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Lying, fake supplements, and the placebo effect

Posted 7 February 2015 by Matt Young

A somewhat outraged (but entirely justified) article by Timothy Egan in the Times reminded me of an interview I heard the other day on Fresh Air. First, the Egan article: Mr. Egan is properly outraged at the New York Attorney General's finding that dietary "supplements" sold by major retailers often contain none of the "active ingredient." Sorry, the scare quotes are mine, not Mr. Egan's, but I think they are entirely apt. Indeed, the fact that the "supplements" contains no active ingredient and people write testimonials to their efficacy hints that even dietary supplements that actually contain the active ingredient may be no more than placebos. Nobody knows, in part, because the dietary supplement industry in the US is virtually unregulated (see also the Times editorial here). Which brings me to Fresh Air. Terry Gross interviewed Johns Hopkins neuroscientist David Linden, the author of a recent book on the science of touch. Fascinating interview, but then, at the 29-min mark, Ms. Gross asked Professor Linden about the placebo effect. He paused and then answered,

The general thing I take from this is that, in the end, the substrate is biology. When things work, whether they are drugs or the placebo effect or acupuncture or meditation or psychotherapy, they work because they are changing the functions of brain circuitry, and my feeling is that, if it works, it works, and it should be used. There is no reason to abandon something that works just because we don't understand all the biological steps in the way it works. In truth, many of the most popular drugs in the armamentarium for neuropsychiatric disorders – we don't understand how they work anyway. We don't understand how antidepressants work. We don't understand how lithium works for bipolar disorder. So if the placebo effect works, then let's use it.

I cannot disagree that, if the placebo effect works, then we should use it. But how? Is it OK to lie to a patient and claim that some worthless herb is in fact a medication or that sticking needles here and there has some specific therapeutic effect? Or is there potentially a better way to harness the placebo effect and really make it work? Professor Linden may have been taken aback by the question, but I thought his response was a bit facile; I will be especially curious to read comments on how others, especially medical professionals, answer these questions.

47 Comments

ksplawn · 7 February 2015

Not related to the placebo effect directly, but in one of the articles I read covering the supplement finding, the supplement makers' representative claimed that the process of making the pills would render the DNA nonviable for testing purposes, so they were essentially trying to attack the results of the study.

One wonders. If the DNA did not survive the pillification intact, how any "active ingredient" is supposed to.

Matt Young · 7 February 2015

If the DNA did not survive the pillification intact, how any “active ingredient” is supposed to.

Homeopathy -- the herb remembers.

harold · 7 February 2015

ksplawn said: Not related to the placebo effect directly, but in one of the articles I read covering the supplement finding, the supplement makers' representative claimed that the process of making the pills would render the DNA nonviable for testing purposes, so they were essentially trying to attack the results of the study. One wonders. If the DNA did not survive the pillification intact, how any "active ingredient" is supposed to.
Not to defend crooked manufacturers who don't put the actual herb in the supplement, but it is true that sequenceable DNA can be denatured and fragmented by conditions that wouldn't much affect the concentration of some small organic acid or amine that may be the actual active ingredient. That's because to sequence DNA in a meaningful way you need intact strands. Conditions don't have to be strong enough to destroy the individual nucleic acids to mess up sequencing, just enough to chop up the long strands into individual nucleic acids and short strands of nucleic acids. I have no doubt that some herbal supplements blatantly don't even contain what they say the contain, but it isn't necessarily true that, say, treating willow bark in a way that made it hard to sequence DNA, would necessarily destroy the active ingredient. It probably would be possible to mess up the DNA while leaving concentrations of some other bioactive molecules intact.

DavidK · 7 February 2015

I heard that the good Senator Orrin Hatch from Utah has blocked efforts to bring supplements within the fold of FDA inspections and rules. Too much money donations at stake for him.

Robert Byers · 7 February 2015

This comment has been moved to The Bathroom Wall.

Scott F · 7 February 2015

I'm all for engaging the trolls when needed, but just this just cries out to be ignored. It's not even wrong.

phhht · 7 February 2015

Robert Byers said: read the interview. there are many good science of touch/senses on youtube. All this is not a problem for a thinking creationist. The placebo effect and other things in these cases do not change the brain but simply affect the triggering mechanism for the memory. Therefore they can affect the body. They can work. Anti depressants are not a mystery as to why they wortk. They simply depress or excite triggering mechanisms for memory. Depression is simply a stuck memory on some matter or without a matter. The doc can tell the patient that some remedy's work because, only, they affect our memories which affect our bodies profoundly .
What nonsense. What complete, utterly ignorant nonsense.

Scott F · 7 February 2015

Two things.

First, Is there any way to do a controlled study for the placebo effect? I mean, with a study of an actual drug, you substitute a sugar pill as the "control" (or some such thing). If you're studying the placebo effect of the sugar pill itself, what possible "control" can you use? No intervention at all, perhaps?

Second, as to the question of "lying" to a patient, might it be really lying? Every drug can have a range of concentrations and dosages. Often times you don't want to use more than you need. What if the bottom of the range of dosages is "zero"? You start at the "minimum" dosage, and work your way up until the desired effect is achieved. Or, perhaps you start at a high dosage, and titrate off, perhaps all the way to zero. Either way, if the patient is actually helped by the "minimum dosage", are you lying?

prongs · 7 February 2015

Remember "water memory"? The placebo (pure water) and the "water with memory" are supposed to have different effects, but are exactly the same.

"Water memory" still has true believers today. Just like cold fusion, and probably polywater too.

Chris · 8 February 2015

There is a better way: an honest placebo. I made the first one, Eebo Plus(tm), back in 2011. The idea is that a person knowingly uses the placebo; in fact, the honest placebo insists that the user study the placebo effect and understand that the only thing the placebo does is suggest an outcome. Oh, and Eebo Plus insists on doctor involvement and, of course, insists that the user continue to follow doctor recommendations in any case.

Since the product never deceives, a doctor could ethically recommend it. My hypothesis is that a doctor would recommend the honest placebo to replace another placebo that the patient was already using. For example, if the patient was replacing their real medication with homeopathic remedies, the doctor could properly decry the deception implicit in homeopathy and recommend an honest alternative.

