition because it emphasizes that placebos are medically ineffectual and that they involve deceiving the patient. Indeed, the necessity of deception is, Kaptchuk’s claims otherwise, part and parcel of placebo use, which is one key reason why using placebos has fallen out of favor. Using placebos outside of a clinical trial is now generally considered at best paternalistic and at worst downright unethical, because it violates informed consent and patient autonomy. Sixty or seventy years ago, it was considered acceptable for physicians to deceive patients that way. in 2012, not so much.

In any case, what we call the “placebo effect” is not a single effect, and it has many components. Placebos area actually best viewed as a rather artificial tool used in clinical trials to control for nonspecific effects. There are expectation effects, in which patients experience what they are led to expect to experience. There are effects due to observation. Patients in clinical trials almost always do better than those not in clinical trials, thanks to the closer attention and more rigorous treatment protocols. This has sometimes been referred to as the “clinical trial effect.” Then there are effects due to reporting, which can introduce bias. There are also a whole host of other factors that determine how strong a placebo effect will occur in any situation. Surgery and invasive procedures are more powerful placebos than pills, for instance. More expensive placebos tend to produce stronger apparent effects. Indeed, there’s a whole hierarchy of placebos, and placebo effects can be enhanced by things like empathy and the doctor-patient relationship. None of these things require the introduction of pseudoscience such as CAM to achieve.

In the end, I’m coming to agree more with Mark Crislip than I used to in that I’m starting to question whether placebos are nearly as powerful as they are commonly advertised, although I don’t think I go so far as to call them a myth. Placebo effects, more than anything else, appear to involve changes in how pain or subjective symptoms are perceived, not any physiological change that concretely affects the course of a disease. Consistent with this concept I have yet to come across a study that provides serious objective evidence that placebos change “hard” objective outcomes, such as survival in cancer. What placebo is frequently claimed to be by advocates like Kaptchuk but is almost certainly not is “mind over matter” or thoughts and mind controlling health. Unfortunately, Kaptchuk and his ilk frequently find willing mouthpieces like Wang to spread this message because it’s such a seductively appealing message. After all, who doesn’t want to believe that we can control our health with our minds? Who doesn’t want to feel that powerful, particularly when disease strips us of control?

More importantly, for people like Kaptchuk who believe in CAM, placebo effects provide a new rationale to use CAM even though the vast majority of it is placebo medicine. By that I mean physiologically inert but represented by practitioners to patients as real medicine. Clinical trials, as ill-advised as many of them are, continue to reinforce that conclusion. In medicine, when a treatment performs no better than placebo, it is interpreted, and correctly so, as meaning that treatment doesn’t work. Thanks to the magic of “mind-body” placebos, propagandists like Kaptchuk have found a new rationale to use the ineffective treatments that make up so much of CAM.

And credulous journalists like Wang are more than happy to help him promote that rationale.

Comments

  1. #1 Dangerous Bacon
    January 4, 2012

    I’ll have to look for this WSJ article. I already get the feeling the Journal is hostile to evidence-based medicine and science in general. This is based on their dreadful editorials and op-ed pieces attacking the FDA for withdrawing approval of Avastin for treating breast cancer, and using the example of a Nobel Prize being awarded to a recipient for a novel theory to justify the claim that consensus is a terrible way to do science (i.e. to support their non-science-based views on climate change).

  2. #2 Denice Walter
    January 4, 2012

    * Du sublime au ridicule, souvent il n’y a qu’un pas.*

    And there’s only a step from talk about “harnessing the placebo effect” to believing in the “Secret”. Woo-meisters like to postulate the Almighty Power of Thought to transcend the limits of time and space.. and biology, physics, et al. Thus, we see NLP and Bruce Lipton. Meditation as a method of cure. EFT ( think and tap).Thought can transcend time and space *figuratively*, not literally: but then woo-meisters often have a problem with abstract vs concrete.

    I think it’s easy for them to travel this route because woo is saturated with spiritualistic ideas as well as belief in an *elan vital*, Chi ( Xi, Ki), Prana, Mana, or “essence” that, being non-corporeal, is amenable to non-physical influence. Using the placebo( to their eyes) would somehow unleash self-healing capacities to flow unrestricted. Using a placebo would be something like praying for cure, relief, or transformation. Oh, Inert Substance heal me!

