The placebo effect, the power of belief, and the mind-body relationship is fascinating. In fact, a desire to understand the mind-body connection was one of the reasons I originally studied neuroscience. This is a huge topic (hello mind-body medicine) so thought I’d start off by sharing this article from Monash University researcher Paul Biegler who presents the ethical dilemma …
If antidepressants may be no better than a placebo, why take them?
Seventeenth-century Oxford scholar Robert Burton’s lifework, The Anatomy of Melancholy, weighs in at a door-stopping 1,400 pages. But his cure for the “Black Choler” of depression came down to just six words: “Be not solitary, be not idle.” Writing today, he might add: “And maybe take a placebo.”
Placebos are sham treatments that work even though they lack an active ingredient. Pills made of sugar or corn starch have improved Parkinson’s disease, anxiety and pain. Now research suggests placebos may be as good as real drugs for treating depression.
In this most recent study, people with at least moderate depression received support and encouragement alone, or coupled with an antidepressant or a placebo. Those who received an antidepressant or placebo did better than those who got only support. But placebos improved depression nearly as much as the active drug and the difference wasn’t significant.
An earlier review found antidepressants offered minimal benefit over placebos except in very severe depression, where the benefit was substantial. And a 2008 study found antidepressants were no more effective even in severe depression; very depressed people were just less responsive to placebos.
One theory suggests placebos work because people expect them to. A grave doctor and austere consulting room help convince patients a drug works. Indeed, believing a dummy pill stops pain triggers endorphins in the same brain area targeted by real painkillers.
Another theory cites Pavlov’s dogs, who, after a while, just had to see the white coats of the assistants who brought their food to start drooling. This conditioning theory suggests people only need to see the pill, cream or syringe to get the intended effect, even without the active drug.
But we know active drugs cause placebo effects too. Painkillers work a lot better when a medical person says they will work. A 1998 study claimed placebo effects accounted for an estimated 75% of the effects of antidepressants.
Nonetheless, the drugs still figure prominently in Australian guidelines and in 2012-13 Australian doctors wrote 20.5 million prescriptions for antidepressants.
The right fit
But if antidepressants are little better than a placebo, why do so many people take them? Well, the placebo data have been criticised, among others, for selective analysis of studies. They may be wrong.
And there are reasons why doctors and patients might favour medication that could help even a little. A busy waiting room makes speedy prescription writing attractive; advertising could make doctors think of drugs as the first option; patients often want a “quick fix”; and our culture reinforces drugs as a natural response to illness.
A trickier question is whether doctors should even prescribe antidepressants if they are really just placebos. But placebos can be powerful and some argue we shouldn’t jeopardise their strength by telling patients. A 2008 US study of 1,200 doctors found more than half prescribe placebos, often vitamin pills.
But there may be differences between countries too. Direct-to-consumer advertising of prescription drugs, legal only in the United States and New Zealand, may influence placebo responses. Advertisements for drugs show dramatic improvements that heighten expectations. Pictures of smiling people and beautiful scenery also promote positive attitudes and beliefs.
Some think advertising is the reason placebos in antidepressant drug trials have become 14% more effective in the last 20 years.
And people with depression may show stronger placebo responses. Psychologist Irving Kirsch thinks this is because hopelessness is so dominant in depression. Placebos give hope so they may work better for this particular illness.
Limiting placebo use
Nonetheless, the American Medical Association has vetoed the use of deceptive placebos, saying they undermine trust, frustrate patient autonomy and delay proper treatment. But a 2010 study showed placebos work even if you tell the patient.
Others argue real drugs are actually superior placebos. In blinded drug trials, people who get side effects often work out they’re on the real drug and not the placebo. This makes them expect to improve, so the placebo effect kicks in.
But this too gets complicated because placebos can also cause side effects. This “nocebo” phenomenon happens when people expect bad things from a sugar pill. Maybe placebos will work better if the doctor “suggests” some side effects too?
An alternative to grappling with this often conflicting information is to raise the profile of non-drug treatments for depression. Psychotherapies such as cognitive behavioural therapy are as good as drugs, except for people with severe depression.
But adding another twist is a recent study that showed psychotherapy isn’t significantly better than a pill placebo for depression. Still, psychotherapy does provide important knowledge that promotes autonomy, a factor not measured in study comparisons.
Many active treatments are effective partly because of the placebo effect. The effect is strong in antidepressants, a fact that may need to be disclosed to patients to ensure fully informed consent. Whether sugar placebos should ever enter medical practice is another question entirely, and one that invites wide community debate.