Marilyn · 8 February 2015

When you're ill and the doctor won't prescribe you antibiotics in desperation it's possible you turn to the herbalist but to hear that the remedies don't contain the active ingredient is defeating once again. Ironically my doctor has prescribed me water for my ailment I have to cut down on the caffeine, so thinking I'm missing out I've started to look to other flavorings such as cinnamon and learnt of the properties of spices such as turmeric and ginger. Also after tasting my water I've invested in a kettle with a water filter to remove the limescale and chlorine and anything else that is as harmful as can be. 'Herbalife' the nutrition and shake company boasts they have a Nobel prize winner on there side developing their supplement tablets and food, there must be some honest brands out there.

harold · 8 February 2015

Scott F said: Two things. First, Is there any way to do a controlled study for the placebo effect? I mean, with a study of an actual drug, you substitute a sugar pill as the "control" (or some such thing). If you're studying the placebo effect of the sugar pill itself, what possible "control" can you use? No intervention at all, perhaps? Second, as to the question of "lying" to a patient, might it be really lying? Every drug can have a range of concentrations and dosages. Often times you don't want to use more than you need. What if the bottom of the range of dosages is "zero"? You start at the "minimum" dosage, and work your way up until the desired effect is achieved. Or, perhaps you start at a high dosage, and titrate off, perhaps all the way to zero. Either way, if the patient is actually helped by the "minimum dosage", are you lying?
Yes, it is easy to demonstrate but raises ethical issues. Relatively few medical trials today use even pure placebo, let alone totally untreated patients (often a new treatment is tested against an old one, or a treatment plus a new treatment is tested against just the old treatment). Fortunately, the placebo effect was documented in controlled trials at the dawn of scientific medicine and we don't need to repeat the work. From Wikipedia... "John Haygarth was the first to investigate the efficacy of the placebo effect in the 18th-century.[36] He tested a popular medical treatment of his time, called "Perkins tractors", and showed that the remedy was ineffectual by demonstrating that the results from a dummy remedy were just as useful as from the alleged "active" remedy.[37] This showed "to a degree which has never been suspected, what powerful influence upon diseases is produced by mere imagination".[38]"

DS · 8 February 2015

Byers seems to have contaminated Marilyn with his disease.

harold · 8 February 2015

Important note: I hope no-one uses the valuable information from this article to reinforce the incorrect idea that "herbal" medicines never work. Plenty of valuable medicines started as traditional herbal medicines (e.g. aspirin, digoxin, quinine, right off the top of my head). Plenty of herbal supplements probably contain the claimed ingredient, and work approximately as they are supposed to. It would be more remarkable if none of them ever worked. The problem is that, in the absence of any type of regulation, it's impossible to tell which contain the ingredients, and which ingredients have an effect.
Yes, it is easy to demonstrate but raises ethical issues.
To elaborate the logic, in case I was cryptic, Haygarth used an ethical method. There was no effective treatment so he tested a claimed remedy against a known placebo. His untreated control was implied. He ascribed all improvement in both groups, since it was equal, to placebo. A more rigorous, but unethical, method, would be to give one group effective treatment, a second group a placebo, and a third group nothing at all. The difference between the second and third group would be placebo. We don't need to do that because we have historical untreated controls, we know what the diseases do if left completely untreated, so untreated control groups are implied.
When you’re ill and the doctor won’t prescribe you antibiotics
It means your doctor thinks that you don't have a bacterial illness, and antibiotics would be useless. There is a small risk of side effects, you'd promote antibiotic resistant bacteria in the community, and it wouldn't make your viral illness any better. (In fairness antibiotics may provide mild symptom relief for people with an upper respiratory viral infection because overgrowth of basically harmless bacteria plays a minor role in the symptoms, but there are better ways to relieve the symptoms.)
in desperation it’s possible you turn to the herbalist
The herbalist doesn't have antibiotics either, unless they prescribe chichona tree root for malaria. There are two herbal things I think can be mildly helpful for common upper respiratory infections. In both cases the evidence is mixed, but in both cases, the products are cheap, there are essentially no reports of negative effects (caveat, absence of evidence is not quite the same as evidence of absence), and the evidence is somewhat suggestive. Unfortunately, one of them, echinacea, is notoriously one of the herbs that isn't even present in the products of some manufacturers (meaning that you can't be sure what actually is there). Pelargonium sidoides is even better supported. It's marketed as "natural" cold products that mimic conventional cold products, like "cherry flavored syrup". Conventional "cold medicines" actually tend to reduce duration, too, even though they are marketed solely for symptom relief. Chicken soup also have documented mild effectiveness. St John's wort certainly has mild psychological effects. A number of herbal products are certainly natural stimulants. Although if you want an herbal stimulant, I recommend caffeine, extracted by natural hot water from natural tea leaves, cocoa beans, or coffee beans.

Alex T · 8 February 2015

When things work, whether they are drugs or the placebo effect or acupuncture or meditation or psychotherapy, they work because they are changing the functions of brain circuitry, and my feeling is that, if it works, it works, and it should be used.
A few things jump out, maybe people can correct me. First, he seems to start with the presumption that they work. That seems ignorant or presumptuous at best, deceptive at worst. Second, he keeps talking about "the placebo effect" as if it were a single thing that was conclusively shown to exist. But is that the case? Re "the" placebo effect - when doing any medical study, there are a lot of factors at play. The experimenters have many degrees of freedom which they can use when analyzing the results and if they aren't blinded they can effectively manufacture statistical significance (if not clinical significance). If we are using subjective measurements then you have to deal with the Subject-expectancy effect where patients will tell the observers what they think they want to hear. And there's always the Hawthorne Effect where patients will work harder and pay closer attention to themselves and their symptoms just because they know they're being studied. All of these will show up as improvements even though nothing has changed, and they'll all get described as being a part of "the placebo effect". This is especially pernicious when dealing with SCAM studies where, for instance, acupuncture is compared with jabbing patients with toothpicks and both treatments have the same outcomes and instead of reporting this as a negative result, it's spun as a vindication of the placebo effect. He also says that these things change the functions of the brain. Well that's trivially true - watching a movie, forming a memory, sleeping, or just reading this sentence will change your brain. Doesn't mean you'd want that for treatment of any illness. Finally, on the subject of what benefits can be achieved, consider the study on asthma with placebos. Widely reported as saying that placebos can work just as well as albuterol, the actual result was scarily different: patients felt (reported) they had improved symptoms but objective measurements showed they had no physical improvements. That means patients who had the placebo could be walking around feeling better while still having restricted airways, a life-threatening situation. The placebo effect was, in effect, a dangerous delusion. If you check Respectful Insolence, you'll see countless examples of patients who took alt-med for cancer and convinced themselves they were improving even as they get worse & worse. Sometimes turning a treatable cancer into one that's eventually terminal. So when someone tells you that the placebo effect works, you shouldn't picture someone cured through the power of their mind, you should picture someone who delusionally believes they're better while they are still sick and getting sicker.

