Placebos and anti-depressants in children and teenagers

A recent ‘meta-analysis’ of the placebo effect on the use of anti-depressants in children and adolescents (shudder …), based on data from trials involving more than 6,500 children and adolescents up to the age of 18, has been published by the University of Basel and Harvard Medical School and published in the journal ‘JAMA Psychiatry’.

The most common mental disorders in children and adolescents include anxiety disorders, depressive disorders, obsessive-compulsive disorder, and post-traumatic stress disorder.

“The results of the meta-analysis show that, although antidepressants work significantly better than placebos across the range of disorders, the difference is small and varies according to the type of mental disorder. However, the results also showed that the placebo effect played a significant role in the efficacy of antidepressants. The study also found that patients treated with antidepressants complained of greater side effects than those who received a placebo. The side effects included everything from mild symptoms such as headaches to suicidal behavior.”

‘Suicidal behaviour’ as a ‘side effect’ … Really?

Consistent with other posts through this blog, the analysis also shows that the placebo effect is stronger in cases of depression.

The placebo’s evil twin

The placebo effect is one of the most mystifying phenomena in medicine. When we expect a pill to make us feel better, it does. If we see others get better while using a medicine, we will too.

But the placebo effect has an evil twin: the nocebo. It can kick in when negative expectations steer our experience of symptoms and create side effects where none should occur.

This means, incredibly, that you can get side effects from a sugar pill. And sometimes these side effects are so severe that patients drop out of clinical trials. More info here.

Recent evidence suggests that the muscle aches might be a big nocebo.

More Research on ‘Open Label’ Placebos

Whether you know you’re taking a placebo pill or not, it will still have a beneficial effect, new research has revealed (Is the rationale more important than deception? A randomized controlled trial of open-label placebo analgesia.)

Scientists from Harvard University and the University of Basel prescribed a group of minor burn victims with a “treatment” cream, telling only some of them that it was a placebo.

After the cream was applied, both groups reported benefits, despite the placebo cream containing no medicine.

Read the full article here

On the subject of Open Label Placebos, here’s a link to research on their efficacy in chronic lower-back pain.

Who is More Likely to Experience a Strong Placebo Effect?

A new study finds that people who have a better handle on their negative emotions may be more likely to experience a stronger placebo effect. Researchers at the University of Luxembourg found that participants who were better at interpreting negative events in a positive light felt more relief from a placebo pain-relieving cream.

The placebo effect has traditionally been viewed in a negative light; however, within the last decade, researchers have investigated the placebo effect itself and found that placebos can trigger real biological changes in the body, including the brain.

In a related article:

“All participants reported less pain: the placebo effect was working. Interestingly, those with a higher capacity to control their negative feelings showed the largest responses to the placebo cream in the brain. Their activity in those brain regions that process pain was most reduced. This suggests that your ability to regulate emotions affects how strong your response to a placebo will be.”

‘Branding acts like a placebo’

“Branding acts like a placebo. It changes consumer perception and, in turn, those perceptions alter the nature of the product.”

Read the fascinating story of Lieutenant Colonel Beecher here (as well as a commentary on the placebo effect in marketing).

A recent example? The internet recently has been alive with stories about research into the placebo effect and our apprehension of the quality of wine – and, perhaps worryingly for some, the brain functions which govern our actual experience of its taste! (Hint: higher price = higher quality).

Here’s a sample article: Why expensive wine appears to taste better: It’s the price tag. The authros point out:

“Price labels influence our liking of wine: The same wine tastes better to participants when it is labeled with a higher price tag. Scientists have discovered that the decision-making and motivation center in the brain plays a pivotal role in such price biases to occur. The medial pre-frontal cortex and the ventral striatum are particularly involved in this.”

PLACEBO AND FAKE SURGERY

Two thought-provoking articles relating the placebo effect to ‘sham surgery’, which has been canvassed in these pages previously.

In this meta-study, the authors point out that ” the literature is not chock full of studies comparing a surgical procedure to placebo. While the study of a drug versus placebo is standard practice, the picture changes radically when the placebo is a sham operation involving incisions and anesthesia …  Of about 3000 articles, 53 full-text articles were selected. They represented randomized controlled studies, with both an active intervention and a placebo arm involving a sham procedure. The authors defined a surgical outcome based on three elements:

•    The critical surgical component – the anatomic changes felt to result in a therapeutic effect

•    Placebo component – the patient’s expectations

•    Non-specific effects – changes in the natural history of an illness that might impact the outcome, the experience of being in a hospital, interactions with staff – the multitude of other factors.

