Talk:Placebo/Archive 2

Deconstructing the Placebo Effect and Finding the Meaning Response

Daniel E. Moerman and Wayne B. Jonas (2002). "Deconstructing the Placebo Effect and Finding the Meaning Response". Ann. Intern. Med. 136 (6): 471–476. PMID 11900500. (This opinion article refers to the Hróbjartsson & Gøtzsche study and gives an overview over different definitions in its introduction) Cacycle (talk) 01:01, 12 November 2008 (UTC)

A good one. There are indeed many phenomena that are improperly lumped together and their effects are then called the "placebo effect". A key point is made:

• "The one thing of which we can be absolutely certain is that placebos do not cause placebo effects. Placebos are inert and don't cause anything."

That sums it up pretty well. That's why placebos are used in clinical research as a means to separate the effects of the medicine from all the effects caused by things that shouldn't really be called the "placebo effect". Call them "expectation effect", "believer effect", or something else. -- Fyslee / talk 06:58, 12 November 2008 (UTC)

If this discussion is about semantics then I point out that effects are very commonly named for things other than the causative agent/s involved. See List of effects SmithBlue (talk) 03:14, 14 November 2008 (UTC)

Excellent reference to add

Here [1] is an overview article from The Economist with pointers to several studies. It could be integrated in this article.MaxPont (talk) 08:44, 14 November 2008 (UTC)

Genetics and lead

As the science progresses we are learning more about placebo effect. We now know it only operates on about 30% of the population and only for certain conditions. A recent study indicated a genetic link. This is pretty important stuff and if there are no objections I think it should be in the lead.Mccready (talk) 23:46, 31 December 2008 (UTC)

I looked at the paper in the Journal of Neuroscience PMID 19052197 upon which the New Scientist piece is based. The finding is interesting but complex and should be in the text (which it should anyway since information in the lead also needs to summarize what is below in the main text). It only concerns social anxiety disorder (SAD) so how far it is general to the more typical placebo effect in treating illness symptoms (pain, coughs etc) is unclear. As the authors note "additional work is necessary to elucidate the generalizability of the findings".--LittleHow (talk) 11:38, 1 January 2009 (UTC)

Archive

This talk page is getting pretty long - any objections to archiving old discussions - say after 60 days? —G716 <^T·_C> 16:08, 1 January 2009 (UTC)

Good idea --LittleHow (talk) 16:34, 1 January 2009 (UTC)

Canadian study

A group of Canadians have done an indepth analysis of the use of placebos for Health Canada and the Canadian Institutes for Health Research under Chair Heather Sampson the report can be found at http://www.cihr-irsc.gc.ca/e/25139.html. -- 24.156.8.4300:59, 1 March 2005

Adding datetime stamp to facilitate archiving —G716 <^T·_C> 04:29, 3 January 2009 (UTC)

Notable absences of placebo effect

This section should be deleted. Citations are available to contradict this in-cited claim. One such citation is here http://dx.doi.org/10.1016/0924-977X(96)88014-X

Adding datetime stamp to facilitate archiving —G716 <^T·_C> 04:29, 3 January 2009 (UTC)

Placebo-controlled studies. Split off into new page? or merge with Clinical trial

Does anyone have comments or objections about splitting off the last section into a new page? A short descriptive section would replace it in Placebo with a comment redirecting readers to the new page. Placebo is over long and this would seem to be the only natural break point in which it can be divided. --LittleHow (talk) 21:17, 31 December 2008 (UTC)

No objection.Mccready (talk) 23:43, 31 December 2008 (UTC)

That section should be moved/merged with Clinical_trial#Design. Xasodfuih (talk) 08:38, 1 January 2009 (UTC)

There are two issues here

• Placebo-controlled studies is disproportionately long compared to the section with which it is proposed to be merged.
• The way the clinical trail design section is structured. This contains two subsections, that are summary that link to independent main articles Clinical_trial_protocol and Study design.