harold · 8 February 2015

A few things jump out, maybe people can correct me. First, he seems to start with the presumption that they work. That seems ignorant or presumptuous at best, deceptive at worst. Second, he keeps talking about “the placebo effect” as if it were a single thing that was conclusively shown to exist. But is that the case?
I think it's fair to say that a subjective perception of symptomatic improvement, when given something that the patient mistakes for an active medicine, does exist, has been documented will for over two centuries, and that all such effects are collectively known as placebo effects.
Re “the” placebo effect - when doing any medical study, there are a lot of factors at play. The experimenters have many degrees of freedom which they can use when analyzing the results and if they aren’t blinded they can effectively manufacture statistical significance (if not clinical significance). If we are using subjective measurements then you have to deal with the Subject-expectancy effect where patients will tell the observers what they think they want to hear. And there’s always the Hawthorne Effect where patients will work harder and pay closer attention to themselves and their symptoms just because they know they’re being studied. All of these will show up as improvements even though nothing has changed, and they’ll all get described as being a part of “the placebo effect”. This is especially pernicious when dealing with SCAM studies where, for instance, acupuncture is compared with jabbing patients with toothpicks and both treatments have the same outcomes and instead of reporting this as a negative result, it’s spun as a vindication of the placebo effect.
This is all true but when other factors are well controlled, the phenomenon known as the placebo effect does seem to exist. Also, some of what you describe here may be part of the placebo effect. The Hawthorne effect may be part of what causes the placebo effect.
He also says that these things change the functions of the brain. Well that’s trivially true - watching a movie, forming a memory, sleeping, or just reading this sentence will change your brain. Doesn’t mean you’d want that for treatment of any illness.
Apparently everyone agrees with the trivial observation that the placebo effect comes from the brain.
Finally, on the subject of what benefits can be achieved, consider the study on asthma with placebos. Widely reported as saying that placebos can work just as well as albuterol, the actual result was scarily different: patients felt (reported) they had improved symptoms but objective measurements showed they had no physical improvements. That means patients who had the placebo could be walking around feeling better while still having restricted airways, a life-threatening situation. The placebo effect was, in effect, a dangerous delusion. If you check Respectful Insolence, you’ll see countless examples of patients who took alt-med for cancer and convinced themselves they were improving even as they get worse & worse. Sometimes turning a treatable cancer into one that’s eventually terminal. So when someone tells you that the placebo effect works, you shouldn’t picture someone cured through the power of their mind, you should picture someone who delusionally believes they’re better while they are still sick and getting sicker.
Yes, the placebo effect is not a "miracle effect". The brain may make you feel subjectively better when you are given a placebo, but cancer cells won't respond significantly to that. No-one ever recommends placebo treatment for any serious illness. In fact, no ethical person ever recommends it for anything at all except an experimental control group, where appropriate. The actual physiologic impact of a placebo depends heavily on the condition for which it is given. There is a great deal of "mind body connection". If you feel emotional stress, your adrenal glands react, for example, with powerful systemic effects, including unequivocal effects on the immune system. Placebo might be "effective" for a purely psychosomatic disorder, but it isn't ethical to use it for that; if you think a patient's problems are psychosomatic, insight-oriented therapy and possibly psychiatric care, with medication if necessary, are indicated, not tricks with placebos. Placebo might help with some mild cases of hypertension, where psychological state can be important, but it would be unethical to offer placebo instead of real treatment. If you think exercise, meditation, and diet will work, you start with that and add medication if necessary. Again, no role for tricking the patient with placebo. Although psychological state has some unequivocal impact on the inflammatory/immune system, most obviously but not exclusively through actions of the adrenal cortex, placebo is clearly totally inadequate for serious infections, cancer, or dangerous autoimmune disorders like asthma, lupus, rheumatoid arthritis, etc. Offering placebo for these conditions is the action of dangerous, unethical quacks.

Paul Burnett · 8 February 2015

Marilyn said: ...there must be some honest brands out there.
No. There. Doesn't.

Alex T · 8 February 2015

harold - I don't think we disagree much. I'm replying in part to clarify or question a few small details.
I think it's fair to say that a subjective perception of symptomatic improvement, when given something that the patient mistakes for an active medicine, does exist, has been documented will for over two centuries, and that all such effects are collectively known as placebo effects.
You call it "placebo effects" (plural) which is a good start - I've got to get into that habit. Linden did not and I didn't get the impression he sees it as anything other than a quasi-magical healing aura. And since some of the factors comprising placebo effects aren't effects but biases & statistical errors, I'd think one shouldn't refer to it as "working", which he also does.
This is all true but when other factors are well controlled, the phenomenon known as the placebo effect does seem to exist.
I'd be interested if you have any more details or links. I've been paying attention when it comes up on Science Based Medicine but the closer anyone looks at it, the more it shrinks. It's the Placebo Effects of the Gaps :) I haven't seen any reason to think that, when you correct for the known factors, there's anything left over. Maybe it's handy to have a short-hand for all these things, but 'placebo effects' has the connotation of something that's almost supernatural.
No-one ever recommends placebo treatment for any serious illness. In fact, no ethical person ever recommends it for anything at all except an experimental control group, where appropriate.
There are homepathic nosodes for malaria, measles and pretty much any other disease they can squeeze onto a label. If that's not a placebo treatment for a serious disease, I don't know what is. I think you're saying that all ethical medical professionals would not compare treatment to a full placebo but to the best available treatment. But when Linden lists acupuncture in the same breath, then he's pretty much precluded medical ethics.
The actual physiologic impact of a placebo depends heavily on the condition for which it is given. There is a great deal of "mind body connection". If you feel emotional stress, your adrenal glands react, for example, with powerful systemic effects, including unequivocal effects on the immune system.
We know relaxation and talk-therapies like CBT can have big impacts on some disorders but despite acting on "mind body connection", it would be deceptive to call these as placebos. But like SCAM which always seeks to re-brand legitimate medicine as an 'alternative' (like running, yoga, or simple nutrition), this sounds an awful lot like an attempt to label anything that isn't a drug or surgical intervention as a placebo effect. But reducing stress doesn't need to be deceptive or shrouded in the 'placebo' cloak.

