

Placebos Are Getting More Effective. Drugmakers Are Desperate to Know Why. - mcantelon
http://www.wired.com/medtech/drugs/magazine/17-09/ff_placebo_effect

======
patio11
My take away from this is that, in addition to checklists, one low-cost
intervention to improve healthcare would be to have the doctor spend a few
minutes chatting the patient up and expressing cheery optimism about their
prognosis. If the doctor's time is too valuable, find some unemployed psych
grad with good people skills and put him in a lab coat.

~~~
Alex3917
Occam's razor suggests that Wired's explanation is complete bullshit. Let me
give a far simpler explanation that would explain all the phenomena mentioned
in the article:

We are seeing a rise in physical health problems due to increasing social
isolation and other mental health risk factors.

As we replace the community barbeques with family grills we're losing more
than a fun weekend activity, we're losing something that's evolved over
hundreds of thousands of years to keep us mentally healthy. And more and more,
scientists are learning that mental health is one of the greatest predictors
(if not the greatest) of physical well being.

Why do you think ~50% of college students experience clinical depression? I'm
sure that stress, poor diet, lack of sleep, and excessive alcohol consumption
are all contributing factors, but at the end of the day these poor lifestyle
"choices" aren't really choices at all; rather, they're triggered by specific
design decisions made at the institutional and societal level.

Placebos aren't working better because people have more faith in medicine,
they're working better because of the Hawthorne effect; people feel like they
have someone who cares about them. That's why the effectiveness is radically
different across populations, depending on the social environment, even though
we're all exposed to the same media.

~~~
tierack
To be blunt: citations needed.

The article not only talks about conditions that are clearly mental
(depression) and ones that are arguably mentally related (IBS), but also ones
that you'd have a hard time attributing to "lifestyle 'choices' that aren't
really choices at all" (Parkinson's).

> Placebos aren't working better because people have more faith in medicine,
> they're working better because of the Hawthorne effect

The article talks about both effects and more (placebos working less well for
conditions that are locally under-diagnosed, for example). The article
presents a rich collection of causes for the rise of the placebo effect
instead of a single cause. And I think Occam, who could appreciate the
complexity of the brain and see that they've got data, would agree that it
couldn't be as simple as you suggest.

(Also, across populations we don't all get exposed to the same media.
Something tells me that there aren't constant erectile dysfunction commercials
in Bangalore.)

~~~
Alex3917
The book Emotional Intelligence references a bunch of scientific studies about
both the effect of mental health on physical health, and also about the
placebo effect. The opening of Gladwell's new book is also about the effect of
mental health on physical health.

There have been many studies done that show clear health benefits to joining
civic organizations or participating in church. As the opportunities for civic
participation decline, participating in medical studies may increasingly make
people feel like they are giving back to society, which causes a change in
brain chemistry that ameliorates the underlying physical symptoms.

Clearly both of my (related) hypotheses need testing, but at least they are
falsifiable, unlike some of the dubious theories posed by the original
article.

~~~
tierack
From your first post (and my real contention):

> Placebos aren't working better because people have more faith in medicine,
> they're working better because of the Hawthorne effect; people feel like
> they have someone who cares about them.

The problem isn't that placebos are working better, the problem is that
they're working better relative to medications. If it was merely an issue of
"someone who cares about [the patients]" then we'd expect that the actual
drugs would benefit from the same effect too. As it stands, the problem is
that placebos have been working better, while the same drugs have been
basically steady. If Prozac couldn't beat placebos now, it tells us something,
but doesn't tell us anything about how much better things were back in the old
days when when we were participating more in civic organizations and church.

~~~
gruseom
_If Prozac couldn't beat placebos now_

If I understand recent findings correctly, it's not that Prozac can't beat
placebos now; it _never_ beat placebos and the studies showing this were
simply suppressed. (I just posted about this:
<http://news.ycombinator.com/item?id=784271>).

------
indiejade
Theory: there isn't anything really all that wrong with most people; it's all
in their minds, so the placebo works.

Watch the evening news on a network and count the number of advertisements you
see for prescription drugs. I did this a couple of weeks ago watching the CBS
Evening news, a half-hour program, and about 65 percent of the commercials
were for pills of some sort: migraine pills, anti-depression pills, pills for
seniors, etc.

The prescription drug industry in the US has got a slimy underbelly; it goes
out of its way to convince people that there's something "wrong" with them,
and then falls all over itself attempting to pat itself on the back for
"curing" them.

