News at NCH
"The Placebo Effect" By Allen Weiss, MD, MBA, President and CEO


The Placebo Effect

January 1, 2011 - What we think, what we anticipate, what we expect has tremendous influence on how we react to a stimulus or situation.

Our perception can become our reality. If we believe a pill, treatment or any other intervention will help us, there is a much greater chance that the remedy will be efficacious.

Ever notice that as soon as you call for an appointment with your physician, things often seem to improve? Taking action, believing you are going to get better, popping a pill—in other words, “doing something”—seems to help. That confidence or faith, combined with having someone pay attention to us, can make a difference. Similarly, a doctor's enthusiasm for a treatment or procedure makes for a better outcome.

Conditioning also has a positive affect. The knowledge that a medication or procedure works usually makes the experience better. If you have had a good experience with a medication or procedure in the past, knowing that you are about to have the same treatment can make you feel better. Anticipation can be therapeutic.

From Bat Wings to Mummy Paint

Many studies have demonstrated the power of a placebo in helping to relieve subjective symptoms. (“I shall please” is the literal translation from Latin for placebo.)

In Dan Ariely's book Predictably Irrational: The Hidden Forces That Shape Our Decisions, this psychology professor shares many interesting experiments. Here are two examples:

  • For a least 20 years starting after World War II, cardiac surgeons treated chest pain (angina) by doing an operation which they thought was effective in redirecting more blood to the surface of the heart. The procedure interrupted the flow of blood to an artery on the inside of the chest called the internal mammary artery. In order to do this, an invasive operation was performed: It split the breastbone. The problem was that no one knew if this procedure was effective. Finally, a group from Seattle did an experiment randomly assigning patients to a “placebo” group who had a sham operation with their chest split open but no change in the artery's blood flow; another group had the traditional surgery. Both groups did well for about three months but after that the patients were indistinguishable. Needless to say, that operation has been consigned to history. The important point is that surgery alone—just opening the chest—helped for a few months. This is just one example of the power of a placebo.
  • During the middle of my career as a rheumatologist in the early 1990s, a treatment involving washing out a knee afflicted with osteoarthritis came into vogue. An orthopedist from Texas did a study on three similar groups of patients with this knee problem. One group got the full operation with removal of damaged cartilage; a second group had the same operation but no removal of cartilage; and a third group had a sham operation with superficial incisions on their knee but nothing done inside the knee. Results at two years surprised and upset the medical community. All three groups had the same relief of pain, improved function and satisfaction with the procedure. Needless to say, we need to make sure procedures are effective in their own right as opposed to benefiting from the placebo effect.

Historically there have been many placebos including worm secretions used in the 18th century in Italy, eye of a toad, wing of a bat, dried fox lungs, mercury, mineral water, magnets, electrical currents, and even more macabre cure-alls. President Lincoln was treated on his deathbed with “mummy paint,” which could be ordered at that time from the E. Merck catalog.

Today, double-blind controlled studies show that some of the treatments and medications we use are only minimally better than placebos. When six leading antidepressants were compared to a placebo, the findings were disquieting. The placebo was 75% as effective as the “real” medication. The learning: Just having a medication prescribed by a caring physician is helpful.

Reducing Pain and Suffering

Pharmaceutical manufacturers evaluate the beneficial effects of placebos in order to understand the mechanism of action. This is important for drug manufacturers because new medications could potentially benefit from the placebo effect in addition to the beneficial effect of the new medication itself. The placebo effect is more than just a nuisance in drug trials. The placebo effect could be used to help relieve pain and suffering.

As it turns out, placebos stimulate the brain's own indigenous endorphins. This phenomenon is known as the “placebo response” and is similar to administering pain relievers. In fact, this beneficial response can be blocked by the same medications that are used to reverse narcotic overdoses.

In an experiment to prove the beneficial “hybrid” treatment effect of using a real medication along with the beneficial placebo response, one study split patients into three groups. One group was simply put on a waiting list. Another group received treatment from a clinician who declined to talk to them. The third group received sham treatment from a caring clinician who engaged them with questions about their symptoms, treatments and prognosis.

All three groups improved initially. The third group, which received the sham medication and someone caring about their illness, showed persistent improvement. The surprise is that just being on a waiting list helped patients, as did having someone care about their condition.

What We See

Here is one final story about how we perceive things.

A man sat in a Metro rail station in Washington, DC, playing the violin. For 45 minutes on a cold January morning, he played six of the most intricate Bach pieces ever written. Thousands of people walked by; most ignored him; a few gave him a couple dollars. The most attention came from several pre-school children. In total, the violist collected $32.

The violinist was none other than Joshua Bell, an internationally acclaimed virtuoso playing on a priceless Stradivarius violin. A few days later Bell played for a sold-out audience in Boston where the minimum seat cost $100. (http://www.washingtonpost.com/wp-dyn/content/article/2007/04/04/AR2007040401721.html)

Why was a famous musician so ignored? Our minds presuppose reality: No one expected to find Joshua Bell playing in the Metro station. Therefore, the musician wasn't “worthy” of the attention of passers-by.

On the other side of the coin: When we receive medical treatment or take a pill, we expect it to work.

What we see has more to do with what is behind our eyes than what is in front of our eyes.
 

Past Health Advice Articles

 
Dr. Allen Weiss is CEO & President of the NCH Healthcare System. He is board certified in Internal Medicine, Rheumatology and Geriatrics, and was in private practice in Naples, Florida from 1977 - 2000. Dr. Weiss is active in a variety of professional organizations and boards, and has been published in numerous medical journals, including the American Journal of Medicine and the Journal of Clinical Investigation.