burllamb · 8 February 2015

"if it works, it works, and it should be used. "
No, no, no! Placebos do NOT work as therapeutic agents. The study, and therapeutic use, of placebos is called homeopathy, shamanry, quackery. Placebos are the very definition of "what does not work as a true medicine" in a proper clinical trial. The "placebo effect" is not a therapeutic modality - the "effect" is as a confounder within and only within the confines of a scientific clinical trial. Clinical trials are special situations. They are usually short-term, and involve protocols which have a (confounding) psychological subjective effect on patients. These effects are not therapy - they merely make interpretation of the true therapeutic effect of valid medicines more difficult because of the constraints of controlled clinical trials. Placebos do not "work" in real life. Whatever clinical effect they seem to have goes away over time. Any placebo that does seem to have a bona fide long-term beneficial effect is merely affecting a particular patient's psychosomatic profile. This idea of the placebo as confounder is crucial to the interpretation of clinical trials. For example, the clinical efficacy of antidepressants has become an issue because of a misunderstanding of the confounding nature of placebos. Psychiatrists who deal with actual patients in the real world, over long time periods, all know that antidepressants do, in fact, treat clinical depression. Indeed, that they work quite well is underscored by the statistics of depressed patients who are taken off their meds - large percentages of these patients commit suicide. Yet, there are many who believe that modern antidepressants do not work, because in clinical trials they often have difficulty outperforming the placebo in the study. This is not because these medicines do not have therapeutic advantage. It is because the placebo effect is especially HUGE in antidepressant trials. If David Linden thinks that a sugar pill has a proper place in the treatment of clinical depression, I suggest he be required to dig the graves of the tens of thousands of suicides his poorly conceived notions might produce.

harold · 8 February 2015

It’s the Placebo Effects of the Gaps :)
Okay, now I get it. We don't disagree at all. My use of the term "placebo effect" is the historic standard use of the term. I simply use it to mean any difference in outcome that a group given a mock treatment with a known inactive agent experiences, versus an implied group given neither treatment nor mock treatment. It isn't some "special magic", it's just the sum of all the psychological and possible mild physiological factors generated by the mock treatment. Of course psychologists are interested in all the different components and mechanisms of this effect. But when the focus is on treating physical disease, we simply want to maximize that effect in the control group, so that if there is a significantly greater change in the treatment group, we can be more sure that the change in the treatment group are due to something more than the sum of psychological effects of mock treatment. If some psychologist breaks down the placebo effect into components or shows how to detect it using imaging for radioactive glucose uptake in the brain or something, more power to them. But it's still part of the placebo effect. The term "placebo" is highly analogous to, and borders on being somewhat synonymous with, the term "bias". By giving an "effective placebo" to the control group, we hope to account for all the bias. Of course a psychologist might be interested in all the different types of bias and so on. Again, if someone is using the term "placebo" as if it means some kind of special magical force that we should use instead of real treatment, that is not what placebo means. Indeed, that is the opposite of what placebo means. Placebo is the total perception of improvement, which may include resolution of minor immune/inflammatory issues or mild hypertension since those are strongly related to psychological state, that the patient experiences due to the biases inherent in the perception of being treated. There can be no "placebo of the gaps" because explaining the placebo effect doesn't mean it isn't the placebo effect. We aren't using the term to mean "something mysterious". We're using it to mean "anything and everything that explains why patients who get mock treatment have slightly different outcomes from an implied control that gets neither real nor mock treatment". If some guy is saying "My overpriced ooga-booga pills are valid because they provide placebo effect", he is being ethically and logically wrong. Logically, we don't need his ooga-booga pills to create a placebo effect; we can do it with extremely low cost material.

Douglas Theobald · 8 February 2015

There is no placebo effect:

http://www.nejm.org/doi/full/10.1056/NEJM200105243442106

Is the Placebo Powerless? — An Analysis of Clinical Trials Comparing Placebo with No Treatment
Asbjørn Hróbjartsson, M.D., and Peter C. Gøtzsche, M.D.
N Engl J Med 2001; 344:1594-1602

Mike Elzinga · 8 February 2015

Douglas Theobald said: There is no placebo effect: http://www.nejm.org/doi/full/10.1056/NEJM200105243442106 Is the Placebo Powerless? — An Analysis of Clinical Trials Comparing Placebo with No Treatment Asbjørn Hróbjartsson, M.D., and Peter C. Gøtzsche, M.D. N Engl J Med 2001; 344:1594-1602
Nice! Remember Emily Rosa and "therapeutic" touch?

callahanpb · 8 February 2015

burllamb said: No, no, no! Placebos do NOT work as therapeutic agents. The study, and therapeutic use, of placebos is called homeopathy, shamanry, quackery. Placebos are the very definition of "what does not work as a true medicine" in a proper clinical trial.
Could a placebo be an effective treatment for hypochondria?

harold · 8 February 2015

Douglas Theobald said: There is no placebo effect: http://www.nejm.org/doi/full/10.1056/NEJM200105243442106 Is the Placebo Powerless? — An Analysis of Clinical Trials Comparing Placebo with No Treatment Asbjørn Hróbjartsson, M.D., and Peter C. Gøtzsche, M.D. N Engl J Med 2001; 344:1594-1602
Please read carefully. In the name of the designer almighty, there is a "placebo effect". If there is ever any difference between patients receiving a mock treatment and patients receiving no appearance of treatment for anything, then that is a placebo effect. That is what it means. If you say there is no placebo effect, you are arguing that this never happens, that patients given a sugar pill will never, ever even report feeling better, etc. That is a totally unreasonable position, and would be disproven by the mere existence of any placebo effect ever. What the article you are quoting argues, absolutely correctly, is that, although there are sometimes differences between patients receiving mock treatments and patients who receive no treatment at all (and those differences are the placebo effect, that is all the term means), those differences are not great enough to constitute a therapeutic effect.

