

Even Knowingly Taking A Placebo Seems To Help (2010) - fakenBisEsRult
http://www.npr.org/2010/12/23/132276823/Even-Knowingly-Taking-A-Placebo-Seems-To-Help

======
tokenadult
Now why did I know that Ted Kaptchuk[1] would be the quoted "expert" (he is
not a medical doctor) in this 23 December 2010 story even before I read it?
Because he is always the guy pushing this line[2] in press releases[3] that
get picked up by the popular media.

Meanwhile, the medical researchers who look at the issue with proper study
designs and statistical controls know that placebos are essentially useless,
as they at most have influence just on self-reported subjective symptoms, not
on any sign that affects the progression of a disease or maintenance of good
health.[4] Ladies and gentlemen, you know you aren't going to seek "placebo
medicine" if you have cancer or congestive heart failure, and you know that no
compassionate parent would seek "placebo medicine" for minor children who have
a childhood disease. So why does this topic keep coming up over and over and
over here on Hacker News, now most recently from a brand-new participant here?
Take the time and effort to learn a bit more about the actual research base
before assuming that this story is anything other than the outcome of
carefully crafted press release.

Findings on placebo effects by researchers who have considered the issue
carefully include

"Despite the spin of the authors – these results put placebo medicine into
crystal clear perspective, and I think they are generalizable and consistent
with other placebo studies. For objective physiological outcomes, there is no
significant placebo effect. Placebos are no better than no treatment at
all."[5]

"We did not find that placebo interventions have important clinical effects in
general. However, in certain settings placebo interventions can influence
patient-reported outcomes, especially pain and nausea, though it is difficult
to distinguish patient-reported effects of placebo from biased reporting. The
effect on pain varied, even among trials with low risk of bias, from
negligible to clinically important. Variations in the effect of placebo were
partly explained by variations in how trials were conducted and how patients
were informed."[6]

[1] [http://harvardmagazine.com/2013/01/the-placebo-
phenomenon](http://harvardmagazine.com/2013/01/the-placebo-phenomenon)

[2] [http://www.sciencebasedmedicine.org/dummy-medicine-dummy-
doc...](http://www.sciencebasedmedicine.org/dummy-medicine-dummy-doctors-and-
a-dummy-degree-part-2-1-harvard-medical-school-and-the-curious-case-of-ted-
kaptchuk-omd-cont/)

[http://www.sciencebasedmedicine.org/dummy-medicine-dummy-
doc...](http://www.sciencebasedmedicine.org/dummy-medicine-dummy-doctors-and-
a-dummy-degree-part-2-2-harvard-medical-school-and-the-curious-case-of-ted-
kaptchuk-omd-cont-again/)

[http://www.sciencebasedmedicine.org/dummy-medicine-dummy-
doc...](http://www.sciencebasedmedicine.org/dummy-medicine-dummy-doctors-and-
a-dummy-degree-part-2-3-harvard-medical-school-and-the-curious-case-of-ted-
kaptchuk-omd/)

[3]
[http://www.phdcomics.com/comics/archive.php?comicid=1174](http://www.phdcomics.com/comics/archive.php?comicid=1174)

[4] [http://www.sciencebasedmedicine.org/michael-specter-on-
the-p...](http://www.sciencebasedmedicine.org/michael-specter-on-the-placebo-
effect/)

[http://www.sciencebasedmedicine.org/ted-kaptchuk-versus-
plac...](http://www.sciencebasedmedicine.org/ted-kaptchuk-versus-placebo-
effects-again/)

[5] [http://theness.com/neurologicablog/index.php/the-rise-and-
fa...](http://theness.com/neurologicablog/index.php/the-rise-and-fall-of-
placebo-medicine/)

[6]
[http://www.ncbi.nlm.nih.gov/pubmed/20091554](http://www.ncbi.nlm.nih.gov/pubmed/20091554)

~~~
disgruntledphd2
I would say that you should perhaps not shoot the messenger in this case.
While I am not a massive fan of Kaptchuk's experimental rigour (and I suspect
most of what those articles say is not news to me), the study also had Irving
Kirsch, who whatever else he may be, is a fine experimentalist. Kaptchuk's
pretty good at getting funding though, so hence his appearance.

Also, if you think that placebo is nonsense, I would humbly suggest that you
read Benedetti [http://www.amazon.com/Placebo-Effects-Understanding-
mechanis...](http://www.amazon.com/Placebo-Effects-Understanding-mechanisms-
disease/dp/0199559120). Its a very good summary of the state of the art in
2008, from someone (Benedetti) who runs extremely tight, well-designed
experiments in reasonably valid conditions (typically post-surgery patients).
Some of the findings are extremely interesting, and it is all well-referenced
and supported.