In this study, the author admits that sham (placebo) srugery already occurs. Because it can work.

How?

“How can sham surgeries work? Bigness. In the same way that placebo pills and other modalities make people get better, the clinical evaluation, workup, stress and travel of surgery day, surgical prep, etc. all make for an almost unbeatable set of placebo-instituting conditions. And with some of the data which exist, sham surgeries perform better in the patients’ minds than a drug treatment that’s a comparator for the same condition.

Placebos and acupuncture

Here’s a link to a fascinating meta-analysis of the effectiveness of acupuncture in the treatment of chronic pain, controlling for some of the dodgy and unscientific ‘studies’ out there.

In this article, the outcomes of the study are listed and discussed, and it’s good news for acupuncturists.

‘When comparing legit acupuncture to standard care, there was a statistically significant benefit to acupuncture … “We saw a measurable effect there,” he explains. “If acupuncture were a drug, we’d say the drug works.”’

…and later, in relation to the placebo effect:

‘Many people equate placebo effects with scams. “The term placebo has always had this very negative connotation,” says Vitaly Napadow, director of the Center for Integrative Pain Neuroimaging at Harvard Medical School. But Napadow says our poor opinion of placebo needs revising. The human body has built-in systems for stoking or calming pain and other subjective sensations. “If a placebo can target and modulate these endogenous systems, that’s a good and a real thing,” he says.’

Meanwhile, in two comprehensive studies into the value of acupuncture treatment in treating women’s health issues, we see mixed results.

‘These studies shed new light on when and when not to consider using acupuncture,” Dr. Josephine Briggs and David Shurtleff, of the U.S. National Center for Complementary and Integrative Health, wrote in an editorial to accompany the studies.

The research done to date on acupuncture has shown that, generally, its benefits are limited to outcomes that are subjective, such as pain, Briggs and Shurtleff wrote. People’s positive expectations and the reassurance they feel from the procedure likely contribute to the benefits. “Clearly these ancient practices are helping reveal the complexity of the links between the mind and the body,” the editorial said.’

Yes, the placebo effect is all in your mind. And it’s real.

It seems that the research on the placebo effect is broadening and deepening.

“Over the last several years, doctors noticed a mystifying trend: Fewer and fewer new pain drugs were getting through double-blind placebo control trials, the gold standard for testing a drug’s effectiveness.”

This recent article, which includes some useful links for further reading, points to the degree in which the placebo effect (classified by the writer as a ‘family of overlapping psychological phenomena’) is being studied and considered. The family of placebo effects ranges ‘from the common sense to some head scratchers’, and include:

1) Regression to the mean
2) Confirmation bias
3) Expectations and learning
4) Pharmacological conditioning (‘This is where things get a little weird’)
5) Social learning
6) A human connection

Interestingly, it seems that at least in pain studies, ‘there’s evidence that placebos actually release opioids in the brain’.

In another article in Mother Jones, What the Heck Is a Placebo Anyway?, the authors propose ‘… we now know that they (placebos) often involve real chemicals produced by the body—real drugs from your “internal pharmacy.” Some of these chemicals are used by the brain to make sure that your expectation meets reality. When expectation doesn’t meet reality, the brain steps in and forces it to fit.’

Over at Fox News (of all people), quoting the Wall Street Journal, they’re suggesting ‘Placebo drugs really work, evidence suggests‘.

Placebo ‘drugs’? Come on, folks, that misses the point a bit!

‘Mind Body’ Healing: The placebo effect and exercise

Damien Finniss was working as a physiotherapist when, on a still winter’s afternoon in 2001, he set up his treatment table in a shed at the perimeter of a Sydney footy ground.

As players came off with sundry aches – a pulled hammy here, a calf strain there – Finniss ministered to them with therapeutic ultrasound, a device that applies sound waves to the injured area with a handheld probe.

“I treated in excess of five or six athletes during the training session. I’d treat them for five or 10 minutes and they’d say ‘I feel much better’ and run back on to the training field,” recalls Finniss, now a medical doctor and Associate Professor at the University of Sydney’s Pain Management and Research Institute.

“But, at the end of the session, I realised that I’d, basically, had the machine turned off.”

Read the whole article here.

Meanwhile, in Germany, researchers reveal some convincing evidence of the impact of the placebo effect, discovering that “a person’s expectations have a major influence on just how strenuous they perceive exercise to be.”