harold · 8 February 2015

callahanpb said:
burllamb said: No, no, no! Placebos do NOT work as therapeutic agents. The study, and therapeutic use, of placebos is called homeopathy, shamanry, quackery. Placebos are the very definition of "what does not work as a true medicine" in a proper clinical trial.
Could a placebo be an effective treatment for hypochondria?
Absolutely not. Hypochondria is a lay term for a group of symptoms that can occur in diverse mental disorders, but the term hypochondriasis is used medically when that is the dominant problem, in absence of an underlying explanatory disorder like schizophrenia http://en.wikipedia.org/wiki/Hypochondriasis#Treatment I actually noted this quite emphatically above. To repeat several points, and I must say I am surprised at the level of repetition required... 1) Placebo effect is merely any and all biases that may result from the patient's perception of being treated and affect the patient's reported or measured response. 2) Placebo effect can be explained scientifically, that doesn't mean that there is no placebo effect, it means that there is a potential explanation for the existence of placebo effect. 3) Placebo effect does not mean "miracle effect", "therapeutic effect" or anything of the sort. It does not imply any magical cures. 4) There is never, ever an ethical reason to try to trick patients with a placebo. Patients on a trial understand in advance that they may receive placebo. Patients not enrolled in a trial should never be deliberately given a placebo. If you think the problem is psychosomatic that means ruling out all other possible explanations and recommending therapy, not trying to pull some kind of asinine trick with a placebo.

harold · 8 February 2015

asinine trick
It would be asinine for a health care professional to do this, that is.

Douglas Theobald · 8 February 2015

Harold, you seem to be confusing a placebo result with an effect. An effect implies causation. Just because a patient reports that the placebo was better than nothing at all is not evidence for an effect, i.e. that the placebo actually caused the result. It could just be random. Statistics of course comes into play here. Reread the conclusion of the study carefully.

callahanpb · 8 February 2015

harold said: Absolutely not. Hypochondria is a lay term for a group of symptoms that can occur in diverse mental disorders, but the term hypochondriasis is used medically when that is the dominant problem, in absence of an underlying explanatory disorder like schizophrenia http://en.wikipedia.org/wiki/Hypochondriasis#Treatment I actually noted this quite emphatically above.
I wasn't serious. It was just something that popped into my head, and not a very original thought. I now see you wrote:
Placebo might be “effective” for a purely psychosomatic disorder, but it isn’t ethical to use it for that;
but I missed that the first time around. I agree completely, now that I think about your comments a little. There is no valid case for using placebos in clinical practice. Doctors should provide effective treatments or concede that they don't have any. Someone who intentionally provided a placebo for a condition that turned out not to be psychosomatic after all would be (or should be) in very serious trouble.

callahanpb · 8 February 2015

I'm probably not alone in drawing medical wisdom from the MASH episodes of my childhood. In one, they built a dialysis machine using sausage casings. In another, they used placebos after running out of morphine.

harold · 8 February 2015

Douglas Theobald said: Harold, you seem to be confusing a placebo result with an effect. An effect implies causation. Just because a patient reports that the placebo was better than nothing at all is not evidence for an effect, i.e. that the placebo actually caused the result. It could just be random. Statistics of course comes into play here. Reread the conclusion of the study carefully.
The commonly used terminology is "placebo effect". That's the way the English langue works. Here is a discussion of the placebo effect from a medical web site for lay people that is usually fairly adequate - http://www.webmd.com/pain-management/what-is-the-placebo-effect You are perfectly free to call it the "placebo result" if you wish, but the rest of us have been calling it the "placebo effect" for hundreds of years and plan to continue to do so. It is NOT a therapeutic effect. It is an effect. It is the psychological effect of mock treatment, to state it briefly. Look, I don't think there is any reason for continued verbal dueling here. Sometimes a pill with no active ingredient or some other type of attention and mock treatment has a transient psychological effect, which may even include mild physiological changes. This is important, because when we test potential therapeutic agents we want to be sure that they have more than placebo effect. Think of "placebo effect" as "minimum effect of the mere appearance of treatment". That's what the terminology means. I may have sounded grouchy. Let me be more positive and persuasive. Your understanding of the basic issue, that placebos don't provide significant therapeutic benefits, is correct. Your only error was a semantic one. There is a "placebo effect", it's the minimal, largely psychological effect that they can produce. This is controlled for in medical trials.

harold · 8 February 2015

harold said:
Douglas Theobald said: Harold, you seem to be confusing a placebo result with an effect. An effect implies causation. Just because a patient reports that the placebo was better than nothing at all is not evidence for an effect, i.e. that the placebo actually caused the result. It could just be random. Statistics of course comes into play here. Reread the conclusion of the study carefully.
The commonly used terminology is "placebo effect". That's the way the English langue works. Here is a discussion of the placebo effect from a medical web site for lay people that is usually fairly adequate - http://www.webmd.com/pain-management/what-is-the-placebo-effect You are perfectly free to call it the "placebo result" if you wish, but the rest of us have been calling it the "placebo effect" for hundreds of years and plan to continue to do so. It is NOT a therapeutic effect. It is an effect. It is the psychological effect of mock treatment, to state it briefly. Look, I don't think there is any reason for continued verbal dueling here. Sometimes a pill with no active ingredient or some other type of attention and mock treatment has a transient psychological effect, which may even include mild physiological changes. This is important, because when we test potential therapeutic agents we want to be sure that they have more than placebo effect. Think of "placebo effect" as "minimum effect of the mere appearance of treatment". That's what the terminology means. I may have sounded grouchy. Let me be more positive and persuasive. Your understanding of the basic issue, that placebos don't provide significant therapeutic benefits, is correct. Your only error was a semantic one. There is a "placebo effect", it's the minimal, largely psychological effect that they can produce. This is controlled for in medical trials.
Also, part of the issue here is that quacks have begun suggesting that their products are worthwhile because of placebo effect. This is a misuse of the term placebo effect. Placebo effect means a transient sensation, perhaps even delusion, of some kind of improvement (OR equally, of negative side effects), when there is no real therapeutic activity. A product that only has placebo effect is worthless. There is no need for expensive quack nostrums to achieve a placebo effect. Creating placebo effect is not an ethical objective to begin with, and if it is created in an ethical context, such as a psychology experiment with appropriate subjects, expensive nostrums from quacks are not needed.