~~~
tokenadult
Thanks for your comments on the quoted researchers. I have been trying to find
the DIRECT link to a quotation from Fabrizio Benedetti, a co-author of one of
the most cited papers who is also a medical doctor, in which he sums up his
view this way: "I am a doctor, it is true, but I am mainly a
neurophysiologist, so I use the placebo response as a model to understand how
our brain works. I am not sure that in the future it will have a clinical
application." (The stuff in the quotation marks appears online in articles on
other websites, but I don't know specifically when Benedetti said that, except
it was after his most famous paper, co-authored with Kaptchuk.)

The state of the art since 2008 has not been an advance in finding clinically
useful placebo effects so much as it has been an advance in finding
statistical flaws in previous studies of placebos. I really appreciated your
comments in dialogue with another participant in this same thread about what
the research shows, and indeed how one might define "placebo effect," and I'll
have to digest that for the next time this issue comes up here on HN. Thanks.

~~~
disgruntledphd2
No worries, I've really enjoyed your postings on many topics, mostly around
hiring techniques (and have always been a big fan of Hunter & Schmidt).

I think that I am somewhat biased, given that I started a PhD in the placebo
effect around then, so I actually (sortof) know all of these people. I would
argue that there are a few problems with placebo research as currently
practiced.

1) clinical studies without no-treatment arms 2) Relatively small experimental
studies with not completely explicit treatment protocols 3) A fascination with
colourful brain images at the expense of good experimental design (though that
is sadly not limited to placebo research).

Statistics is very, very difficult to get right (and I've often struggled) and
the incentives are not lined up in the correct way. For instance, if I find a
counter-intuitive results in an experiment, it does not benefit me to engage
in rigorous fact-checking, I am more likely to benefit if I just publish it,
given the demands of tenure-track. To be honest, its a wonder any science gets
done at all.

And hence why I no longer work in science.

~~~
gruseom
That's fascinating. What did you leave science to do?

~~~
disgruntledphd2
I work for a tech company as an analyst. Better perks, less ethical
committees, and (somewhat) more career stability.

------
mikehall314
The Placebo Effect is something of a misnomer, as there are actually many
different placebo effects, which bias trial data in subtle and interesting
ways. Effects like regression to the mean and the natural history of the
disease, for example, will result in objective changes to a patient's
condition even in cases where the patient is acutely aware they are only
taking a placebo.

Analyses comparing placebo interventions to no treatment reveal that the
apparent power of the placebo may be overstated. No placebo effects are
observed, for example, when comparing placebo to no treatment for objective
endpoints, or binary endpoints (Hróbjartsson et al, 2001). They are observed
in subjective endpoints (e.g. pain, nausea) where the condition of the patient
is filtered through the opinion and biases of the patient and/or the clinician
- which makes it quite possible that this aspect of placebo action can be
accounted for by the experimenter effect.

All of which leads to my primary problem with this paper. It is a comparison
of open-label placebo to no treatment, with a relatively small number of
participants (n = 80), studying only subjective end-points (hello,
experimenter effect). The media coverage of this paper (c.f. the NPR article)
makes the claim that an "honest placebo" was given, with the patients informed
they were only taking placebo, which is true. But patients were also told the
placebo could "present significant improvement in IBS symptoms through mind-
body self-healing processes", which just as readily primes the patient for the
experimenter effect as does telling them they're taking a drug.

On top of that, the clinical relevance of the IBS-GIS improvement seen in the
placebo arm is questionable, improvement from "(4) no change" to "(5) slight
improvement" on a seven point scale.

Small effect, small numbers, and potentially flawed methodology.

~~~
disgruntledphd2
OK, lets take this in order. Hrobjarrtsson and Goetzche's review actually
undermines your point around there being many placebo effects (which is the
approach taken by Benedetti), as they modelled wildly different clinical
trials (the inclusion criteria were simply possessing both a placebo and no-
treatment arm).

Furthermore, Meissner et al 2007 re-analysed those studies and found large
effects where the outcome could be mediated by nervous system, and very low
effects where there was no direct nervous system link.

