How should we, as practicing psychiatrists, use this information to make the most of the placebo effect? Jerome Frank16 wrote about the curative elements of placebo treatment. He believed that because no one has been able to demonstrate a substantial difference in the outcome of different psychotherapies, the active components of psychotherapy are the components that are common to all the psychotherapies and to placebo treatment. He also suggested that the curative elements of placebo and psychotherapy begin with a person in distress who goes to an expert for help. The expert provides an explanation for the condition, and the patient undergoes a healing ritual (Table 3, see Psychiatric Times, October 2006, p 16). The stronger the healer's belief in the ritual, the more likely it is to work. This is why it is good to have a theory about what you are doing, even if the theory is wrong.
If we consider the placebo effect as one of the components of healing, we can feel more comfortable applying it. In fact, most of us do many of the required things intuitively (Table 4). For example, we inspire confidence by dressing in attire that most patients consider more appropriate for an office than for the garden. We display our diplomas and certificates where patients can see them.
Harnessing the placebo effect
|Look and dress like a physician
|Display signs and symbols of healing|
|Use symbols of healing|
|Make notes in medical chart|
|Use a prescription pad|
|Perform or order simple diagnostic tests|
|Provide a diagnosis|
|Explanation for symptoms|
|Need not be from DSM-IV|
|Enhance response to treatment|
|Elicit patient's beliefs about treatment|
|Select treatment that is consistent with patient beliefs|
|Consider concomitant alternative therapy|
|Use treatment that has worked before|
|Offer optimistic prognosis|
|Use prescription pad|
When we evaluate patients, it is important to take the time to listen and ask questions, even when we might not need the answers to those questions. This behavior gives patients the security of knowing that you are paying careful attention. An internist may know immediately when a patient walks through the door that he has bronchitis. Nonetheless, the physician performs chest auscultation and has at least a brief conversation with that patient before discussing treatment. Psychiatrists do not order routine blood tests in as many patients as our internal medicine colleagues do, but we do order tests if we have any reason to believe the results could be helpful. Simple tests go a long way toward making people believe they are cared for.
Providing a diagnosis is also crucial, even if it is not a diagnosis from DSM-IV. People benefit from getting an explanation for their distress. It brings the problem down to size and makes their suffering seem more manageable.
Suggesting honest, appropriate, and positive expectations about a patient's illness can be worthwhile. If you give a patient with a backache an analgesic, you maximize the chances of a good response by saying: "This is a powerful painkiller. It's going to help you." Saying, "Try this, it may work," is less helpful. It is essential to tell people with anxiety conditions, particularly panic disorder, that you expect the benzodiazepine you prescribe to make them feel better very quickly. If you prescribe an antidepressant, explain that the patient may have some nausea or a dry mouth initially, but that you fully expect him or her to feel much better in a few weeks.
Do you know what your patients believe about their illnesses? To provide the most effective care, you need to understand what they think they may have and what they think might help. If a patient is convinced that he needs a medication his cousin received, you'll have difficulty in getting him to discuss cognitive therapy. Once you know the patient's point of view, it is easier to work with it or attempt to persuade him to your point of view. An alternative therapy that the patient believes will be helpful can be given in conjunction with conventional therapy. Herbal teas, acupuncture, or massage are some examples.When might you prescribe placebos?
I would not recommend that a psychiatrist prescribe a placebo for a depressed or anxious patient and tell him that it is an active drug. In some circum-stances, however, a patient has a condition that is highly placebo-responsive, such as mild depression or an anxiety disorder, and is reluctant to take medication. In such a situation, if your judgment is that the patient is not likely to suffer significant harm from a delay of several weeks before taking a conventional medication, you could say, "I know you don't want to take an SSRI, so I would suggest you try this pill (or herbal tea, or exercise regimen). We don't know how these treatments work. The pill contains no medicine, but a lot of people get better while taking it. It may stimulate the body's own healing processes, or it may do something else. If you're not feeling better in a few weeks, we should reconsider the SSRI."Conclusion
What we call the placebo response is probably a complex interaction of expectation, conditioning, endorphin effects, and distress relief. Our role as psychiatrists is to be aware of the conditions in which the placebo response may be likely to play a strong role in recovery. We have an important part to play in inspiring confidence, evaluating the patient and providing a diagnosis, and enhancing the treatment response. Many of these facets of the placebo response are components of "bedside manner." We do not need to have a full understanding of how the placebo response works in order to harness some of its benefits in practice.
Dr Brown is clinical professor of psychiatry at Brown Medical School, Providence, RI, and Tufts University School of Medicine, Boston, and a practicing psychiatrist. Dr Brown reports no conflicts of interest concerning the subject matter of this article. This article is based on a presentation at the US Psychiatric and Mental Health Congress, Las Vegas, November 7-10, 2005.