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Placebo prozac

Author: joe

Sunday, 09 March, 2008 - 17:29

SSRIs are no better than placebo at treating depression in the majority of cases. It's been a couple of weeks since this story broke, but it was infinitely fascinating, and for a while I was amazed that no-one seemed to be examining the weird reflexive problem that breaking the story itself seemed to present. Placebo (in my limited understanding) works because patients believe they are being treated - and presumably the improvement in the psychological state of the patient has physiological benefits. But then if the national media tells everyone that even though the pills they take are actual 'medicines' as defined by NICE and the pharma-industry (rather than sugar-pills), actually the benefit they're getting is really only a placebo, doesn't that mean that you remove the efficacy of even the placebo (because now everyone knows their benefits are 'only' psychological)?

As the author of the report, (and by the way, isn't the PLOS open access peer-review journal an awesome thing), Irving Kirsch, stated on the Channel 4 News coverage:

one of the core characteristics of depression is a sense of hopelessness, and anything that combats that, and instils a sense of hope is going to help people feel better.

Doesn't the coverage of this report tell those patients that their hope is illusory? I know that about 10 years ago I enquired about a stop-smoking trial. The researcher taking applications said that the trial would use a placebo, and that half of the participants would be given a glucose sweet, while the other half would be given a 'placebo'. I mentioned that I had heard that glucose sweets helped to combat the physical symptoms of nicotine withdrawal because they mitigated the drop in blood sugar levels, and had tried it before (with obviously limited success). At this point, of course, the researcher said I couldn't take part because, since I had used glucose sweets before, I would be able to tell whether I was being given the sweets or the placebo, rendering my participation in the trial meaningless.

In fact, this is precisely the point of double-blind trials which use placebos: the researchers don't know who is getting the medicine and who the placebo; and equally, the patients don't know either. Ethically-speaking, they have to know there is a chance, because I think the procedural codes of these trials require that participants are told that some of them will receive placebo.

Of course, all of this acknowledges the fact that a patient's psychological state, their expectation, hope and optimism, has an important and measurable effect on the likelihood that their prognosis improves.

So it was interesting to see Ben Goldacre look at the topic in his unfailingly interesting column Bad Science:

Do drugs stop working if you know they are little better than a sugar pill? And do cultural factors, like our collective faith in a treatment, have a measurable effect on the benefits? On this, there has been a only tiny amount of highly tenuous research.

And in the little research that has been done on the subject, while some reports might imply that declining 'belief' in a medicine reduces its efficacy, there is also evidence that even when patients are told explicitly that they are being given a placebo, nevertheless, the treatment has a beneficial effect.

This, I suppose, gets the media off the hook for telling millions of people that their medicine is no better than sugar pills, and perhaps we'll see more in the coming years as to whether the use and efficacy of these SSRIs change. And of course, exposing the the cravenness of the pharma-industry can never be a bad thing. But it does still leave the question, what exactly is it about the change in expectation that using a placebo encourages, that works therapeutically, even when people know it is just a placebo? And, indeed, why can't I just heal my head, by believing it will be healed?

Categories: medicine, placebo, therapy, depression, pharmaceutical,
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