Placebo is raining not far from the doctor

Proven content

There is a big difference between a lie that heals and a faith that works miracles. What is a placebo really? We talk with the psychiatrist Dr. Sławomir Murawec about why expert explanations are more important than the power of suggestion.

1. The meaning of suggestions for therapeutic effects has been used since the very beginning of medicine
2. The placebo effect is a situation in which the patient’s condition improves despite the fact that the administered “drug” did not contain any active substances
3. Placebo is used in drug performance studies, using it in blind and double-blind trials

Despite informing patients about the use of the placebo method, favorable “treatment” results were achieved in people suffering from back pain, depression, allergic rhinitis, irritable bowel syndrome and hyperactivity disorder, or ADHD.

Zuzanna Opolska, MedTvoiLokony: The magazine «Pain» reports that the placebo works even if it is exposed. Does this mean that we can use “tick-tock” in clinical trials without ethical dilemmas?

Dr Sławomir Murawiec, psychiatrist: Contrary to appearances, the study by scientists from the University of Basel and the Harvard Medical School is not the first to use the so-called open placebo. So we are talking about a situation where the patient is openly informed that he is receiving an inactive substance and not a drug. Until now, it seemed that the placebo effect only worked if the patient was convinced that they were receiving the real drug, but in fact was secretly receiving an inert substance. Now we have more and more evidence that playing open cards with a patient does not reduce their effectiveness at all. Not only in analgesia or, to some extent, in depression, but also in people with irritable bowel syndrome and hyperactivity disorder, i.e. ADHD.

This time, the usual ointment turned out to be effective in relieving pain after burns …

Yes, the study participants were divided into four groups. The first did not receive any treatment, the second cream without lidocaine, that is, a placebo, of which she was informed. The participants in the third group were also given a placebo but were also explained why an inert substance could relieve pain. In contrast, subjects assigned to the fourth group were told that they were receiving lidocaine ointment when in fact, like the others, they were given a placebo. Interestingly, only the third and fourth groups reported a decrease in pain and discomfort.

So in the clash between “open placebo” versus “traditionally understood placebo” we have a draw?

Yes, as long as the patient is informed why the inert substance may bring improvement. In this case, the explanations were based on three points. First, researchers told participants that placebo had been proven to be effective in many clinical trials. Second, the placebo effects result from classical conditioning. So, just as the dog Pavlov’s salivary gland system reacted to the bell, our body can react to an inert substance by activating self-healing mechanisms. Third, positive expectations increase the placebo effect, which doesn’t mean there’s no doubt about it. A similar formula has already been used in the 2012 Open Label Placebo for Major Depressive Disorder: A Pilot Randomized Controlled Trial.

The main author of the study, prof. Cosima Locher commented on the results saying: “We need to rethink what the placebo effect is”. It’s not just a suggestion?

I started wondering about it too. It seems that rationale is the decisive element. The title of the article from the “Pain” magazine says it explicitly: “Is the rationale more important than deception?” (Is the explanation more important than the cheat?)

Suppose the explanation is made by a politician – will it work?

I think not. The concept of a doctor as a medicine was already used by the psychoanalyst Michael Balint in the 60s. In the book “The Doctor, His Patient and the Illness” he wrote that “there are no guides that would define the doses in which the doctor should prescribe himself, in what form, how often and what the therapeutic and maintenance doses should be”. How many of us, after leaving the doctor’s office, feel better, more confident and safer? Unfortunately, as my experience shows, the improvement effect does not last longer than a week.

The report “E-health in the eyes of Poles” showed that there is usually no time for medical explanations. It takes a doctor 3,86 minutes to search for a medical history, 4,01 minutes to write out prescriptions, 4,09 minutes to write out sick leave, as does filling in personal data. As a result, less than 20 out of a 4-minute visit is time to examine and talk to the patient …

Perhaps this is one of the reasons why Poland is one of the countries with the lowest confidence index in the medical profession. Certainly, the media campaign against health care workers or the irrational elimination of corruption and bribery in the light of cameras will not improve the situation. On the contrary, they work to the disadvantage of the patient, increasing the number of people who do not trust the doctor. The authors of the study point out that by meeting the expectations and needs of patients through open communication, we can strengthen the placebo effect. This means that by talking to the patient, I can intensify the biological effects of the drug.