    As would be expected, Mike Adams has greeted the new year with an essay on consciousness: I suspect that when he or the other idiot ramble on about “consciousness” they are *really* talking about manipulating the Chi( or whatever term they use) to get it to comply with their wishes, while self-massaging their egos simultaneously: self-serving as well as self-servicing.

  3. #3 Paratope
    January 4, 2012

    Good critique of a “field” that is regretably gaining traction. Michael Specter, the author of Denialism, has an article about Kaptchuk in a recent issue of the New Yorker. (He is a bit more credulous than you are.) Great question posed by Kaptchuk:“Do you think this entire field is based on a foundation of magical thinking, or do you not?” Well, yes, I do.

    http://www.newyorker.com/reporting/2011/12/12/111212fa_fact_specter#ixzz1iUvuwo7khttp://www.newyorker.com/reporting/2011/12/12/111212fa_fact_specter

  4. #4 Calli Arcale
    January 4, 2012

    I think it is possible that placebos may increase compliance with other elements of a person’s health management, consequently appearing to have a significant health benefit, when in fact they’re really just acting as a motivator. What the placebo is isn’t really important, and that key is frequently ignored by those who tout the wonders of placebos. “Placebos can do great things, therefore acupuncture is awesome!” Um, no. It might mean people could use a little more motivation, but that doesn’t mean any particular form of motivation is good. Dumbo had a magic feather that tricked him into having the courage to fly, which the crows already knew he could do. It couldn’t get his mouse friend to fly, though, and it didn’t teach Dumbo to fly nor give him the improbable anatomy that permitted cartoon flight. It’s just a motivator, and it can backfire spectacularly; the crows are fortunate Dumbo didn’t get mad when he learned that he’d been tricked into doing something that terrified him. Had it not been a Disney cartoon, and had it not enabled him to win fame, fortune, and his mother back, he might have been furious with the crows for having sport with him.

    What studies like this show us is, at most, that people can unconsciously change their outlook on discomfort and can be motivated to work harder and comply better with treatment plans. There should be ways to achieve this without fooling people. I know, the placebo as seen on Dumbo is an archetypal theme; on some level, we like that as a storytelling device. But unless the story is a tragedy, it seldom goes on to show the erosion of trust after the deception is revealed. Like so many things in fairy tales, it’s rarely that tidy in reality, and life goes on after the Happily Ever After. There are ways to motivate people that don’t involve deception. They’re harder, but I suspect they work a lot better. And they won’t have the nasty side-effect of the person expecting the placebo to do things it can’t and then abdicating responsibility to it.

  5. #5 Anj
    January 4, 2012

    so…

    If it’s really all about being led to feel GOOD and feel BETTER, then do you really need anything more than belief to make CAM “work”?

    In a way, I can see the value in that. Not as a replacement for SBM, but as for the cheapest low risk therapy possible. Alas, the problem with CAM is that not all of it is low risk and many people want a replacement for EBM.

    The fallacy that CAM can both replace SBM and be as effective as SBM is appealing to Some People.

    Is there a way to make SBM seem more attractive? I keep coming back to the problem that SBM is inherently less accessible in many respects. I find myself giving some medical advice to people I know. I told one person that they needed to make sure their hive reaction to an antibiotic was part of their medical record, and why.

    Their physician should know about that, heck their physician should have known about it! They didn’t call their physician, they called me. I probably should have told them to call their physician….my mistake.

    Do practices tell their patients “If you have ANY questions, please call!”. ? Do they mean it?

    How can the medical professionals give their patients the ability to ask questions and get answers, easily and promptly? What services are available, or would you like to see available to patients to help address their concerns?

    People who are anxious or afraid want reassurance – and they will seek it out. Their SBM professionals should be their first choice to do so – and if they aren’t, why NOT?

  6. #6 hibob
    January 4, 2012

    “but there is no excuse whatsoever anymore for journalists, newspapers, and magazines not to include PubMed links to the actual studies in online versions ”

    1. The search engine optimization people will yell at them if their articles have too many outbound links. Or maybe if it has any outbound links at all. The point isn’t to get people to understand the science; it’s to get them to click on the ads or at least click somewhere else on the site.

    2. Most readers won’t have a login that gets them past the journal’s firewall, so giving them a link (pubmed or the journal) is a bit of a tease.

    So there are definitely excuses – just not very good ones.

  7. #7 Igor
    January 4, 2012

    “Is there a way to make SBM seem more attractive?”

