I don’t suppose she publishes data, but I would be fascinated to know whether her approach works better than that of someone who believes in their particular form of therapy.

http://www.bmj.com/cgi/content/extract/338/may20_1/b2055

Fascinating thread – maybe you’d be interested in our story. Having become interested, and absorbed a lot of the online (and growing) discourse about the ‘placebo effect’, a small group of us (one a practising homeopath) set out to find how we might buy products actually branded as ‘placebos’.

There are historical precedents for such, listed in Wikipedia and elsewhere, and there are interesting studies on the ‘informal’ (deceptive?) prescription of placebos by modern physicians – e.g. provision of antibiotics to treat a virus, provision of saline injections – with all the accompanying ethical dilemmas.

But the closest we’ve come to a branded placebo is CEBOCAP, available through Walgreens in three strengths (!) by prescription only (!!) – see http://www.walgreens.com/library/finddrug/druginfo.jsp?particularDrug=Cebocap&searchChar=

It seems that Cebocap is manufactured by Forest Pharmaceuticals (www.frx.com/products/index.aspx) but we can’t find any reference to them on the Forest site. Cebocap is also listed at http://www.canadacure.com/drugsearchAtoZlist.asp?Search=n,
but that site notes that it’s “Only Available By Prescription … and Not available in Canada”.

There are some great spoof sites around, like the article in the Onion already referred to in this thread, and we have a terrific spoof poster from a head site called Tripzine. But no REAL placebos

As adherents of homeopathy, criticised by many as one big placebo anyway, we’re fascinated by this. We’re able to source plain sugar pills, since that’s the base for many of the homeopathic remedies, but no one seems to have taken the step (had the nerve?) to come straight out and label something as a placebo. Perhaps it’s the assumption that the patient mustn’t *know* it’s a placebo s/he’s taking, but as also cited elsewhere in these pages, there are tantalising suggestions that even in such cases the placebo effect may still kick in. (And it’s not so strange anyway to imagine why ‘no blind’ placebo tests – on placebos – don’t often take place!)

Like homeopathy and other CAMs, the value of it all seems to reside in intangibles, which makes it so problematic for materialist views of the world – values such as trust, intention, confidence, mutuality, relationship with practitioner. It’s like the placebo can offer us the affordance of ‘getting out of our own way’ and allow room for the body’s innate capacity to heal.

So … the long and the short of it is we recently decided to set up a website as a clearinghouse for information and references to the placebo effect, and to actually package and offer placebo pills for sale online. As far as we know, we’re the only ones actually doing it, rather than just joking about it. And the content of our placebo pills? 100% sucrose. Why should anyone buy a bottle of placebos rather than, say, eat the occasional few grains of sugar from a bowl, or self-inject saline? As we say, we think it has to do with the contract, the intangible qualities involved in engaging with a formal interaction which inspires healthy somatic affects. This goes to the heart of homeopathy as well – we don’t see placebos and homeopathy as uncomplementary (to use a phrase).

It’s early days, but so far the reaction has been good. Our intention is absolutely serious, stemming from our commitment to CAMs, but we also want to hold the information lightly, have fun with it, and take a bit of a poke at the medico-pharmaco juggernaut.

Check us out if you like – http://www.placebo.com.au

With best wishes

Universal Placebos

http://www.bloomberg.com/apps/news?pid=20601202&sid=aAmdWrOf6gl0&refer=healthcare

Rebecca L. Waber; Baba Shiv; Ziv Carmon; Dan Ariely.
Commercial Features of Placebo and Therapeutic Efficacy
JAMA, March 5, 2008;299:1016-17.

In fact, the findings of research on psychotherapy often contradict popular opinion, and thereby refute certain aspects of “common sense.” By contrast, what people mean by good or sound “common sense” is, paradoxically, a very rare thing.

In the non-blind placebo study cited by Ben, the researchers conclude that the effect of placebo pills which subjects were told were “sugar pills” without any active ingredients resembled that of psychotherapy. Of one subject, they write,

“The patient indicated that she was quite suggestible, and she thought the treatment had been effective through a form of ‘hypnosis’ because she had been told so many times she would improve.” (Park & Covi, 1965)

Perhaps this patient was right, at least her interpretation of the experiment would be consistent with the model of hypnosis developed by Braid, its founder, as I’ve mentioned above.

Don Robertson

Better still, we could re-package common sense as “CBT”, aggressively market that (at huge cost to the NHS and with less benefits than pills) and spend the next 5 years believing in that.

You’re right that you’ll often find this in education: someone will say “Let’s teach the kids Latin/philosophy/yoga and see what happens,” and what happens is the kids get all keen and their results improve. People put it down to the Latin/philosophy/yoga, when in fact, the children improve because they know someone’s making an effort. (I guess this is where the fish oils business comes in.)