Is it better then not to inform patients about possible side effects?

If the actions are frequent, I always mention it, thanks to which the patient is not surprised. For most antidepressants, side effects should subside within the first few weeks of treatment. For me as a doctor, this is convenient information because it gives the patient hope that they will disappear quickly.

Not everyone is suggestive – do personal characteristics matter?

Indeed, depending on the disease, the placebo effect is seen on average in about 1/3 of patients. I think, however, that it is more than individual features about what we expect from the world. People who fundamentally assume that life is good, the world rationally arranged, and others who are sympathetic and ready to help, will have a greater tendency to the placebo effect. On the other hand, those who have experienced life traumas, have been hurt or abused on an unconscious level in the past will expect negative intentions from others. Such patients will come to an appointment and even in the most holy doctor they will see a cheater, and they will put the prescribed drug on a par with the harmful agent.

Does the form of administration affect the strength of the placebo?

Regardless of patients’ attitudes, the effectiveness of placebo has been shown to increase with the size and number of tablets administered. In general, injections are more effective than the oral form. Research has also been conducted on the colors of tablets. It turns out that the red ones have a stimulating effect, and the blue ones have a calming effect. It is worth remembering that a placebo is not only an inert substance, i.e. a tablet, injection, ointment, but also a sham surgical intervention or medical equipment that gives the impression of being functional.

Apparently, the more expensive the drug, the better it works?

It depends again. If I have a narcissistic patient and give him the cheapest drug on the market, his condition will not improve. He will appreciate the extremely expensive and rarely used preparation. On the other hand, if a cheap drug is offered to a depressed patient, he will simply accept it.

Does placebo have a dark side?

Just as a positive suggestion can cause a placebo effect, a negative suggestion can have the opposite effect, i.e. nocebo (Latin I will harm). We are talking about a situation in which the patient has not taken the drug yet and feels worse. Most often it is associated with a negative attitude towards therapy, prescribed medication or a doctor. People prone to depression, anxiety and hypochondria are much more susceptible to the influence of negative suggestion. The nocebo effect will also be stronger in pain sensitive patients and those with a history of long and difficult-to-diagnose complaints.

How come thoughts are translated into physiological processes and health – vomiting, swelling, allergies?

Jakub Grabowski and Leszek Bidzan wrote in great detail about the neurobiology of the placebo / nocebo effect. It turns out that the mere expectation of improvement by the patient affects not only the increase / decrease of certain neurotransmitters, but also the activity of specific brain centers. For example, in people suffering from Parkinson’s disease (in which we observe a deficiency of the neurotransmitter dopamine), changes may affect the level of dopamine in areas of the brain crucial for the development of degenerative disease of the central nervous system. In depression – changes in the metabolism of the cortical and paralimbic areas, in analgesia – changes in the activity of centers related to the processing and control of pain.

In the Middle Ages, it was common to apply the principle: ante patientum latina lingua est (use only Latin in the presence of the sick person), similarly, the current discussions of “whether to inform dying patients about their condition” are based on belief in placebo. To say or not, Doctor?

Fortunately, this is a dilemma for oncologists and other specialists. For me, as a doctor, the practical advice is: explain honestly and truthfully how and why the drug has a chance to work, in relation to these symptoms and in the specific life situation of the person being treated. If what I say then confirms the effect of the drug as perceived by the patient, the biological effect of the drug and the explanatory effect will favorably combine.

Sławomir Murawie, MD, PhDc, psychiatrist, psychodynamic psychotherapist. Editor-in-chief of “Psychiatria”, president of the Scientific Society for Psychodynamic Psychotherapy. For many years he was associated with the Institute of Psychiatry and Neurology in Warsaw. Founding member of the International Neuropsychoanalytical Society. Laureate of the Professor Stefan Leder, a distinction awarded by the Polish Psychiatric Association for merits in the field of psychotherapy.