    Free flu shot giveaways? Oh wait…

  8. #8 Jay Chaplin
    January 4, 2012

    @ hibob (#6) The vast majority of journals are now compelled to provide free access to articles older than six months due to NIH funding/publication rules. The amount of primary literature available to the public for free is increasing very quickly – argument #2 is invalid.

  9. #9 Todd W.
    January 4, 2012

    @hibob and Jay Chaplin

    Even if an article is behind a pay wall, a link to the article will still give readers the authors, title and journal in which the referenced study appeared, so they can find out more later. Also, even with pay walls, the abstracts are generally free.

  10. #10 Sastra
    January 4, 2012

    Calli Arcale #4 wrote:

    What the placebo is isn’t really important, and that key is frequently ignored by those who tout the wonders of placebos. “Placebos can do great things, therefore acupuncture is awesome!”

    The fact that it doesn’t matter what the placebo is may in part explain the curious lack of self-criticism among alties: even when directly challenged they are very reluctant to criticize any alternative method, even when it specifically contradicts one they endorse.

    I recently asked a friend who supports and touts alternative medicine if she could look over the history of alternative medicine since the 1890′s and tell me which methods or therapies have since been rejected because they don’t work. When it became clear that I was not going to allow her to bring in examples of mainstream “allopathic” medicine but wanted her answer restricted only to alternative methods — she admitted that they were all acceptable. They all work, every single one.

    However, they work for different people and at different times: it’s all up to the individual. Every individual is unique. You just keep trying to see what fits.

    It’s the sort of answer you’d get if you asked which placebo is “best.” Whichever one most effectively appeals to the person you’re giving it to. They’re all the same.

    Not by coincidence, I’m sure, this person is also a strong believer in idealistic monism and the ability of consciousness to create, form, and change reality. Things are only real if we believe they are. She was into “The Secret” before it was called “the Secret.”

  11. #11 Composer99
    January 4, 2012

    I would conjecture, if the placebo effect does in fact alter recipients’ subjective responses to pain or other symptoms, that it is having a physiological effect: not on the cause of the pain or other symptoms of course, but perhaps on the signalling between the sites where the pain-causing damage or other symptom-causing effects (immune system activity, bacterial-emitted toxins, whatever) and the central nervous system?

    (Total layman wild guess, mind you.)

  12. #12 E. Harding
    January 4, 2012

    Isn’t it amazing how alt-medders claim that science-based medicine does not treat the underlying cause of disease when their own methods are often designed only to make the patient feel better and not treat the underlying cause(es) (c.f., acupuncture and cancer)?

  13. #13 Matthew Cline
    January 4, 2012

    @hibob:

    The point isn’t to get people to understand the science; it’s to get them to click on the ads or at least click somewhere else on the site.

    Ah, yes. “Once they get to our site, don’t let them leave!” *bleargh*

  14. #14 JakeS
    January 5, 2012

    @6: But that’s not the reason newsies don’t link to the study they describe. The reason newsies don’t link to the study they describe is that they base their articles on press releases from the PR flacks at the institutions associated with the study. And those PR flacks typically provide neither links nor citations (nor, in many cases, even identification of the paper adequate to enable a layman to find it without jumping through too many hoops).

    And of course newsies don’t link to the press releases they plagiarize (sorry, “cover”) because, well, then it would become obvious to even the dumbest reader (a) how narrow their range of sources actually is (more than half of the value added of a quality newspaper can be obtained from a free Google news alert for press releases – tabloids are worse) and (b) how much of said releases are reprinted verbatim or near enough as makes no matter.

    - Jake

  15. #15 nancy brownlee
    January 5, 2012

    @Jake
    Reproducing the information in a press release- even word for word- is not plagiarizing. That’s what press releases are for. The vast (VAST) majority of press releases sent out are the straight information, who what when where type: “Come to the airshow at Colonel Numnutz Air Base on Thursday, June 32nd at 4pm- bring your own lawn chairs and a fire extinguisher!” The problem is that features journalists are rarely informed enough to understand the difference in those press releases and the releases about science and medicine – they are not usually taught to examine the information critically and are sometimes actively discouraged from doing so. The place to complain is to the senior editors. Sometimes they’re old enough to have been taught the primary rule of journalism: Your mother says she loves you? Check it out.

  16. #16 Laura
    January 5, 2012

    Orac:

    I have yet to come across a study that provides serious objective evidence that placebos change “hard” objective outcomes, such as survival in cancer.