Additionally, uncertain expectations (you may receive a drug) are given in
clinical trials and Vase (2002) found that placebo effect sizes were much
smaller in this context than they are when placebos are deceptively
administered (this is a potent painkiller) (as they normally are in clinical
practice and experimental research) (c.f. Kirsch & Wiexel 1998, Amanzio et al
2001). Also certain vs uncertain expectations are associated with differential
amounts of dopamine release, which has been associated with response to
placebo (Scott et al 2007, DeLa Fuente-Fernandez, 2002, 2004).

I agree with many of your comments around this paper, and essentially it was
only published because Kaptchuk and Kirsch are two of the leading names in the
non-clinical field.

And the papers from 2010, and has been getting this treatment for a while....

~~~
mikehall314
Indeed, all fair points.

Though I disagree that Hróbjartsson et al undermines the notion of many
placebo effects.. or maybe I don't, depending on our definition of placebo
effect.

If we define "placebo effect" as any clinically significant change observed in
the placebo wing of a clinical trial, there are many placebo effects. As I
mentioned before, regression to the mean, natural history of the disease,
experimenter effect, and so on.

Alternatively, we could define it as any clinically significant change
observed in the placebo wing of a clinical trial which is not also observed in
a no treatment wing. This would eliminate things like regression to the mean
and arguably leave behind only a "true" placebo effect. Though even here, we
have to account for bias (and perhaps even classical conditioning?) I wonder
how much placebo effect is left if these are controlled for?

Within the context of analysing trial data, it is the former definition we are
interested in. But within the context of discussing "the placebo effect" as a
standalone phenomenon, I'd argue the latter definition is more useful.

Unfortunately, as most trials don't have no treatment arms, any clinically
significant changes observed in the placebo arm are chalked up to "the placebo
effect", especially by the media (though sometimes by clinicians), even when
there is good reason to think many of those same changes would have been
observed under no treatment. Which IMHO leads to a distorted view of the
clinical relevance of the placebo effect outside the context of a clinical
trial. Especially as the placebo effect appears to have a reputation as a
bizarre mind-over-matter affair.

~~~
disgruntledphd2
Ah, I see what the issue is here. I typically (used to) work in experimental
placebo research, rather than clinical placebo research (I'm a psychologist by
trade) so I would be more interested in those studies, rather than clinical
trials.

In terms of what's left over after accounting for no treatment, Vase and H&G
got into a big academic fight about this, and it appears that the effect size
for placebo effects in pain is approximately (d=0.5), which is a relatively
large effect (especially within psychology). This doesn't entirely account for
experimenter effects, though with the use of a balanced-placebo design, those
can be accounted for.

In terms of clinical trials, I would tend to agree with your second
definition. Its not perfect, but its as good as it tends to get.

I think that one of the issues with placebo research is this notion of mind-
over-matter, in that such a viewpoint is the reason that it is perceived as
special, and also a reason why people disbelieve in it.

Based on old research (Levine, 1979) many (but not all) placebo effects in
pain appear to be mediated by endogenous opioids,which I would take to mean
that they are pretty naturally mediated by the brain, and so its a physical
phenomenon. Many people do go a bit crazy with the woo around it though, I do
agree.

Funny that this came up today, when I'm currently finalising a hopefully final
draft of my thesis on the placebo (PROTIP: never, ever leave your university
before submitting a PhD, it tends to go badly).

~~~
garyrob
Are you posting your thesis online? I'd like to have a look.

~~~
disgruntledphd2
Its on Github, in a private repository. When I'm finished, I plan to make the
repository public (which is probably going to be embarrassing).

------
disgruntledphd2
This is quite an old paper, and I actually wrote a blog post about it (back
when I had a blog). However, my issue with this study is that there was no
deceptive placebo condition (i.e. what normally happens). I actually attempted
to replicate this finding and didn't find any effect when a deceptive
condition was involved, suggesting that IBS may be a special case.

Interestingly enough, IBS patients have been found to have non-opioid mediated
relief of pain, which is atypical (normally naloxone blocks these effects) so
there may be something weird going on with this condition in more general
terms.

Also, its worth noting that in modern conceptions of placebo, its part of
every treatment. If you have ever felt the effects of a cup of coffee before
approximately 30 minutes, that's probably a placebo. Ditto for headache
tablets that work immediately, before the active substance could have gotten
into the bloodstream.

