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This is fascinating. The title is incomplete; the most interesting part of the article is that the placebo effect varies not just among placebos, but in time, for the same placebo!
_The implications of this are pretty serious - the placebo effect in the United States has actually become quite a lot stronger over time, meaning that drugs that once would have been approved may not be now - because their performance relative to that of placebo is less convincing._
The reason why is not explained. It would be good to know more.
The other thing that is surprising is that the effect of (effective) drugs doesn't vary over time; one would think the effect of a drug is placebo+drug, i.e. that the effect of the drug is on top that of the placebo, since obviously a drug is also a placebo. And so, if the placebo gets better with time, then the drug should too. But it doesn't seem to be the case.
Maybe I'm underthinking it, but isn't it likely that the duck is actually a duck? We are approving less effective medications than we used to, because pharma companies are better than they used to be at working the system.
I am not sure thats exactly what the article was saying, picture 3.B [1] seems to show that the placebos themselves are getting stronger over time, both in an absolute sense, and relative to the drugs.
Approving less effective medications could definitely explain the improvement placebos relative to drugs, but not the improvement of placebos relative to placebos.
I wonder, and as I am kinda young, I am not sure, but since 1990, has the experience of the "Doctors Office" become more standardized? As in, are placebos looking less* like placebos?
[1].
https://cdn.substack.com/image/fetch/f_auto,q_auto:good,fl_p...
* accidentally wrote more
This increasing placebo effect over time has been discussed for a number of years now. I'm familiar with it in the context of antidepressant efficacy, which has shown decreased effects over time relative to placebos for the reasons outlined in the piece.
There was supposed to be a big study of it jointly between the FDA and pharm companies, but the results were never published. I have this fuzzy memory that the FDA arranged something where the pharm companies would basically open their data vaults under the condition that nothing would be publicly released.
The speculation was, at least with antidepressants, that when antidepressants were first gaining traction, that people were unfamiliar with them and skeptical of the idea that a pill would decrease depression, or would do so without lots of side effects etc. As time went on, the theory goes, people developed this schema that "pill equals feeling more happy, less depressed" and so the placebo effect increased. So the increase in placebo efficacy had more to do with changing culturally mediated expectations (marketing?) than anything else.
Or at least that was the theory last time I read about it in any depth.
This stuff is fascinating to me for all sorts of reasons really and I believe it's really understudied.
There's some analogous debates in the psychotherapy literature, for what it's worth. The problem there is that therapy has been shown to work in all sorts of ways, but different types of therapy don't really have differential efficacy, espcially when you control for publication bias etc. But designing a "behavioral placebo" is really difficult, in part because it's so transparent, but also because at some point a behavioral control starts to look like a therapy. You can use drug placebos as controls, but that's not really the same.
My guess is the implications of placebo effects extend far beyond medicine into all sorts of other things, into psychosocial phenomena etc. E.g., what about a placebo for quality of living increases? Relationship satisfaction? Etc.
The differences in effect were so intuitive I’d either already assumed them or they came to me before reading each respective outcome. Which I’d attribute to thinking a lot about what contributes to a placebo effect before reading this (which is good for my critical thinking, but bad for my capacity to benefit from good bedside manner, perceived competence, etc).
What surprised me was I hadn’t thought at all about how this systemically affects care, i.e. treatment approval for lower effectiveness relative to placebo (bad for my critical thinking!).
What wouldn’t have ever crossed my mind in a million years is the possibility that there could be some bias in favor of those social factors in the US medical system. In my experience, the people serving the most vulnerable and unable to access care have exceptionally poor bedside manner and appear exceptionally incompetent; it’s probably through no fault of their own, they’re likely overworked and seriously under-resourced. But I would have expected that to show the US as less responsive to the placebo effect, not more. (I’m assuming there are substituted placebo false positives which stand in for attentive medical care in these scenarios, which would very much line up with experiences I’ve had and many of my loved ones have had being pushed antidepressants and pain killers and such for any inconvenient medical issue.)
This article seems to forget that all the placebo effects should be visible in the responses to the actual medicine. You see a stronger placebo effect from a shot, so both the placebo shot and the medicinal shot's results should have a similar amount of people relieved just by getting such a shot. I assume medicinal studies require the same kind of dose and administration already.
This is why they talk about improvement over placebo
This is what drives me crazy about people who dismiss alternative therapies as placebo and therefore worthless. There's something mich more interesting going on, and studies on the placebo effect have barely scratched the surface regarding the range of placebo effects and what can modulate the strength of those effects.