Douglas Theobald · 8 February 2015

harold said:
Douglas Theobald said: Harold, you seem to be confusing a placebo result with an effect. An effect implies causation. Just because a patient reports that the placebo was better than nothing at all is not evidence for an effect, i.e. that the placebo actually caused the result. It could just be random. Statistics of course comes into play here. Reread the conclusion of the study carefully.
The commonly used terminology is "placebo effect". That's the way the English langue works. Here is a discussion of the placebo effect from a medical web site for lay people that is usually fairly adequate - http://www.webmd.com/pain-management/what-is-the-placebo-effect You are perfectly free to call it the "placebo result" if you wish, but the rest of us have been calling it the "placebo effect" for hundreds of years and plan to continue to do so. It is NOT a therapeutic effect. It is an effect. It is the psychological effect of mock treatment, to state it briefly. Look, I don't think there is any reason for continued verbal dueling here. Sometimes a pill with no active ingredient or some other type of attention and mock treatment has a transient psychological effect, which may even include mild physiological changes. This is important, because when we test potential therapeutic agents we want to be sure that they have more than placebo effect. Think of "placebo effect" as "minimum effect of the mere appearance of treatment". That's what the terminology means. I may have sounded grouchy. Let me be more positive and persuasive. Your understanding of the basic issue, that placebos don't provide significant therapeutic benefits, is correct. Your only error was a semantic one. There is a "placebo effect", it's the minimal, largely psychological effect that they can produce. This is controlled for in medical trials.
Well then I must conclude you don't understand the article I linked to. And you also seem to be making up your own definitions. For objective outcomes, there is no evidence for a placebo effect, period. Of course certain individuals may have an apparent benefit, but the results from this study show that is a statistical artifact. To quote: "we found little evidence that placebos in general have powerful clinical effects. Placebos had no significant pooled effect on subjective or objective binary or continuous objective outcomes. " I.e., no placebo effect.

Mike Elzinga · 8 February 2015

So, apparently the pseudoscience in a sectarian's belief in ID/creationism doesn't cure sectarian angst about not being in control of society and what it teaches kids in public schools.

There is no "physical ingredient" of science within ID/creationism that allows control over natural events, yet it gives adherents the apparent smug satisfaction that they have a superior set of religious beliefs that makes them morally superior to secular society.

Instead of learning the real science, ID/creationists justify their beliefs by "metaphilosophical" arguments that are supposed to "rise above" and dispense with the need to put forth the effort to learn real science in order to debunk science and given them "peace of mind."

Clearly there are a lot of psychological events taking place that give come kind of comfort and relief to ID/creationists.

It would appear that the belief systems and beliefs about interrelationships among things in the universe have emotional - and perhaps subsequent physiological - effects that soothe anxieties about one's own relationships with the surrounding world.

There is no actual physical interaction with anything physical in the universe; only a belief that such an interaction exists. So a non-interaction with a non-existent external physical phenomenon isn't causing or affecting anything; but psychological states can and do affect physiological states. The "effects" come from within; not from without.

Mike Elzinga · 8 February 2015

There might be another counter-argument to a placebo affecting something.

Since something non-existent that has no interaction with any physical system in a person's body can't possibly cause anything - i.e., a placebo has no effect; it is the internal mental states that are affecting something - suppose we reverse the mental state and an external phenomenon that physically interacts with something in the body.

Convince someone that they are getting a placebo that will have no effect, but make it a chemical that will induce vomiting. Can believing it will have no effect stop the vomiting?

harold · 9 February 2015

Douglas Theobold mistakenly wrote -
Well then I must conclude you don’t understand the article I linked to.
Yet in fact the authors arrive at the same conclusion that I have been trying to get Douglas Theobold to understand. From the article (emphasis mine).
CONCLUSIONS We found little evidence in general that placebos had powerful clinical effects. Although placebos had no significant effects on objective or binary outcomes, they had possible small benefits in studies with continuous subjective outcomes and for the treatment of pain. Outside the setting of clinical trials, there is no justification for the use of placebos.
This is literally almost a perfect paraphrase of my prior comments. The placebo effect, to the extent that there is one, is a minor, psychological effect. In many settings a mock treatment may not even produce a placebo effect. The sole reason to be concerned with it is to be sure that real treatments have more than a placebo effect. However, if such an effect ever exists, we call it the placebo effect. It is exceptionally obvious that I completely agree with the authors of this study and endorse their conclusion. It does not surprise me that placebo effects are usually at best mild, and may even be difficult to document. As the FSM in her infinite patience and wisdom must be noting with an ironic chuckle, the sole message that I have been trying to get into stubborn heads here is that "the placebo effect" is just a term for any nonspecific, presumably psychological effect, which may occur, in some settings, if a mock treatment is given, as opposed to if nothing is given. It's a term that is highly related to "bias", "error", and so on. It's just a name for a trivial potential source of error. At a superficial level there is little difference between what I am saying and what Douglas Theobold is saying. I am saying that the placebo effect is a term for any weak psychological impact that a mock treatment may have, and that the only reason to care is to be sure that real treatments exceed this. Douglas Theobold is basically saying that such effects can never, ever exist. That's actually far less wrong than thinking such effects can cure cancer. However, it's a little bit wrong. Douglas Theobold is arguing that all medical studies, including those for treatment of subjective pain and the like, should never, ever use a placebo control, because there can never, ever be any kind of placebo effect. That is a fair logical extrapolation from his argument. Incidentally, Douglas Theobold, will you please demonstrate honesty and consistency by making the equivalent of the following statement: "I, Douglas Theobold, strongly agree that, since I am arguing that no placebo effect can ever exist under any circumstances, it follows logically from my claim that there is never, ever, any need for any placebo control in any medical or psychological trial whatsoever, and that the practice of using such controls should be immediately dispensed with?" Because that does follow logically from your claim. He should not ascribe this argument to the authors of the paper. The current consensus is that placebo effects can occasionally occur and we should use controls to make sure we don't mistake a placebo effect for a real effect. As I tried to explain to Douglas Theobold the authors are correctly arguing against any misguided idea that placebo effect is therapeutic, not denying the possible existence, ever, of any placebo effect.

