Search results for "therapy "
Placebo prozac
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?
Health fiction
Monday, 12 November, 2007 - 18:45
I considered going to the hospital carrying a copy of 'Narrative Based Medicine' by Greenhalgh and Hurwitz. My experience has become so reflexively, regressively contingent that I thought I might as well go the whole hog, and encourage the consultants and nurses, by noticing the book, to become radically self-aware of the experience they were creating around me.
Earlier in the year I registered for my PhD, which I intend to focus on the therapeutic uses of creative activity. There is evidence that people who keep journals during their treatment for serious illnesses such as cancer have a statistically significantly improved prognosis. Why might this be? Is it the case that our experiences of serious illness are such chaotic, disempowering transactions with the machine of healthcare, that the productive act of creating our own purposeful, narrativised story out of the bare, brute facts of therapy and treatment actually improves our bodies' ability to survive?
My father was diagnosed with cancer 7 years ago and died six months later. He said the process of pin-balling between consultants and treatments was frustrating precisely because doctors want to tell you as little as possible. Perhaps for good reason. Perhaps euphemism ('growths' rather than 'tumours') helps to minimise the psychological trauma. Perhaps a gradual induction into the language of primary and secondary, benign and malignant, potassium levels, morphine and death spray is a therapeutically beneficial approach, and ignorance is convalescent bliss. Perhaps knowing little, and trusting in the authority of the medicinal apparatus improves the prognosis.
"How is your hearing?" one nurse asked him. "Pardon?" he replied.
And so, as I have had constant headaches since February of this year, which usually recede only after the self-medication of Nurofen, I have been witnessing at first hand the efficiencies of the British healthcare system. And rather like a media studies student who is suddenly noticing how adverts are constructed, I can't not examine the story of illness (or lack of narrative) the actors in my performance are creating. My consultant informed first, not me, but his dictaphone, of my almost certainly necessary surgery. What surgery, I am still only able to speculate. It is sinusitis, an infection, pus in the ethmoid. Today's MRI scan of my head was olympically efficient - I arrived 15 mins early and had left the hospital by the time my appointment was supposed to take place. I, rather unnecessarily, slowed things down by asking the nurse what happened next. "Your scans go to the consultant now, and then he will contact you soon. Just turn left out of the doors."
Of course I have the problem of Einstein's observer, watching trains travelling in different directions at the speed of light. I'm in the train, and can't get out of it to look. I can't experience medicine without thinking about the experience of medicine, and I can't think about the experience without picking out the moments that are self-selected to illustrate the competing narratives that constitute the phenomenon of medical treatment.
I also can't help but think there is a certain kind of guilt associated with querying the treatment that our noble welfare-state doctors and nurses provide. One is supposed to say "mustn't grumble...", adopt the Blitz spirit, "there are people worse off than me..", "oh it's just a touch of sinusitis..." How self-indulgent to expect a consultant to spend an extra few minutes explaining the diagnosis and how the treatment will pan out, when he must dash off to start someone's heart any second now. "Remember that the appointment that you cannot attend is very valuable to someone in pain or distress" the leaflet says. Unusual, fatal, healing, fictions.