> There's something mich more interesting going on
But at that point, it's not the therapy itself that's doing it, so we're right to dismiss them as worthless.
Do these pills work? No, we couldn't separate their effects from placebo, so there is nothing about these pills that work. Should we investigate placebo effects? Sure, definitely, they are interesting. Doesn't mean that the alt-med added anything to any picture though.
My mom was an advocate of therapeutic touch, which was taught in nursing schools and was reportedly effective in hospital settings.
Is there something to it? I don’t know, but nobody really does as real trials aren’t financially practical.
The vast majority of people have at least some positive emotional response to kind, attentive physical touch. It’s important to acknowledge that there are people who don’t and for them it’s detrimental (I am one of both depending on circumstances).
Even if there isn’t a clinical trial that specifically validates it, I think it’s a reasonable assumption that kind and attentive communication (to determine welcomeness of touch) and kind attentive touch can benefit most patients.
I'm sure it's beneficial, I know there's a ton of studies on the importance of touch for infant health in particular.
I don't know if there is or not, but if I'm ever dying alone in a hospice and therapeutic manual therapy is offered I assure you I'll take it.
So are you advocating taking alternative therapies more seriously as advanced placebos or something? Do you question whether it’s important to distinguish between the placebo and a “real” effect?
I do think the distinction is important, but I'd hope for a more precise terminology than "real" vs "fake" effects. "psychosomatic" is okay but has some similar baggage. There should be a thorough technical vocabulary for "placebo" effects. Currently the biological mechanisms aren't even understood for many of the effects.
I'm all for more precise terminology, and yes "real" would not be that terminology.
As far as distinguishing mechanisms, for any drug that doesn't have a perceptible side effect (drowsiness, euphoria, numbness, etc), it seems the only assumption required is that the effect is due to _some_ chemical property. That doesn't require much understanding to make a meaningful distinction.
Yeah, I think it's a cultural and systemic issue, not a vocabulary issue. Similar to how words like crippled and retarded became slurs. The problem is not the word, it's that we have cultural connotations associated with these conditions, no matter what name we call it by.
I agree the effectiveness of placebo shouldn’t be so readily dismissed. I also think it would be good, for a lot of patients for a lot of diagnostics, to treat somatic symptoms as real. They are real, at least for the person experiencing them, but often objectively too.
One thing I've seen about alternative therapies that work better than "mainstream" medicine simply has to do with a therapist who actually cares about his patients, and at the same time, suggests positive lifestyle changes.
The same effect could be achieved by skipping the magic rituals and by replacing the therapist by a doctor, problem is: we don't have enough doctors! As a result, doctor appointments are rushed. A 10 minute diagnostic, get your prescription, take your medicine, next patient. No time to discuss how your life is going, how you eat, how you sleep, the kind of exercise you are doing, make suggestions, etc...
Homeopathy is one of the best example. The sugar pills don't matter. What matters is that you are supposed to spend a lot of time with your homeopath so that he can find the right treatment for you, good practice also require an impeccable lifestyle. Hahnemann, the father of homeopathy recommended rest, a good diet, good hygiene, sunshine and fresh air. Yep, by telling you to open the windows, homeopathy can prevent covid!
> The same effect could be achieved by skipping the magic rituals and by replacing the therapist by a doctor
This is not in evidence and deserves a supporting case.
Here is my source (in french):
https://lepharmachien.com/reiki/
It is linked to the study here:
https://pubmed.ncbi.nlm.nih.gov/21531671/
This is a bit of an extrapolation from the study. The study just says that real reiki and sham reiki (placebo) work just as well at improving cancer patients comfort, and are better than doing nothing.
Now if there is an actual study that compares the efficacy of typical "rushed" care vs a more "holistic" approach by doctors vs alternative therapies, I would be very interested.
I can only use translate for the text of the first link, and from the title/abstract of the second both appear to support the portions of your comment I didn’t dispute. I agree with those. To clarify where I take issue, I’ll requote the portion that stands out as unsupported to me:
> The same effect could be achieved […] by replacing the therapist by a doctor
Therapists, across a wide spectrum of practices and disciplines, are doing a whole job without also addressing their patients’ medical needs. The inverse is true too. While some increased focus on emotional wellbeing by medical practitioners would absolutely be welcome, I think it’s _a very bold claim_ that they could replace therapists even “just” in a medical context. It’s also quite a lot of burden to place on doctors and patients alike.
I’m all for doctors appreciating the psychological benefits of emotional care, but I don’t think that’s nearly enough to “replace the therapist”, even if anyone involved actually wanted that.
