Doling out the placebo effect
For decades, research physicians have furrowed their brows at the mysterious powers of a treatment known in many medical circles as Obecalp.
In clinical studies, Obecalp has been shown to have occasionally remarkable effects -- and on a remarkable range of maladies. In one 2002 study at UCLA, one-third of patients reported relief from symptoms of depression (and had changes in brain function that reflected that improvement) when treated with Obecalp. Patients with Parkinson’s disease have observed their tremors decrease, those with chronic aches have felt their pain ease and hypertensive patients have seen their blood pressure fall -- all in response to Obecalp. Medical journals are filled with testimonials to the frequency with which Obecalp, often administered at little or no cost, can improve patients’ health.
Now, as a recent study published in the Archives of General Internal Medicine found, physicians on the front lines of patient care are reaching for the power of Obecalp -- a backward spelling of the word “placebo” -- with surprising frequency, and for different reasons, than patients might suspect.
In a survey published in the January issue of the Journal of General Internal Medicine, about 45% of Chicago-area physicians responding acknowledged that they have treated patients with a placebo. Almost 1 in 4 of those responding had offered a placebo to at least one patient in the last year, and 8% said they had resorted to treatment with a placebo more than 10 times in the last year.
Placebo treatments, as defined by the researchers and the doctors they surveyed, go well beyond the popular notion of placebo as a “sugar pill.” Some physicians do write a prescription for a capsule filled with inert ingredients: a classic “dummy pill” called Cebocap that comes in three colors. (The blue capsules listed as Cebocap No. 1 on the Walgreen’s pharmacy website are reputed to be “extra potent,” according to the website Over My Med Body, which is frequented by physicians in training.)
But placebo treatments might also include a prescription for an antibiotic when a viral infection is suspected, or an extremely low dose of some long-used pharmaceutical agent. They might be a vitamin supplement, a meditation class or directions to spend a little more time in the fresh air. In short, they’re simply treatments that might have an effect on the patient -- but for no clear biological reason.
In the days before physicians were expected to discuss forthrightly with patients the pros and cons of treatment and the manner in which it might work, placebo was a code word for “you’re an attention-seeking fake,” “what will it take to get you out of my office?” and “it’s all in your head.” Past studies have found that when physicians acknowledged the use of placebos, it was typically for ailments with likely psychological roots.
The study published this week, however, finds a change in physicians’ attitudes toward that mind-body distinction. Four in five of the 231 doctors responding to the current survey -- all based in Chicago and affiliated with a teaching institution -- rejected the idea that “placebo intervention can help distinguish symptoms that have a psychogenic versus an organic origin.”
Rachel Sherman, a fifth-year medical student who conducted the study with Dr. John Hickner of University of Chicago Medical School calls that “conceptual shift” one of the study’s most surprising findings. “Nearly all [who used placebo treatments] believed in their therapeutic potential,” Sherman says. That, she adds, reflects “a trend in the belief that the mind and body are interconnected.”
Dr. Howard Brody, professor of family medicine at the University of Texas Medical Branch in Galveston, says many physicians have witnessed the power of the placebo effect accidentally -- say, when a patient mistook a diagnostic procedure for treatment and pronounced himself “much better” as a result. But the prevailing view of “placebo” as a means of dismissing or downplaying a patient’s symptoms has long made it tricky to talk about openly, Brody says.
“Twenty years ago, a doctor would whisper that kind of story to me as some kind of guilty secret,” Brody says. Today, he adds, physicians’ growing belief in the connection between mental and physical health has caused many to acknowledge that sometimes patients can be made to feel better, and even get better, simply because their doctor did something to help them.
The latest study underscores this point. Of those who had used placebos in clinical practice, 92% cited “psychological factors” as contributing to their effect on patients. Half cited “unexplained factors,” and 28% suggested that “biochemical factors” might be at work when placebo treatment provides relief. (When asked how they perceived placebos as working to relieve symptoms, physicians were allowed to check more than one possibility.)
UCLA psychiatrist Dr. Andrew Leuchter stresses that even when a doctor doesn’t reach for a placebo to treat a patient, he or she should have no qualms about employing a placebo’s power -- essentially, the power of suggestion -- to help bring about relief. Physicians are accustomed to thinking of placebo as the “no-treatment option” in clinical trials and as a result tend to doubt its effects, says Leuchter, who has studied those effects extensively. “But as a clinician, the placebo is my friend,” says Leuchter. “Whatever will help a patient get better is a good thing.”
Leuchter says that in proposing treatment, say, for a patient with depression, “I always tell [the patient], ‘I think this medication is going to help you get better.’ ” He does so, first, because he knows from clinical experience “there’s a better than even chance” that a patient’s depression will yield to some antidepressant. But he also does it because “I do think that hope is one of the most powerful treatments we have, and the confidence that patients have in the healthcare practitioner -- that is a powerful treatment that we have to take full advantage of.”
Marjorie Gaitan, a 35-year-old Los Angeles resident, was shocked to learn in November that she had been taking a placebo pill instead of an antidepressant for three months, when she was a subject in a trial by Leuchter. It had taken at least a couple months for her to feel better. But Gaitan, who had just moved to L.A. from New York, found she was progressively overcoming her sadness and emotional paralysis and able to organize herself for a job search. She presumed the improvement was the work of the pills she was taking.
“I couldn’t believe I was leveling my mood swings on my own,” says Gaitan. “I felt better! It’s like you’re playing tricks with your mind, and you don’t even know the power of it.”
But can a physician, who is obligated to speak honestly about a proposed treatment with a patient, be both candid about the dearth of evidence (and clinical confidence) in a treatment and still expect it to help?
Physicians who acknowledged using placebos made clear that they walk that tightrope carefully. About 1 in 3 introduced the placebo treatment as “a substance that may help and will not hurt.” Another third of respondents gave other information to patients, including “this may help you, but I am not sure how it works.” Only 4% explicitly told a patient they were being offered placebo.
Graham Walker, a fifth-year medical student at Stanford University who maintains the Over My Med Body website, thinks candor may have to win when it comes to dispensing placebos. He adds that acknowledging uncertainty (as in, “I’m not sure how this works”) goes against everything he’s been taught as a medical student. Walker, the son of a psychiatrist, is a firm believer in the link between mind and body. But the need to maintain the trust of a patient is paramount he says, and it could suffer irreparably if a patient felt after the fact that he had been duped.
“You want to instill hope in your patient. You don’t want to leave a patient feeling there’s nothing we can do,” says Walker. “But you don’t also want to mislead them. It’s such a fine line to walk sometimes.”