    But who’s going to do such a study?
    You can imagine a study of people desperately ill with cancer, where half the people get an ineffective remedy and they’re told it works; half the people get an ineffective remedy and they’re told it’s a sham. Who could ever get funding for such a study? Why would the people who were told it’s a sham, stay in the study?
    Slightly more realistically, you could imagine a study of people desperately ill with cancer. All of them are given a treatment that’s already known to improve survival. But half of them are told they got a sham treatment. They spend their time threatening lawsuits and being pissed off. The ones who are told they’re getting something helpful, feel relatively relaxed. That also seems like measuring the placebo effect, because the placebo effect is also involved with treatments that do better than placebo.
    But is anyone going to do such a study? How would they get funding for it, since they aren’t trying to develop a treatment? Why wouldn’t the people who think it’s a sham, just leave?
    So a lack of specific evidence doesn’t seem a good argument against hard benefits from the placebo effect.
    There seems to be a lot of evidence in a general way that a person’s state of feeling affects their health – that cancer patients who laugh a lot live longer, etc. And if a placebo improves one’s mood, it may well be better than doing nothing.
    Many alt-med believers seem to be people who give primary importance to their feelings. Like, one person who told me that alt-med is the underdog (and therefore I ought to feel an allegiance with it). And if they go humming along coping with cancer in ways they feel are “natural” or somehow feel right and nurturing to them – unlike chemotherapy, which is a very ugly thing to have done to one’s body – maybe it does help them more than doing nothing would.
    It’s not guaranteed to work that way. Maybe the people who are threatening lawsuits and full of stress hormones in the scenario above, actually fight cancer better. But it seems that what we do know, suggests that placebos are likely to have actual benefits.

  17. #17 JakeS
    January 5, 2012

    Maybe I just don’t pay attention to the fluff about Colonel Numnutz’ air shows, but I find that a disturbing number of news articles run under a reporter’s own byline contain a substantial percentage of verbatim copypasta from a “think tank,” university PR department, lobbyist or political pressure group.

    That may not be plagiarism, but it sure is dishonest: When something is run under an in-house byline, the reader is lead to believe that the information has been vetted in some manner. I can understand that a reporter may not feel confident in his ability to translate a press release from the central bank into English, but in that case the reader is owed a disclaimer that what is reported is a partisan submission, not the reporter’s best attempt at the facts.

    - Jake

  18. #18 Krebiozen
    January 5, 2012

    Laura,

    cancer patients who laugh a lot live longer

    Sadly that doesn’t seem to be true. There were a couple of studies some years ago that suggested a positive attitude improved survival, but more recent studies have found no effect. It’s probably that the people with a negative attitude were sicker, and that explained both their attitude and their reduced survival.

    It’s one of those things that “everyone knows” but isn’t true.

    If you Google my ‘nym “Krebiozen” you will find a fascinating tale that is supposed to be evidence of a placebo having a dramatic effect on cancer, but very probably isn’t.

  19. #19 Laura
    January 6, 2012

    I also don’t think that it’s an argument for alternative medicine, if placebos turn out to have a good effect on “hard” outcomes like cancer survival.
    Mainstream medicine has the advantage in placebo effect, hands down – because carries with it the sense of authority, of treatments that have been validated by science.
    Most people don’t initially seek out alternative medicine because of a conviction that it works – more because it pleases them somehow ideologically, or feels better than mainstream treatment, or they’ve encountered bad treatment or incompetence from a mainstream doctor. They say things like “they did something that sounded totally wacky, but it worked!”. So the placebo effect doesn’t seem to be operating, at least initially, with people who use alternative medicine.
    If alternative medicine feels better than mainstream medicine, this may be something that mainstream medicine can learn from.
    Any tendency to believe the placebo effect can’t have “hard” advantages, as a way of opposing the alt-med advocates who believe otherwise, should be resisted. That would be a terrible reason for taking that position, and as I said, it’s overly defensive.

  20. #20 phayes
    January 6, 2012
  21. #21 Beamup
    January 6, 2012

    SciFri’s definitely seeming to go downhill lately. A couple weeks ago Ira had Andrew Weil on, with only the vaguest sort of challenge. Certainly no acknowledgement that he’s such a confirmed antiscience quack.

  22. #22 Prometheus
    January 6, 2012

    I read this article in the Wall Street Journal and was terribly disappointed by it. Apart from overly credulous reporting (sadly, quite typical in science reporting), the researchers seem to have overlooked – deliberately, perhaps – the fact that there are two categories of “placebo response”.