~~~
JimmyL
Pharma advertising is something that always strikes me when I watch US TV
feeds. Here in Canada, pharma advertising is very heavily regulated by the
Federal government.

It can come in essentially two forms. One is the "for sale" form, in which
case the ad is limited to the drug name, the amount, and the price - no
description of what it's for, or any other information. The other is the
"informational" form, in which case the ad can talk about a symptom, like
"acid reflux is dangerous - here are some signs", but it can't mention the
name of the drug or pharmaceutical company producing it, and it has to talk
about alternative non-drug remedies.

The net result is that there are very few pharmaceutical ads on TV here, since
they have so little value in what they're allowed to say.

~~~
wallflower
> Here in Canada, pharma advertising is very heavily regulated by the Federal
> government

"The United States is one of only two developed countries that allows direct-
to-consumer advertising (DTCA) of prescription drugs. (The other country is
New Zealand)."

[http://www.sourcewatch.org/index.php?title=Direct-to-
consume...](http://www.sourcewatch.org/index.php?title=Direct-to-
consumer_advertising_in_the_United_States)

~~~
lupin_sansei
I read this as only 2 countries in the world trust their citizens enough to
make their own drug choices.

~~~
Avshalom
Except it's regulations on PRESCRIPTION drugs, so it's still up to the
doctors.

------
olefoo
I have a theory as to why Placebos are getting _more_ effective; which is the
real curiosity of this article.

Television. If as a child, you watch 10,000 hours of commercials telling you
how effective drugs are. Is it any wonder that you are convinced enough that
your body actually makes it true, even if you got the Obecal P instead of the
real deal.

~~~
lanaer
[http://www.slash7.com/articles/2009/8/25/oh-yeah-there-s-
a-s...](http://www.slash7.com/articles/2009/8/25/oh-yeah-there-s-a-sugar-pill-
for-that)

------
gruseom
It's been shown that antidepressants are no better clinically than placebos.
The drug companies simply suppressed the trials that didn't yield the results
they wanted and cherry-picked the ones that did in order to get FDA approval.
This all came out a couple of years ago when a long-running Freedom of
Information Act suit forced them to release all the trials.

[http://www.guardian.co.uk/society/2008/feb/26/mentalhealth.m...](http://www.guardian.co.uk/society/2008/feb/26/mentalhealth.medicalresearch)

Edit: I just remembered that I posted about this to HN back when the study
came out: <http://news.ycombinator.com/item?id=123575>. A commenter pointed
out that the study was limited to SSRIs, the most widely used antidepressants.

------
jasonkester
I've always thought you could make a killing on the late night infomercial
market, selling "Placebo" to people.

Think of all the research out there on the well-documented Placebo Effect. Now
you can benefit from this safe, effective, miracle cure. Order now and we'll
throw in a second bottle of Placebo free of charge!

Considering the things that stupid people fall for, this would seem guaranteed
to work.

~~~
run4yourlives
They already do that, it's called a q-ray bracelet I think.

------
datums
The book predictably irrational discusses the placebo effect on surgery.
<http://www.predictablyirrational.com/pdfs/Placebo1.pdf> Very interesting
results.

------
clofresh
The unsung hero in all this is the analytics data they used to debunk widely
held assumptions about the placebo effect in clinical trials. Nothing like
cold, hard data to inflict some cognitive dissonance on some "experts".

------
ghshephard
This is an incredibly interesting article - one of the more effective ways of
healing the body is to engage the brain to heal it for you. Placebo Effects,
in many cases, are as powerful as the effects of the drug. Previously, the
Pharma industry took this as in indication their drug's weren't effective. The
central thesis of this article isn't that the drugs are ineffective, it's that
the Placebo effect is a real, and sometimes _very_ effective mechanism for
healing people.

From the article:

"one way that placebo aids recovery is by hacking the mind's ability to
predict the future. We are constantly parsing the reactions of those around
us—such as the tone a doctor uses to deliver a diagnosis—to generate more-
accurate estimations of our fate. One of the most powerful placebogenic
triggers is watching someone else experience the benefits of an alleged drug.
Researchers call these social aspects of medicine the therapeutic ritual."

------
delackner
If placebo works by helping the brain decide that we _should_ get better,
causing it to release its own defensive chemicals then it stands to reason
that other actions might also be able to induce the same response. The
mechanisms involved pre-exist the entire concept of "drugs". Maybe the old-
time "placebo" was going to the local healer who jumped up and down and
proclaimed that you will get better.

Derren Brown's videos come to mind, especially his bit on the subway where he
convincingly causes a man to become incapable of recalling where he is going,
simply by commanding him to not remember.

If other people can cause such powerful changes in our brain function, then
there should be ways to do it yourself.