I don't know what Reiki is, but maybe it's actually just really easy to learn, and the people who happened to name it don't have a monopoly on the behaviors that it consists of.
It is a form of energy healing mediated by touch. Behavior-wise you are just touching people, so yes, really easy, but it is not what reiki is about.
In the study, the sham reiki was performed by a non-believer who thought about maths problems while doing his things, as to completely eliminate the spiritual aspect.
On alternative therapy: is the magnitude and actual relief from the placebo effect (e.g. how much pain relief are we really talking here) more important than the damage it causes by promoting unscientific thinking (e.g. which gives rise to avoiding vaccinations or avoiding chemotherapy that directly leads to deaths)?
What's the most impressive placebo effect and its limits? Can it cure cancer? Fix broken bones? Give you virus immunity? Is it mostly a bit of pain relief we're talking about?
Can we take advantage of this effect without having to wrap it with all the unscientific thinking and pseudoscience that comes with alternative therapy?
Whenever I read people defending alternative medicine and how powerful the placebo effect is, I don't think e.g. a little bit of pain relief is good enough to justify billion dollar industries that are allowed to sell products where they can't prove they work more than a placebo. This is as close as you can get to saying it's been proven these medicines do not work and yet they're still allowed to sell them.
You can't confuse the public like this and be surprised when they won't listen to the science behind masks and vaccines.
>Can we take advantage of this effect without having to wrap it with all the unscientific thinking and pseudoscience that comes with alternative therapy?
New thought is probably an attempt to do that, one could say it seeks to isolate pure belief and apply it to problems directly. Not sure if you'd call it unscientific or very scientific.
That kind of consideration should not influence medical empirics or practice. If placebo is a real phenomenon, it needs to be understood.
To the dead comment talking about the second Pfizer dose, it's nothing to do with placebo, it's because the first dose induced memory in the cell-mediated immune systems. You can feel the aggressive cytokine, killer T-cell, and interferon response. If I remember correctly, they are most of the cause of people "feeling sick" during (and after, in the case of a cytokine storm) a viral infection.
He is feeling nauseous because of this response you are talking about? You mention that a viral infection causes it. Can you elaborate on this? He got the second Pfizer dose. What does it have to do with viral infection?
He mentioned no "viral infection". He mentioned an immune system response. Feelings of nausea are, exactly, an immune system response.
When I received my second COVID-19 shot, I felt nauseous for days. The person who administered it was a lot older than the first. Normally I am very strong so it was weird that I felt anything. I feel like this placebo effect is exactly what was the difference for me, now that you mention it.
"This study makes the point clearly - by 2013, drugs produced 8.9% more pain relief than placebos, compared to 27.3% in 1996. In the charts above, it can be seen that the effect of placebo drugs has increased a lot, whereas the effectiveness of pain relief drugs has barely changed, meaning that the treatment advantage (the effectiveness of active drugs as opposed to placebos) has fallen dramatically. Weirdly, it seems like this is only happening in the United States, whereas other countries haven’t seen particularly large increases in the effect size of placebos."
Forever, Pharmaceutical companies were cherry picking studies that proved their drug worked better than Placebo.
Drug companies are notorious for dropping a study that didn't show their drug in a positive light, and including a better study.
A Psychologist (Irving Kirsch--I belive?) started to wonder if antidepressants actually work, after seeing so much treatment failure. I belive he took them for awhile.
He decided to look into the drug studies, but included All the studies.
He used the Freedom of Information Act to get the all the drug studies from the government. Not just the cherry picked ones. He found that antidepressants don't work better than placebo.
When the drug companies, and Psychiatrists, heard about his work they got nervous. A psychiatrists bread and butter is dolling out these drugs at $450 office visits.
Well--he upset the boys. He even concluded with his research that drugs might make depression worse in some patients.
This was a decade ago I believe.
Current studies are a tiny bit more positive in terms of antidepressant drugs that might work in some people.
(I was interested in this research because I probally tried 8 antidepressants over the years, and felt just worse. I just couldn't understand it. I felt terrible, but the drugs did absolutely nothing besides making by noodle soft. Actually could orgasm, or it took circus help. I still have a ex-girlfriend who thought it was her. I told her everytime it's the meds, and not you.
I'm to tired to hunt down his study, but one of you can.
My point is two fold.
1. Drug companies play with stastistics, and even studies (dropping a study because it didn't pan out is wrong).
2. I have a weird feeling Pharmacutical lawyers have been telling those executives to be more ethical over the years in order to thwart off lawsuits.
I feel certain drugs, even the older drugs, might not work as well as we think. We just trusted drug companies up until lately.
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