Rather than do a full merge, it would be better to create a main article on Placebo-controlled studies and then add a third summary and link it in a similar way to it as a article. --LittleHow (talk) 11:03, 1 January 2009 (UTC)

• Support splitting into separate article with brief sections in both this article and Clinical trial. —G716 <^T·_C> 15:59, 1 January 2009 (UTC)
• Support split and summary LeeVJ (talk) 12:59, 3 January 2009 (UTC)
• Support, but I think it should be placebo control, with redirects for variants. Looie496 (talk) 18:00, 3 January 2009 (UTC)

Split off Placebo-controlled studies

I have created a new page from the Placebo-controlled studies section (to reduce the length of the placebo page), I have put proper inline citations with pubmed links and in some cases links to the actual source material. I have also reorganized and edited it in various ways to make it read with greater continuity.

From this page, I have removed the categories and the "see also links" that related to that now moved section. I hope after a short break to write a brief piece for the new Placebo-controlled studies section that now now directs to this main page. --LittleHow (talk) 10:20, 9 January 2009 (UTC)

Cool, but you're supposed to put actual information into the Splitfrom template. I have fixed it for you. Looie496 (talk) 19:02, 9 January 2009 (UTC)

Thanks for this Looie496--LittleHow (talk) 21:07, 9 January 2009 (UTC)

Fyi, I just created redirects placebo-controlled study, placebo controlled study, and placebo control, to your new article, so that all (well, some) of the plausible variants will find it. Looie496 (talk) 22:43, 9 January 2009 (UTC)

That is brilliant. I had thought of placebo-controlled trial and placebo-controlled trials but your ones are great additions —Preceding unsigned comment added by LittleHow (talk • contribs) 02:59, 10 January 2009 (UTC)

New section

I have added a list of conditions in which placebo effects have been reliably reported (meta-analyis; comparison against no treatment etc). This information has as far as I can find not been listed together previously in one place. For the last few weeks I have been reading reviews upon placebos and checking various research papers so I will be putting on more into this article with some reorganization. Since this will reuse the online citations in this new section in earlier parts, could the format of its citations be left in its present form for a week or so.--LittleHow (talk) 07:43, 16 January 2009 (UTC)

Wow! Quite an addition. Thanks for the hard work. — Scientizzle 18:59, 16 January 2009 (UTC)

If you haven't seen it, this template filler works well for PubMed entries... — Scientizzle 01:11, 17 January 2009 (UTC)

The problem with the template filler is that it does not fill in links to online pdf reprints. For example it would miss that the citation of Sandler AD, Sutton KA, DeWeese J, Girardi MA, Sheppard V, Bodfish JW. (1999) Lack of benefit of a single dose of synthetic human secretin in the treatment of autism and pervasive developmental disorder. N Engl J Med. 341:1801 PMID: 10588965 has a a link to its pdf reprint [2]. Many readers will lack access to university ejournal subscriptions so where the actual cited papers are openly available, the citation should show this link. In this case, someone--perhaps a parent of an individual with autism--would like to know more and have a look at the actual research paper.--LittleHow (talk) 07:44, 17 January 2009 (UTC)

In that case, it's easy enough to add the relevant link into the |url= field of template:cite journal. — Scientizzle 08:04, 17 January 2009 (UTC)

Bold rewrite and reorganization

The placebo effect article is described on the WikiProject Medicine/Collaboration of the Week as “a rambling, out-of-date treatise that can and should give clearer information”. It has numerous areas requiring attention:

• the “introductory text” does not “provide an accessible overview”
• there is no illustration to provide an engaging visual introduction to the concept of the placebo effect
• most statements lack inline citations
• it is poorly organized, and in many places very wordy

I have spent the time since December rereading the research and review literature and in view of that made a major rewriting of the article (are we not invited to “be bold when updating pages”?). I have attempted to include most what was previously present in some form, though much has been move around, made more focused, and put in new sections. I have reordered information so the information most likely to be of interest to a nonspecialist is at the beginning. I have rewritten the introduction to provide an explanation appropriate to the length of the article. One of the problems of the placebo effect mentioned constantly in the literature is difficulty in defining it. I do not think any short definition using simple ordinary words will be completely satisfactory. I have used two images to illustrate the concept of placebo: I did this with my rewrite of evolutionary medicine as it allows the reader to see the abstract connection that exists between apparently different issues (placebos are as much sham surgery as inert pills).