~~~
Luc
I wouldn't put it past Derren Brown to have represented that situation on the
subway somewhat differently than it actually happened - he is an entertainer
after all (his program about faith healing and religious beliefs was amusing).
Your point about influence still stands of course.

I found 'Meaning, Medicine and the Placebo Effect' to be rather good:
<http://cambridge.org/catalogue/catalogue.asp?isbn=0521000874>

------
David
My question: why do the pharms think this is bad news for them?

The placebo effect requires belief that the placebo is fixing the problem.
Studies are double-blind so that the patient does have that belief. Without
the expectation of being cured, there is no improvement.

For the placebo effect to be a significant influence in general health, the
public needs to be convinced that it is receiving a legitimate fix. The best
way to show people it's a real cure? Give them a real cure, and tell them all
about how it works. The need for chemical compounds that change some aspect of
body chemistry will not decrease because of the placebo effect; instead, these
compounds become the placebo. It's another, more effective layer of
manipulation.

But despite my wording, I see no problem with it. It might technically be a
giant fraud, if the power of healing lies with the buyer all along. But if it
happened in finance, who would complain? "Company convinces clients they have
more money; buying power mysteriously increases" doesn't sound all that
fraudulent to me.

Essentially, it's business as usual for pharms. Develop compounds that may or
may not work, tell everyone they work, sell them, produce actual results.
What's all the fuss about?

------
electromagnetic
IMO it's quite a simple explanation. You only have to watch 5 minutes of US
advertising (I'm from the UK and living in Canada) to think you should have
something wrong with you. If you think you should have something wrong with
you for long enough, you will, it's called hypochondria and there's long been
the suggestion of prescribing placebos to them until they're capable of
getting access to a psychologist or psychiatrist.

You get the problem that when pills cure everything and you're sick and _not_
on a pill, you worry. This makes you feel worse, which makes you sicker. The
sugar pill not only has a placebo effect, but it also stops you worrying so
really its having two effects opposed to the usual one we've classically seen.

When stress is the leading form of disease in the western world, you're going
to have to remove stressed people from the drug tests to get impartial
results. It just happens to suck that most sick people are stressed out. I
guess they'll have to give a placebo to the test and control group to relieve
stress and then give a second to the control group pretending its actual
medicine.

------
blhack
The problem is the depression (clinical depression) is one of the most
horrifyingly over-diagnosed diseases on the face of the planet.

 _EVERYONE_ gets depressed. If people didn't, we'd be living in Utopia. When
you hand some person who is having a crappy day a pill and say something like
"this is full of magic chemicals that are going to make you feel better",
their outlook on life improves, and they aren't depressed anymore!

Clinical depression is different. Clinical depression is as much a real
disease as anything else, and it cannot be treated with a placebo any more
than a broken leg can. Real depression is not a psychological problem, it is a
neurochemical one...

Clinical depression does not even always manifest itself as feeling sad or
anxious. It can present itself as bad memory, poor focus, decreased
creativity...These things, while psychologicacl problems, have neurological
causes.

Yes, being sad does as well, but being sad is as easy to "cure" as being
hungry.

This is why the placebo worked.

~~~
ars
That's what the drug companies want people to think. But it's not actually
true.

Even the type of depression you are talking about responds to placebos. And it
responds very well to therapy, but barely at all to drugs - except that the
drugs work well as placebos.

It is a real condition - don't get me wrong, I'm not saying it isn't. It's
just that the drugs don't do as much as people think they do.

Most people when they first hear about placebos flatly refuse to believe they
work as well as they do. But they do.

~~~
blhack
I'm sorry, but no. If you're depressed, a placebo may improve your outlook and
this improved outlook may present itself as a decrease in symptoms which, like
I said, manifest psycologically, but unless you've got something to increase
the amount of seratonin in your brain (which is used as a
neurotransmitter...this is why depression can present as poor short-term
memory, and poor focus) then you're fixing a physical problem with a
psychological solution.

If this makes somebody feel better, then fantastic for them! I'm sorry for
being a bit combative about this...sever mania and depression is something
that runs in my family, and debilitating depression and anxiety are something
I've dealt with my entire life. Believe me, if there was a placebo-based
solution to this, I would be the first person in line to get it...