    The type of “placebo response” that gets all the press are those responses that require the subjects to be aware they are receiving treatment. These are “expectation of benefit” (the subjects feel better because they expect the treatment to work) and “desire to cooperate” (the subjects report improvement even if they feel roughly the same because they want to be “good patients”).

    The other type of “placebo response” are those that would happen even if the subject wasn’t aware they were receiving anything. These include various flavours of spontaneous improvement (subjects feel better because their condition improves, temporarily or permanently) and habituation (after a time, subjects grow accustomed to the symptoms and so tend to perceive an improvement).

    In a study, the purpose of a placebo arm is to compensate for the two types of “placebo response”, so as to not mistakenly attribute all improvement to the action of the study drug or procedure. The placebo itself – and this bears emphasis – does nothing, by definition.

    Using placebo in clinical practice is unethical because it involves deliberate deception of the patient. The patient awareness dependent aspects of placebo – those so prized in the Wall Street Journal article – won’t work if the patient knows that what they are getting is a placebo.

    I think that it’s also worth mentioning that, for conditions that have study-tested effective treatments, giving a placebo would be sub-standard medical care, since all of the proven treatments have been shown – again, by definition – to work better than placebo. As a result, placebo would less effective.

    One final note. There is much nattering on in the “alternative” medicine world about how “mainstream” medicine (i.e. real medicine) “only treats the symptoms of disease” – which is, obviously, rubbish. Yet here we have yet another “alternative” medical treatment that is defined as “effective” (by the “alt-med” crowd) because it treats the symptoms of the disease without – again, by definition – having any effect on the root pathology of that disease.

    Prometheus

  23. #23 Penny
    January 10, 2012

    http://www.reuters.com/article/2012/01/10/idUS144116+10-Jan-2012+PRN20120110

    “Evidently, on two separate press releases, the Company reported its brand extracts successful Cancer treatments as reported by Squamous Cell Carcinoma and Skin Cancer self-medicating patients with continued shrinking of Cancer cells.”

    *blinks twice*

  24. #24 Penny
    January 10, 2012

    “Evidently, on two separate press releases, the Company reported its brand extracts successful Cancer treatments as reported by Squamous Cell Carcinoma and Skin Cancer self-medicating patients with continued shrinking of Cancer cells.”

    *blinks twice*

  25. #25 g724
    January 12, 2012

    Re. the “intriguing” finding about blood pressure: “For example, the change in weight in the informed group was from 145.5 lbs to 143.72 lbs, and in body mass index from 26.05 to 25.7. These are, of course, good things, but small changes, although the ten point decline in systolic blood pressure was intriguing.”

    Seems pretty straightforward to me. Emotional stress increases blood pressure. Hotel housekeeping jobs tend to be stressful. The “feeling of stress” was reframed as “the feeling of getting a good workout.” That may very well have reduced the unpleasant emotions associated with the pace of the work, and thereby reduced the emotional stress of the work, and thereby contributed toward lower blood pressure. “This isn’t bad for me, it’s good for me, like exercise! I feel better already!”

    I’ll disagree that prescribing placebos in clinical practice is necessarily unethical. Like this:

    “I’m not certain yet, what’s causing your symptoms, but in the meantime how’d you like to try an experiment? If you like, I can prescribe you a placebo. That’s a compound that isn’t known to have any specific medical effect. But sometimes when people take placebos, they report that their feelings of pain and discomfort are reduced. Want to try it?”

    That’s informed consent with a reasonable expectation and no deception about the placebo curing the condition. If the patient is of normal intelligence, s/he should understand this and be able to consent or decline.

  26. #26 Howard
    January 16, 2012

    An N=1 anecdote. Can knowledge change the placebo effect?

    My sister used an herbal remedy for menopausal symptoms. Worked fine for a couple of months. She visited her doctor, explained what she was doing and received the explanation that it was a placebo. Like a switch, the effects stopped and her symptoms returned.

    No deception involved here (unless ignorance counts) but the loss of symptom control was real enough.

  27. #27 questioner
    January 16, 2012

    Rather embarressed to admit but I was suffering from a mild depression-took part
    in a top Ivy League college research institute for a depession medication study-double blind placebo controlled. Felt more energy after receiving the pill and this lasted for many days. Found out it was a placebo.
    Never, never would have thought it.

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