harold · 9 February 2015

harold said: There is more than one scholarly article on the placebo effect, by the way
Damn link doesn't work; go to PubMed or Google Scholar and search for articles on placebo effect.

eric · 9 February 2015

I don't mind individual GPs using it in cases of minor illness, in particular where the goal is temporarily relieving symptoms and they have no better option. I would leave the choice of whether to do that or not up to the GP. What I *do* mind is:

1. GP's prescribing antibiotics for viruses, because that hurts all of us long-term

2. False advertising of herbal products with/without active ingredients...and/or lack of regulatory quality control that essentially results in the same. Included here is not just "lack of a promised ingredient," but also "including medicine not on the list," which I believe a couple of homeopathy manufacturers have gotten in serious trouble for. That's highly dangerous and highly unethical.

3. Doctors (and I'm speaking hypothetically here, I don't know of any cases) who would attempt to use the placebo effect to cure or mitigate serious illness. That, to my mind, is unethical because it prevents the patient from making a truly informed decision as to whether to seek other advice or other treatment options. If they think you're treating them and you aren't, then they may not go for a second opinion or seek out other medical help...and the results of that is on you. I consider that unethical. If some GP wants to prescribe sugar pills for the common cold, okay. When the sh*t gets serious, tell the truth, even if you think there's no option and they would feel better with a sugal pill.

***

My overall general thought here is that there are many more egregious systemic or ethical problems in medicine (like the three above) than the placebo effect. If we want to tackle problems in medicine that will make the system better, we could tackle a lot of things before the ethicalness of sugar pills for pain was worth a place at the table.

harold · 9 February 2015

eric -

I totally agree with you, but want to emphasize that except under some sort of bizarre concocted circumstance, deliberately prescribing placebo for anything is unethical.

No-one is deliberately prescribing pure placebo. There may be a fair degree of "this might help and it can't hurt" prescriptions for minor crap, but it's always in the hope of a true therapeutic effect.

In mainstream biomedical science, placebo effect is a type of bias we control for in trials, to make sure any statistically significant effect is real, not the product of either patient or investigator bias.

Medical ethics have shifted in the last five decades. Up through the 1950's, doctors tried to be ethical but took a view that concealing some information was beneficial to naïve patients. This view literally dates back at least to the Ancient Greeks. It's possible that as recently as the 1950's a doctor might have thought that it was in the best interest of the patient to trick them with a placebo, hoping it would make them feel better, or at least cared about.

That is no longer the case. We shifted to the model of the fully informed and autonomous patient (or person responsible for patient, where necessary) decades ago. We have found this to work better. The Ancient Greeks and Victorians meant well but their ethical system has been incrementally improved upon.

It violates basic medical ethics to deliberately give a placebo treatment. The answer to psychological problems is psychological and psychiatric treatment, not placebo.

burllamb · 9 February 2015

3. Doctors (and I’m speaking hypothetically here, I don’t know of any cases) who would attempt to use the placebo effect to cure or mitigate serious illness.
I know of lots of doctors who do this. They call themselves chiropractors, acupuncturists, and naturopaths. And they all like to be called "Doc".

eric · 9 February 2015

harold said: No-one is deliberately prescribing pure placebo. There may be a fair degree of "this might help and it can't hurt" prescriptions for minor crap, but it's always in the hope of a true therapeutic effect.
I disagree. A well-trained western doctor who gives out a prescription for antibiotics for the flu or a cold has no realistic expectation that there will be a 'true therapeutic effect.' And I think a lot of them do exactly that, just because they want the person out of their office and its easier than arguing. Modern doctors are extremely pressed for time, pressured by insurance companies to get people in and out fast, and they respond to that pressure by handing out useless prescriptions for problems they know will go away in time anyway, so as not to disgruntle their patients. Or take a look at the response to the 2001 Anthrax attacks and the distribution of Cipro. Literally hundreds of thousands of people took it, and the FDA knew this was medically wrong to do (see #6). They knew that for the vast, vast majority of people (exceeding 99.9%) coming in for treatment, the risks posed by potential side effects and statistical drug resistance was much much higher than the risk of actual anthrax inhalation. This was a political decision based on the placebo effect: we knew people would manifest psychosomatic symptoms, and we chose to hand out Cipro to fight them knowing Cipro as a drug is a placebo in terms of its ability to fight psychologically-induced symptoms. The same thing will inevitably occur in the future: bioattacks and wierd diseases produce hundreds or thousands of "worried well" for each actual sick person. Economically, we can't provide actual therapeutic treatment (hospital beds and doctor visits) to these people, its unfeasible. Politically, we can't tell them 'you aren't sick, go home.' So guess what intentional and planned response our political and medical establishments work together to provide? Placebos. They do it on purpose, they do it knowing exactly what the pills they hand out can and can't do.