I don't mean to take offense, I know you don't mean any, but saying what
you're saying is a bit akin to telling a cancer patient that they need to just
get over it.

~~~
ars
> Believe me, if there was a placebo-based solution to this, I would be the
> first person in line to get it...

If you are taking drugs for this, then you are in line already. Every one I
have read about has studies showing it is only slightly more effective than
placebos.

I really am not trying to say the problem is not real. I'm only saying that
placebos are far more effective than you realize.

For example some quotes from wikipedia:

"Notably, however, a recent Cochrane review of the efficacy of the SSRIs
concluded that they were only slightly more effective than placebo for the
treatment of people with depression."

"A widely-reported meta-analysis combined 35 clinical trials submitted to the
U.S. Food and Drug Administration (FDA) before licensing of four newer
antidepressants (including the SSRIs paroxetine and fluoxetine, and two non-
SSRI antidepressants nefazodone and venlafaxine). The authors found that
although the antidepressants were statistically superior to placebo they did
not exceed the NICE criteria for a 'clinically significant' effect. In
particular they found that the effect size was very small for moderate
depression but increased with severity reaching 'clinical significance' for
very severe depression. The relationship between severity and efficacy was
attributed to a reduction of the placebo effect in severely depressed
patients, rather than an increase in the effect of the medication."

(Especially note the last sentence.)

Please don't understand this in reverse and assume people should/can do
nothing. My point is placebos work, and people should make more use of them.

Another thing: just because something is all in your head does not mean it's
not real. People often assume that "since a placebo fixed it, it was not real
to begin with". NO! That's is NOT the case. The problem was REAL, and the
placebo fixed it.

------
gruseom
Fascinating article. But they didn't mention the obvious economic reason why
placebo effects have been shunned or suppressed: placebos are free.

If the pharmaceutical industry gets clever about finding ways to make money
off the placebo effect, as opposed to getting more devious about pushing drugs
into people, that seems to me a good thing.

~~~
eru
Homeopathy anyone?

------
JacobAldridge
They should just sell the placebo. No FDA issues, and if it does what tests
show it does can you imagine the profit margin!

On a serious note, I'm enjoying keeping an eye on the US Health Care debate
from afar (Australia, to be precise). Anybody think it will result in
sustainable change for the better?

~~~
wmeredith
They do. It's called homeopathy or gingko balboa or any other number of items
that can be found in natural foods stores and the like. It doesn't matter if
they _work_ or not, what matters is people think they work.

~~~
ars
Well they do work - that's the point.

True it's not because of what they are made off, but it doesn't matter. What
matters is they work.

That's why so many people take them (they work), and why they always fail when
tested against placebos - it's because they basically ARE placebos. And very
effective ones too.

The typical response when hearing that is: get rid of them, they do nothing.
But the correct response is use them, because placebos are very effective.

------
jsz0
It's probably directly related to the number of people regularly taking
medication for other conditions. More people have more faith in magic pills to
solve all their problems. We have become a heavily medicated society.

------
ahoyhere
Well, the US govt took the prohibitions off drug advertising in the mid-90s
and now it's a >6 billion-a-year industry. Just the ads and promotions, that
is.

All those ads say that pills work for all range of problems (even imaginary
ones that the drug makers made up to sell more pills - such as pre-menstrual
dysphoric disorder, to sell renamed Prozac and renew their patent).

Those ads weren't there before. The ads still aren't shown in Europe, where
the real drugs are beating the placebo effect (the article mentions trials in
France and Italy where diazepam wins; in the US, diazepam fails against the
placebo).

Drug advertising is simply not legal in most parts of the EU.

They don't think that has something to do with it? Ads affect belief - maybe
nobody says "Oh, well now I believe xyz will cure me," because they pretend to
be immune to advertising, but if you're surrounding by messaging that pill =
cure, you are going to eventually believe it as it is absorbed as cultural
knowledge. Just like low-fat = healthy has become a "fact" that "everyone
knows."

I was shocked that the article barely even made a nod to this, and didn't
follow it to the its conclusion.

I think it's hilarious that the drug co's went along thinking that they won
big with that repeal of consumer protection laws, and that their own
exploitation of known human weakness is causing their drugs to be less
effective than sugar pills.

------
torpor
A person is responsible for their own mental condition. Period.

That is what this placebo situation demonstrates, more than anything. YOU are
responsible for YOUR condition.

~~~
warfangle
I'll be sure to tell that to the homeless dude who digs through my garbage
every night and has heated arguments with the fire hydrant..

~~~
torpor
Tell him. If he doesn't /take/ responsibility, it doesn't change the fact that
his life is his own and whatever he is experiencing, belongs to him alone.

