Studying Placebo Effects Advance the Neuropsychiatric Understanding of Medical Interventions
I hope that the editorial by Fiona Godlee (1), the work of Kaptchuk, et al.(2) and the comments by Pittrof and Rubenstein (3) continue the process of exploring the potential of the Placebo Effect. Since it is not a null effect and has a good safety profile, it deserves more than the dismissive response offered by Dr. Szasz in his 04 May 2008 commentary. (4) Furthermore, Dr. Szasz’ comments are not entirely accurate. His suggestion that placebo treatments only have ‘effect’ when provided to conscious patients assumes that he can demonstrate that there is no effect to patients with altered levels of consciousness, including unconsciousness. However, that work has not been adequately performed and, therefore, his commentary is, at best, premature.
Medicine has never been concrete or absolute. That is, perhaps, truer for psychiatry, where clinical practitioner results and the risk- benefit ratios of medicines and medical devices are more difficult to quantitate and, therefore, more difficult to predict. Psychiatry, like medicine, has always been an art [some aspects of which were highlighted in BM Hegde’s Rapid Response of 05 May 2008 (5)], which, at its best, provides hope and encouragement to live a life that is free from torment, to be personally fulfilling and interpersonally satisfying.
The Placebo Effect is not a lie because it has a neurobiological mechanism of action. That that mechanism has not been fully elaborated is of little consequence(not unlike obesity, HIV/AIDS or schizophrenia). To assume that it does NOT have a neurochemical basis would require enlisting spiritual or completely random or unknown forces to explain its effect on patients’ immune, nervous and endocrinological systems that give rise to positive-or negative- responses. That argument is unlikely because it bypasses the scientific understanding of human neuropsychiatric reactions. Since we know that human cortical reactivity changes when individuals are confronted with subtle verbal interventions, facial grimaces or body movements, and those changes in cortical reactivity produce changes in feeling states, cognition, emotional tone and behaviors, we already have verifiable scientific proof that placebo therapies, in whatever form they are provided, unquestionably produce neurobehavioral consequences. When the consequences of Placebo Effects are able to provide relief from pain or other suffering, we should endeavor to explore how to use them wisely, carefully and gracefully.
Stefan P. Kruszewski, M.D.
(1)Godlee F, editor. Reclaiming the placebo effect [Online]. BMJ 2008 May 3 [cited 2008 May 7]; 336. Available from: URL:http://www.bmj.com/cgi/content/full/336/7651/0.
(2)Kaptchuk TJ, Kelley JM, Conboy LA, Davis RB, Kerr CE, Jacobson EE, et al. Components of placebo effect: randomized controlled trial in patients with irritable bowel syndrome [Online]. BMJ 2008 May 3 [cited 2008 May 7]; 336:999-1003. Available from: URL:http://www.bmj.com/cgi/content/full/336/7651/999?ijkey=45db1e7332413b3ce10342ab04fe640b6c8c5450.
(3)Pittrof R, Rubenstein I. The thinking doctor’s guide to placebos [Online]. BMJ 2008 May 3 [cited 2008 May 7]; 336:1020. Available from: URL:http://www.bmj.com/cgi/content/full/336/7651/1020.
(4)Szasz T. The “placebo effect” [Online]. BMJ Rapid Response 2008 May 4 [cited 2008 May 7]. Available from: URL:http://www.bmj.com/cgi/eletters/336/7651/0#194707.
(5)Hegde BM. A perfection of means, and confusion of aims, seems to be our main problem [Online]. BMJ Rapid Response 2008 May 5 [cited 2008 May 7]. Available from: URL:http://www.bmj.com/cgi/eletters/336/7651/0#194632
Competing interests: None declared
Competing interests: No competing interests