Douglas Theobald · 9 February 2015

harold said: Douglas Theobold mistakenly wrote -
Well then I must conclude you don’t understand the article I linked to.
Yet in fact the authors arrive at the same conclusion that I have been trying to get Douglas Theobold to understand. From the article (emphasis mine).
CONCLUSIONS We found little evidence in general that placebos had powerful clinical effects. Although placebos had no significant effects on objective or binary outcomes, they had possible small benefits in studies with continuous subjective outcomes and for the treatment of pain. Outside the setting of clinical trials, there is no justification for the use of placebos.
This is literally almost a perfect paraphrase of my prior comments. The placebo effect, to the extent that there is one, is a minor, psychological effect. In many settings a mock treatment may not even produce a placebo effect. The sole reason to be concerned with it is to be sure that real treatments have more than a placebo effect. However, if such an effect ever exists, we call it the placebo effect. It is exceptionally obvious that I completely agree with the authors of this study and endorse their conclusion. It does not surprise me that placebo effects are usually at best mild, and may even be difficult to document. As the FSM in her infinite patience and wisdom must be noting with an ironic chuckle, the sole message that I have been trying to get into stubborn heads here is that "the placebo effect" is just a term for any nonspecific, presumably psychological effect, which may occur, in some settings, if a mock treatment is given, as opposed to if nothing is given. It's a term that is highly related to "bias", "error", and so on. It's just a name for a trivial potential source of error. At a superficial level there is little difference between what I am saying and what Douglas Theobold is saying. I am saying that the placebo effect is a term for any weak psychological impact that a mock treatment may have, and that the only reason to care is to be sure that real treatments exceed this. Douglas Theobold is basically saying that such effects can never, ever exist. That's actually far less wrong than thinking such effects can cure cancer. However, it's a little bit wrong. Douglas Theobold is arguing that all medical studies, including those for treatment of subjective pain and the like, should never, ever use a placebo control, because there can never, ever be any kind of placebo effect. That is a fair logical extrapolation from his argument. Incidentally, Douglas Theobold, will you please demonstrate honesty and consistency by making the equivalent of the following statement: "I, Douglas Theobold, strongly agree that, since I am arguing that no placebo effect can ever exist under any circumstances, it follows logically from my claim that there is never, ever, any need for any placebo control in any medical or psychological trial whatsoever, and that the practice of using such controls should be immediately dispensed with?" Because that does follow logically from your claim. He should not ascribe this argument to the authors of the paper. The current consensus is that placebo effects can occasionally occur and we should use controls to make sure we don't mistake a placebo effect for a real effect. As I tried to explain to Douglas Theobold the authors are correctly arguing against any misguided idea that placebo effect is therapeutic, not denying the possible existence, ever, of any placebo effect.
Harold, you are a nut. I'm not claiming there is no placebo effect whatsoever --- in fact, the paper I linked to show that there is, sometimes, a minor effect for subjective outcomes. But a large body of evidence, not confined to the single paper I linked to, now shows that for objective outcomes, there is no placebo effect. None. It's not that the "placebo effect" is not therapeutic, its that there is no effect from a placebo period for objective outcomes. If there is no effect then obviously the absent effect cannot be therapeutic. For subjective outcomes, the story is a bit different, and for certain subjective cases there may be a minor placebo affect. Whether we should use a real, yet minor placebo effect therapeutically is a different question. As far as negative controls, I am of course for them. Just because we have absolutely no reason to think the negative control will work is no reason to not use them. In fact, by definition we must have strong prior evidence that a negative control will be completely ineffectual --- otherwise its not a valid negative control.

CJColucci · 9 February 2015

I'm addicted to placebos. I tried to kick the habit, but then decided, why bother?

harold · 9 February 2015

Harold, you are a nut. I’m not claiming there is no placebo effect whatsoever — in fact, the paper I linked to show that there is, sometimes, a minor effect for subjective outcomes.
Whether I'm a nut is irrelevant, but this is exactly what I have been saying from my very first comment.
But a large body of evidence, not confined to the single paper I linked to, now shows that for objective outcomes, there is no placebo effect.
The name of that minor effect for subjective outcomes is "placebo effect". "a harmless pill, medicine, or procedure prescribed more for the psychological benefit to the patient than for any physiological effect."
None. It’s not that the “placebo effect” is not therapeutic, its that there is no effect from a placebo period for objective outcomes. If there is no effect then obviously the absent effect cannot be therapeutic. For subjective outcomes, the story is a bit different, and for certain subjective cases there may be a minor placebo affect. Whether we should use a real, yet minor placebo effect therapeutically is a different question.
Look, "placebo" means something that has no actual effect beyond the psychological. That was Haygarth's point in eighteenth century. Haygarth didn't think that "Perkin's tractors" were effective medication. He thought they were worthless. He proved that by showing that they were no better than placebo, providing only subjective improvement. That is what the term "placebo effect" has meant since then. Your own paper makes mention of an asthma study in which patients felt that they were doing better but by objective measure their asthma was just as bad. That is the placebo effect. That they felt they were doing better. As far as using placebos for any kind of therapy, it violates basic ethics. If you think the patient's problem is anxiety, you tell them that honestly and suggest effective treatments for anxiety.
As far as negative controls, I am of course for them. Just because we have absolutely no reason to think the negative control will work is no reason to not use them. In fact, by definition we must have strong prior evidence that a negative control will be completely ineffectual — otherwise its not a valid negative control.
A placebo is effectively a negative control, but we use it instead of doing nothing. That is so that we can be sure, particularly in cases where the therapeutic effect of the drug is mild, that the drug did something more than act as a placebo. Because we don't want to use drugs that act as placebos. Because you are right, they don't work in any important way. Now, we don't always use placebo controls. Penicillin was never tested in a controlled trial. It was blazingly obvious that patients given penicillin did radically better than patients given the best alternative available at the time. A placebo control would be really important in something like a trial for an anti-depressant. In a trial to see whether adding a new drug to the standard drugs would help in Hodgkin lymphoma, say, placebo is much less important. We know that placebos have no real effect on Hodgkin Lymphoma. It would be a felony to represent yourself as treating a Hodgkin lymphoma patient and then give them placebo.

bigdakine · 10 February 2015

CJColucci said: I'm addicted to placebos. I tried to kick the habit, but then decided, why bother?
The Placebo was Steve martin's favorite drug.

MememicBottleneck · 11 February 2015

CJColucci said: I'm addicted to placebos.
I hear they have a pill for that.

https://me.yahoo.com/a/VCNNdkJ8n848znvV2Pa9Jx6fbjhynPM5Uw--#7e243 · 24 February 2015

As harold notes, until ~100 years ago, it was considered ethical to administer a placebo. Today it is not. I don't think it was ever considered ethical to charge lots of money for them, however. Ironically, this may have impaired their psychosomatic efficacy:
http://www.medicalnewstoday.com/articles/288563.php

DNA_Jock