Also, with respect to the drinking of water, that's unlikely to be an
explanation as that quantity of water is typically not enough to provide
relief from IBS.

~~~
sizzle
I have definitely experienced the coffee and pain killer placebo more often
than not.

Thinking about it now, it make sense that once you ingest either to alleviate
certain symptoms, you let go of a portion of directed anxiety/overt attention
in expectation of relief thereafter.

Despite knowing the placebo pill beforehand, I'd hazard a guess that the same
brain areas associated with non-placebo oral administration will light up with
activity in an MRI scan.

Anyone know if there is any scientific literature on this phenomenon?

~~~
disgruntledphd2
For the placebo effects of coffee - Kirsch & Wiexel 1988 (can't find it
online, annoyingly enough).

There probably are some fMRI studies, but I really don't trust most of those
due to the difficulties in avoiding multiple comparisions (see Vul et al 2009,
Voodoo Neuroscience).

------
BoppreH
I was under the impression "placebo" includes the effects of:

\- the extra exercise of going to the medical center

\- better behavior under monitoring

\- talking to the test administrators (important for e.g. depression)

\- better organization to follow the intake schedule

Which are not affected by knowing you are in the control group. Is this really
a surprise to the medical community, or is the article just going for the
"mind over matter" and general woo line?

Also:

    
    
        open a door toward ethical use of placebos in daily
        medical practice
    

Haven't this been extensively discussed and ultimately rejected for a long
time?

------
NatW
This study seemed to deal with people experiencing digestion problems. I
wonder if it was the act of drinking extra glasses of water (to swallow the
placebos) that helped the situation, rather than the psychology here.

~~~
ajcarpy2005
Exactly. And just being involved in a study, having the feeling of
purpose...lots of variables.

------
nysv
Short humorous video of Ben Goldacre talking about placebo studies and the
weird effects found:
[http://www.youtube.com/watch?v=O1Q3jZw4FGs](http://www.youtube.com/watch?v=O1Q3jZw4FGs)

------
majc2
BBC's Horizon covered the Placebo Effect last week and folks in UK can see
here:
[http://www.bbc.co.uk/iplayer/episode/b03wcchn/Horizon_201320...](http://www.bbc.co.uk/iplayer/episode/b03wcchn/Horizon_20132014_The_Power_of_the_Placebo/)

~~~
RoryH
Came on here to say the same thing... Youtube mirror here:
[http://www.youtube.com/watch?v=oKG1lgI4zIk](http://www.youtube.com/watch?v=oKG1lgI4zIk)

------
jaekwon
Well, now it's _known_ that a placebo works, and the mind being mysterious
still, a placebo is only a known _unknown_.

But if you give a sugar pill to a person who had never heard of the placebo
effect, and tell him/her that the pill is only sugar with no effect
whatsoever, perhaps we might find that the placebo effect does not manifest.

------
k2enemy
Here's a clever guess at why this might be true from an economics perspective
(I'm not the author): [http://cheaptalk.org/2010/08/10/blogging-something-i-
know-no...](http://cheaptalk.org/2010/08/10/blogging-something-i-know-nothing-
about-3/)

~~~
dfc
A clever response titled: "Blogging Something I Know Nothing About."

------
mihaifm
Aha, this confirms my long time suspicion that people can get drunk with non-
alcoholic beer.

~~~
aestra
There's been some limited research on the placebo effect of alcohol.

[http://link.springer.com/article/10.1007/BF00652249](http://link.springer.com/article/10.1007/BF00652249)

[http://www.jsad.com/jsad/article/Offspring_of_Alcoholics_Hav...](http://www.jsad.com/jsad/article/Offspring_of_Alcoholics_Have_Enhanced_Antagonistic_Placebo_Response/3506.html)

[http://www.jsad.com/jsad/article/Alcohol_and_Aggression_in_M...](http://www.jsad.com/jsad/article/Alcohol_and_Aggression_in_Men_A_Comparison_of_Brewed_and_Distilled_Beverag/3353.html)

[http://link.springer.com/article/10.1007/BF02245081#page-1](http://link.springer.com/article/10.1007/BF02245081#page-1)

------
monkeyninja
"taking a placebo knowing(or hoping) placebo can help" pretty much works the
same way as taking placebo without knowing it. Why it is surprise?

------
CJefferson
I take homoeopathic medicine for hayfever. I was recommended it by a friend
when I was much younger, and found it was very successful.

I now know it's homoeopathic and what that means, but I still find it greatly
improves my symptoms, and assume it isn't having any negative side effects (as
the pills are just tiny sugar pills). Part of me doesn't like taking it, but
it does help, and it doesn't seem worth stopping at this point.

------
sizzle
*makes sense

