I’m going to take a break for a while from writing posts on COVID-19. I will do a post later on the Omicron variant, but we don’t yet know enough about it to make that useful right now. This post is about a powerful effect of any treatment that is independent of its direct effect on a system in the body.
Placebos in double blind trials
We normally think of placebos (medicines that have no direct effect) in the context of research. In order to tell if any treatment really works it has to be compared to a placebo. In this kind of research the placebo is an inactive pill that looks just like the active pill being tested. Why is it necessary to use placebos in clinical trials? Because a substantial portion, often up to twenty to thirty per cent of people will get better with the inactive medicine. These are not people just convincing themselves that they are better. One can measure changes in endorphins (the body’s natural pain killer) and other physiological changes. This is powerful medicine!
The placebo effect in everyday medical care
Placebo effects happen all the time in any visit to a health professional and with any medicine that is prescribed. I prefer to call these context effects. The word placebo should be reserved for clinical trials. It would be unethical for a clinician to give a patient something that he or she knew was inactive. Nonetheless there are context effects that enhance the effect of any active medicine or treatment. Master clinicians know this and know how to maximize the context effects that enhance the effect of any treatment. Below are a few of the things that clinicians can do that research has shown produce context effects that enhance medical treatment.
Believing in the treatment
Clinicians who really believe that a treatment will work explain it confidently and maximize the patient’s hope and expectation that he/she will get better.
Invite patients to be partners
Patients who feel that they have some control over treatment decisions and/or timing have less pain and side effects from medicines. The clinician must be still be seen as the confident leader of the treatment team in order to maximize this context effect.
Patient Factors
Expectation that a treatment will work produces the strongest context effects. Context effects are also strengthened by the amount of confidence a person has in his/her physician.
How big are context effects?
The best way to evaluate the power of context effects is to look at data from treatments that were thought initially to be effective and were later found out to be ineffective in clinical trials. In a study of five treatments for angina (heart pain related to partial blockage of blood flow to the heart) that were later shown to be ineffective it was found that over 80% of the patients who received these treatments had substantial improvement in their heart pain that in some cases lasted for a year or more! That is a powerful effect!
How do context effects work?
Expectation that a treatment will work produces physiological changes. I already talked about how patients produce opioid substances called endorphins that can decrease pain.
Another example is Parkinson’s disease. People with Parkinson’s disease have trouble starting movements. A placebo that a Parkinson’s patient expects will help their movement causes measurable releases of dopamine in the brain that does in fact help them move better.
Context effects may also affect the immune system. Reseach is ongoing here, but it is possible that a positive attitude may speed recovery from or even prevent certain infections.
Nocebo effects
There are also things that clinicians or other health professionals can do that can make a patient worse, despite being given the correct medicine. As opposed to the placebo effect, things that make people worse are called nocebo effects. If a researcher carefully explains all the possible side effects of a medicine in a placebo controlled clinical trial, a substantial portion of the people who get the placebo (inactive medicine) will experience some of the side effects that they were told about. This also happens in clinical practice with effective medicines. Some clinicians, worried about malpractice law suits, will detail all the possible side effects of a medicine or treatment and remain somewhat neutral about the positive effects. In this case the patient is much more likely to have side effects from the medicine than if the clinician emphasizes the potential benefit of the medicine.
Patients who expect to have lots of pain after a surgical procedure will experience much more pain than someone who expects to be able to manage their pain after the same surgical procedure.
What can you do?
Many years ago, Norman Vincent Peale wrote a book called ”The Power of Positive Thinking.” At the time, there was absolutely no evidence for his claims. It turns out though that now there is a lot of evidence supporting health benefits of a positive attitude. Many studies have shown that optimists are healthier than pessimists, have up to 50% less heart disease than pessimists and have longer life expectancy then pessimists. Pessimists are more realistic about their expectations than optimists, but that realism comes with less good health. Clearly optimists experience positive context effects. What you can do to maximize these effects on your health is to cultivate a positive attitude in general. Easier said than done, of course, but the evidence is clear.
Bottom Line
The context in which medicines and other treatments are administered can have powerful physiologic effects independent of the direct effect of the medicine or treatment. These effects can be positive or negative. Clinicians can enhance the effect of medicines or treatments by projecting confidence that patients will improve and by giving patients appropriate control over decisions about treatment and timing of treatment. Patients who have confidence in their physician and who have high expectations of treatment also are more likely to have positive context effects. A positive attitude in general leads to less illness, less chronic disease and a longer life expectancy.