The whole notion of a “self-fulfilling prophecy” relies on the fact that if you tell a group that a new method has been proved that it is going to help them then it is more likely to have a beneficial effect.

There are many examples in education where new methods of teaching are proclaimed as proven by research to be effective, but what is happening is just the placebo effect where teachers and pupils respond to the idea that the new way is going to bring about success. As a result there is measurable improvement. After some time this placebo effect wears off, results revert to the mean, new research promotes alternatives and everyone loses faith in the method. This cycle goes on and on in many aspects of education (think of the way the teaching of reading has changed over the years).

spk76 – others have pointed this out, but to be honest, it’s pretty simple – if there were no placebo effect, you’d never need a control group of patients having a placebo, would you? You’d just give the control group nothing at all, and see what happens. The group receiving the placebo is there in recognition of the fact that there will be some placebo effect attached to the active drug.

This triggers a comment, and another interesting paper:

COMMENT – Moerman, in his book, reviewed studies which were not “psychiatric” … including cardiac surgery!

ANOTHER PAPER – documenting a “loss of efficacy with time” for a major anticancer drug [doxorubicin] was published a few years back. As follows:

Does a drug do better when it is new?
Fossati R, Confalonieri C, Apolone G, Cavuto S, Garattini S.
2002. Annals of oncology. 13: 470-473.

Now, of course, to highlight another crucial point that usually gets neglected, you have to measure and subtract the spontaneous remission rate from a placebo control outcome to know what the actual “placebo effect” is. Beecher claimed that 35% of people in placebo control groups on average shows signs of significant improvement. However, if 20% would report improvement on waiting lists, with no treatment, then the placebo effect only accounts for 15% instead of 35%.

Nevertheless, the social-psychological phenomenon of the placebo effect clearly acts upon the mind in such a way as to trigger changes which are normally involuntary. That’s not inconceivable because I can’t voluntarily raise or lower my heart rate, but if someone says something threatening to me, it might go up quite a lot, and I might produce various stress hormones. Psychological events can often have pronounced physiological effects, the placebo effect in medicine is, at the very least, continuous with this common sense observation, a more interesting instance of the same sort of thing.

The comments about saline injection and Pavlovian conditioning… I agree. However, even Pavlov accepted that the effects of classical conditioning were mediated by social-psychological factors such as context and expectation in the case of humans. I would say that the ritual of injecting acts as a powerful conditioned stiumulus, mediated by expectation and motivation to experience the high, i.e., a combination of cognitive suggestion and classical conditioning. That “cognitive-behavioural” (suggestion and habit conditioning) model was already explicit in hypnotism from the outset in the writings of its founder James Braid.

Don Robertson

OTOH, some conditions, such as depression, are wholly or mostly about how the patient feels, subjectively. There don’t seem to be any objective measurements that could matter more than a person’s own report on the internal feelings.

In these cases, whatever (legal) means makes someone feel better seems fine. There’s no chance of missing out on some other objectively effective treatment. You, the sufferer, are the arbiter of effectiveness.

Someone with a better handle on study design and interpretation might speculate better than I can, about how you might unpack the ‘placebo’ effect into the ‘someone paying me attention’ effect’ as against the ‘taking positive action’ effect, as against the ‘soothing voice’ effect, & etc.

I’d like to hope that the most effective elements will turn out not to be being lied to people pretending to hold bogus expertise.

Of course, placebos, like homeopathy, are widely available, but their cost is massively overinflated and unjustifiable. A single drop of water from any tap contains whatever homeopaths may prescribe, diluted (succussed) to wondrous levels of potency!

Joking aside, lets not forget that ‘Placebo’ can never replace drugs that act in a true pharmacological way. It can never be an option for Type I diabetes, it will never be antibiotic and will never play any role in curing infection with HIV……………..

A capable doctor should not let their own confidence in a drug influence the patient. Bluff them!

As for improved placebo performance in different tests over time, how can different trials be compared? But it could represent an increasing public understanding of depression and public confidence in pills for it.

You seem to know what you are talking about, and i am in no position to claim superior knowledge. But what you have said seems to flatly contradict what Moerman says on the subject, which of course is intended to be warrented by extensive empirical research. Is your disagrement based on a different reading of the same or similar evidence, or based on different research? Or perhaps easier to answer, is it the case that a serious debate exists within the relevent circles as to the existence of the placebo affect (understood as meaning a ‘meaning response’), or are either one of you somewhat maverick?

(BTW, I bought the Moerman book on Ben’s advice a while back; I read it in an evening and thought about it for many more. I recommend it throughly, even to scientifically semi-literates like myself. Thanks for the tip Ben)

‘knowing’ it is only saline does nothing to stop that pathway.