Understanding the placebo effect

Before addressing the topic of placebo effect, I would like to begin by explaining the initials following my name, so readers will know the credentials of the person addressing this topic. In Ohio, nurses who hold a master's or doctorate degree and are licensed as nurse practitioners, nurse midwives, nurse anesthetists and clinical nurse specialists are considered Advanced Practice Registered Nurses (APRN) and are licensed to treat clients and prescribe medications within their specialities. In my case, I treat adults with mental health concerns.

I chose the subject of the placebo effect because it has been an interest of mine for at least the past 10 years. To get FDA approval for a new medication, trials are conducted usually comparing the new chemical compound with a "fake" pill that looks exactly the same. The participants in the study do not know if they are getting the new medicine or a tablet with no active ingredient.

The findings of studies on the effectiveness of antidepressant medications are fairly consistent. All antidepressant medications show benefit for about 67 percent of the depressed study subjects and the percent of study subjects with depression who respond favorably to placebo is around 33 percent.

So when you know the response rate to placebo, you find that only about one-third of the study subjects receiving the new compound are most likely responding favorably to the active ingredient in the medication being tested.

Actually the overall levels of improvement which result from the chemical compound may be even lower as the persons receiving the medicine being tested may also in part be responding to the conditions of the study. Some are hopeful for a response and may begin more optimistic about the outcome, some respond to the caring and compassion of the prescriber, and we cannot discount the effect of being paid to participate in some studies.

Similar factors occur in non-study circumstances. A client may be treated for depression in a clinician's office and experience a noticeable amount of improvement after taking a low starting dose of medication for a short period of time. The client returns and asks the prescriber if the medication is working this well or "is this all in my head?"

The client's fear is that if it is psychological, the effect will not last. One helpful way to respond is "we can't know for sure," but it would be very helpful if the client's beliefs and expectations brought about at least some of the improvement as the placebo effect comes without the risk of side effects, unlike all pills with an active ingredient.

What factors can enhance the client's positive beliefs and expectations? There are many. Some may include having a friend or family member recommend the provider or the medication as having been of benefit to them. Other factors may include the appearance of the treatment setting, the professionalism of the treater, the level of interest and understanding the client feels was accorded her as opposed to feeling like another number, seen briefly and prescribed a medicine with little discussion or education about why this particular medicine.

We can take this discussion of the placebo effect a step further. There have been reports and studies with prescribers giving their clients the option of taking "a pill with no active ingredient" (full disclosure), to determine if it may be effective.

Clients are informed that the tablet has no active ingredient and has been found beneficial for some conditions. The client is given the option to try this alternative for a period of time and if there is no or an inadequate response, another option will be offered.

Studies show that benefits are more likely to accrue to persons with mild to moderate depressive symptoms, rather than severe depression. A few other examples of conditions that may improve include cancer-related fatigue, the symptoms of irritable bowel syndrome and chronic low back pain. Conditions that are defined by "self-observation" or more subjective findings show the most improvement. It is doubtful that a placebo can lower cholesterol or cure cancer.

The bottom line is that our beliefs and expectations can make a significant difference in terms of healing. The goal is to continue to discern what enhances the placebo effect, so these factors can be kept to a minimum in research studies of treatment efficacy, and on the other hand, the same factors can be maximized in treatment settings.