The author of this article Paul Biegler has received funding from the Australian Research Council. He is a former emergency physician and the author of The Ethical Treatment of Depression: Autonomy through Psychotherapy (MIT Press 2011) which won the Australian Museum Eureka Prize for Research in Ethics.
This article was originally published on The Conversation. Read the original article. Image credit “Prozac pills” by Tom Varco – Own work. Licensed under Creative Commons Attribution-Share Alike 3.0 via Wikimedia Commons.
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Do you think doctors should tell patients any effects of antidepressants might be partly because of the placebo effect?
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About Dr Sarah
I’m an Oxford University-educated neuroscientist, presenter of ABC Catalyst, director of The Neuroscience Academy, and author of The Women's Brain Book. The neuroscience of health, hormones and happiness.
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Hello, Sarah…the tragedy in Sidney is terrible, I am not insensitive to these events, however out of a need to survive the sadness, the anger, the despair, the feeling of helplessness, and weakness to be able to do anything to stop people from acting out their pain and anger..thus I have learned the crisis, chaos, danger=opportunity mode of acceptance of powerlessness over the occurrences. These have become the “norm” rather than the infrequent incidence. Thus I have learned to expect trauma, and tragedy rather than peace and wellness and lovingness… and as I am far from being insensitive, I cry internally, I shout silently, I grieve continually…thus open to any and all opportunities to reach out and share this with others in order to show them there is peace within when we look at others and try to palliate their crisis with love. Even if it is as slight as their car died, or they injured their leg…each crisis in that moment in an inconvenience beyond tolerable to many. So when we reach out and help them look at REAL suffering that others have no control over (such as the Veteran with no legs or the people living a nightmare beyond tolerable, in Sidney.
This is actually connected with the placebo/anti depression question. We need not to numb our feelings, not look for a quick fix for the pain, not do the easiest action, but we need to FEEL all the pain, in order to learn compassion for all the other people who are suffering, and to learn what we can do for another human who is suffering, because reaching out with acceptance, understanding, and compassionate love is the only way to heal our chaos/crisis/traumatic PTSD/ sadness/ helplessness. STRENGTH comes from compassion, and doing for others not being self centered, self absorbed. The Doctor should have some other means to help people deal/cope/ transfer the loss/pain and transform all that sadness (because holding onto it is usually a selfish act where we are self absorbed and needy for attention) than pills/ painkillers& antidepressants. They keep people a cripple rather than a strength and force to soothe others and pick the next causality up. This is what makes the solider to solider connection so strong…they say they are willing to go back into the action for the sake of their injured and fallen brothers. They admit that they have never had such a connection with any person as they have with their was buddies…WHY? because they feel what the other one feels, they each have the others back and they will risk their lives for each other…they know their Bro feels the same…trust, love, strength…it’d when they come home and lose that connection that they become suicidal…they,(unlike us here at home) have formed a bond of cohesiveness, a common bond. If they were all out fighting as an individual solider, fighting alone…they would never prevail.
Many of us don’t want to face our pain, thus depend on the drugs…they don’t even know IF they are getting any benefit from them…when getting out and meeting a challenge, engaging in an activity of public service, will give other the feeling of self worth, and they will shed their need to medicate…life would have true meaning. Even a placebo is offering a crutch rather than building strength of character by exercising good will and practicing being grateful for what we do have, not what we have lost. Materialism seems to be more powerful for way too many than exercising our brains in areas of how we can ease others suffering.
I wonder if you checked out Dr. Gabor Mate’s site/
May you feel the love and comfort I feel deeply and send your way, they may not be people we know, however they are people/humans/ that others love and care about…may all our hearts sob with the injustice and loss. Than rise up and give out of our larder, with no thoughts of self, in complete faith we will be rewarded ten fold…the universe provides, as long as we listen to our hearts.
Peace and kindness,
Hi Sarah, great article, absolutely fascinated by the placebo affect, mainly because as a coach its one of my main tools principally by the fact that I have to believe that their going to make the change that they need and I’f I’m absolutely congruent with it they will pick up on it and half way there, I once read an article on anti depressant medication trails in a psychology today magazine and that on a scale of one to ten on effectiveness, the very best real drugs scored somewhere from 5-6 on effectiveness while the least affective scored more or less around 3-4, the interesting thing is that placebo’s regularly scored in the range of 5-5.5. I loved your analogy about Pavlov’s dogs and have heard another story that it took just seeing the lab coats to start salivating and then it was the sound of the cupboard for the tuning fork and then the assistant coming in for the day. 🙂
Interesting heartfelt reply Joan thanks for putting my onto Dr Mate, In how we perceive suffering just thought you might be interested in the work of Dr John Demartini and his work on Values and Voids