December 12, 2012 - The placebo effect
is one of the most misunderstood, misrepresented, misused and maligned effects of health and medical products. Placebo
is an interesting word, the definition of which helps to create a false image of the placebo effect. Placebo, according to Webster, is "a usually pharmacologically inert preparation prescribed more for the mental relief of the patient than for its actual effect on a disorder". Written as if placebos do not provide physical relief. But they do.
Many doctors prescribe 'placebos' because they recognize that mental relief is an important aspect of physical relief. Even if they don't understand the details. These doctors are not 'deceiving', they are acting in the best interests of the patient. They often prescribe 'patent medicines' that, in theory, will have no effect on the condition, rather than an alternative medicine - because paying more, and going to a pharmacy, increases the placebo effect.
Some doctors recognize that drugs with an actual effect - not specifically related to the patients (untreatable by medicine) condition have a stronger placebo effect. In those cases, the most effective placebo is not an inert pill, but one that the patient can 'feel working'.
1. The basic placebo effect, in theory, increases your response to a treatment. It doesn't matter if the treatment is a patent medicine, an alternative medicine, a surgery, or a prayer - all benefit from the placebo effect.
2. The nocebo effect (a reverse placebo effect) can increase your awareness of, or the presence of side effects of a treatment.
3. Regression to the mean is a natural physical process that moves statistical outliers, e.g. people who are outside the normal range of healthiness, back into the normal range. It works equally well with golf tournaments, coin tosses, protest movements, and health conditions.
Drug manufacturers hate the placebo effect, because it forces them to try and do better than mere 'suggestion'. As if that was a false requirement. Drugs also benefit from the placebo effect. And are hurt by the nocebo effect.
Doctors (and others) often claim that the effects of 'alternative' medicines are entirely due to the placebo effect. This allows them to ignore 'facts' in favour of untested 'fictions'.
Neither seriously considers the symptoms of healing or healthiness. What are the symptoms of healing? How does the placebo effect affect the symptoms of healing? What are the symptoms of healthiness? How does the nocebo effect affect the symptoms of healthiness?
Studies of the nocebo effect are generally aimed at minimizing its effect in patients. But, it's strange to note that studies of the placebo effect are also aimed at minimizing it, even though it has a positive effect on patients health.
Almost everyone ignores, or is ignorant of 'regression to the mean'.
In many cases, scientific studies ignore 'regression to the mean'. Even though it has a huge effect on results.
Scientific studies of medicines typically compare a 'product being tested' vs a placebo. So, of course, they are DOUBLY affected by the placebo effect. And the researchers think they are accurately measuring the placebo effect, and thus, accurately measuring the 'product effect'. But they often ignore regression to the mean, which pretends to be, or is mistaken for placebo effect.
How does regression to the mean work?
Golf scores provide an interesting example. If you review the field of competitors from a golf tournament, and rank them according to their score on the 10th hole, some will have good scores - and some will have bad scores. But the scores on the 10th hole will, likely, have little predictive value for the tournament. If you add in the scores from the 2nd hole, some of the people with the highest score will 'regress to the mean'. Their scores will move towards the average. But with two holes counted, you might still have the final leader - in the bottom half.
The more rounds you add to the score - the more the scores bunch together, and the better your information. We tend to watch golf score from round 1, to round 2, to round 3, and we only pay attention to the leaders - so we miss the big picture. We miss regression to the mean entirely, because we perceive little effect on the leaders. In round 1 - someone is ahead (often as random as who did the best in round 10). Then in round 2, someone else is ahead - because the leader in round 1 was the farthest from the mean, and his score 'regressed to the mean'. And so on.
In medicine, it's more complicated. If you select a group of people suffering from a cold, for example, some will have mild colds, some moderate colds, and some - severe colds. Some will have had a cold for one day, some for 3 days, etc. The mean appears to be those with 'moderate colds'. But that's a poor understanding. Colds
are not normal. It's even more complicated. Some are very healthy people, some are less healthy and some are very unhealthy - where healthiness is measured independent of their colds. Some eat nutritious diets, some junk food diets. Some exercise regularly - some are couch potatoes. Some are misdiagnosed, they don't really have a cold, they have allergies, or even heart failure.
The mean they are regressing towards is actually 'the mean' from the normal population. Most people do not have colds. In a very short time - the members of your test group will 'regress to the mean' and most of them will no longer have colds. This is 'normal'.
Regression to the mean happens with any random sample monitored over time. It's a statistical fact, not a 'placebo effect'. It will happen if they take medicines - prescription or alternative medicines, and it will happen if they do not take any medicines.
As a result, studies that struggle with 'placebo effect' and ignore 'regression to the mean' constantly find confusing, conflicting results. Who to blame? Not themselves, it's much easier to blame 'placebo effect'.
If we are to learn the truth about health, we need to stop ignoring or hiding behind real effects. Placebo
and nocebo effects are real effects. As is regression to the mean.
There is another important aspect of the placebo effect. Very important. We can use the common hypertension (high blood presssure) as an example, but it applies to any illness.
The variations factor.
If we are studying a group of people with athritis (or any chronic illness), there is a huge variety in their conditions. Some have mild athritis. Some have moderate arthritis. And some have severe arthritis. Some have had arthritis for years - some for decades or generations. Some eat healthy diets and some don't. Some exercise regularly - but some don't. Some might take up, or drop, an exercise plan during the study. Each of them is sometimes healing - and thus they have symptoms of healing. Their healing status might change during the study, due to 'control' conditions, or uncontrolled conditions. But scientific studies tend to 'not measure' symptoms of healing'.
So called 'scientific studies' generally ignore these variations, or deliberately trying to minimize them. Of course when a drug is marketed, the marketing is 'expanded' beyond the variations studied. A treatment is tested on the selected group. The treatment has an effect. Placebo
effect has an effect. The outliers in the group tend to regress to the mean (unless they die of heart failure, in which case their results might be excluded from the published study).
Scientific studies want nice clean results. The placebo effect is a nuisance. Nocebo
effects are not relevant until the packaging is published. Regression to the mean is easy to ignore.
One of the severe weaknesses of science based medicine is the need to be 'right' or to find the 'true' answers. The simple truth is that truth is complex. There are many truths, and many views of truth. Many valid views of truth - but medical science wants to find 'the one'.
The placebo effect, however, has different effects on different people. Just as some people exercise more than others, some exercise more than others - some are more suggestible than others. And this suggestibility can change over time. Some doctors are more 'placebo effect enhancing'. and all of this will regress to the mean, towards the average as time passes and as more results are gathered.
The placebo effect, and the nocebo effect (but not regression to the mean) are effects that lie on the borders between body and mind, and between mind and spirit. Our medical system is less and less effective as it moves away from the body to the mind, the spirit and the community layers of the hierarchy of healthiness. So it tires to ignore and disparage placebo effects.
When we hide behind, or from the placebo effects, our knowledge of health is decreased. As a result of decreased knowledge, our health freedom is decreased.
Everyone has a right to life, liberty, and the pursuit of healthiness. Even a right to the most effective placebos we can design.