I am fairly dyslexic so there could be a need for copy editing (I tend to leave words out).

I have not edited the reference reading lists in regard to papers and books that are now redundant since they are also in the citations, nor for that matter those now moved into the Placebo-controlled studies article. Nor have I edited in any detail the placebo history and placebo controversies sections.--LittleHow (talk) 17:53, 17 January 2009 (UTC)

While I wouldn't go as far as "rambling, out-of-date treatise", I agree there is definitely room for improvement. I am going to suggest a few ideas for better organising this page and attempt to implement them following discussion.

Remove the shopping cart list of conditions the placebo is relevant to ("List of medical conditions section") and clarify statements such as "Inert placebo drug unless otherwise stated" (I don't know what this is meant to say). One study is not enough to support the effectiveness/non-effectiveness of the placebo for any condition, especially in light of reviews such as "Hróbjartsson A, Gøtzsche PC (2001). "Is the placebo powerless? An analysis of clinical trials comparing placebo with no treatment". New England Journal of Medicine 344 (21): 1594–1602. PMID 11372012. http://content.nejm.org/cgi/content/short/344/21/1594." which point out methodological flaws. This section should be replaced with a more inclusive review that suggests what types of conditions the placebo may work for and find a way to align positive and negative findings. A reliance should be replaced on reviews over individual studies.

Align the "enhancing factors" and "expectations" sections. These sections are best treated as one as all the enhancing factors could conceivably affect expectations. I'm sure I could find a review that states something to this effect.

Merge the "The individual" and "scientific theories" section as both are related to reasons the placebo may or may not work. JamesStewart7 (talk) 00:31, 12 February 2009 (UTC)

Aligning lead with article

Here are the changes I've made with the explanations: rm ", but its scientific basis is not well-understood" - several scientific explanations in the article, some quite well fleshed out. rm "[It is believed that the patient's beliefs about what the placebo will do are linked to changes in the body's neurological regulatory systems] particularly in the higher cerebral cortex" - The fMRI evidence in the cites activation in many subcortical areas. rm reference to "homeostasis" - never mentioned again. Does not really assist in explaining what the sympathetic and parasympathetic nervous systems are. rm "The nature of the link is not yet clear." again, several theroies and nothing in science is ever 100% certain. rm "Historians of medicine believe that placebo effects were responsible for the efficacy of most medicine until the twentieth century." I'm not sure what this is trying to say (Historians believe?) and there is no support for this within the article. I also did a little copy editing. We should probably also look at fleshing the lead out a bit to summarise the other sections such as the scientific explanations section and the conditions it works for. I'll try to do that later if no one else does. JamesStewart7 (talk) 11:29, 13 February 2009 (UTC)

List of medical conditions section

I think this should be removed or at least highly modified for three reasons:

• I do not think a long list of conditions on which the placebo effect may act is very informative and a summary on the types of conditions the placebo effect may be effective for is more informative.
• Most of the references are primary sources which are not related to the placebo per se.
• Most of the references are not examples of the placebo effect - "The placebo effect is a phenomenon in which a physiologically inert treatment, or placebo, improves a patient's condition relative to similar patients who receive no treatment." Without a no treatment group you cannot demonstrate the existence of a no treatment group. You may simply be measuring regression to the mean or natural healing.

I'm going to go ahead and remove the inaccurate references which do not demonstrate a placebo effect but I think we should discuss how to convey the list of conditions the placebo effect may be effective for. JamesStewart7 (talk) 07:39, 14 February 2009 (UTC)

By the way, even a large number of journal authors seem to mess up the placebo/regression to the mean distinction, as Hróbjartsson and Peter Gøtzsche point out, which makes the use of primary sources even more problematic. JamesStewart7 (talk) 07:45, 14 February 2009 (UTC)

On review, I"m going to start with removing the studies which lack a no treatment group and make no direct mention to the placebo response. There are also several studies which made reference to the "placebo response" but lacked a no treatment group. The studies that refer to a placebo response but lack a no treatment group should also be removed, but I'm sure this will be far more controversial so I'll wait until someone comments on this first. JamesStewart7 (talk) 07:55, 14 February 2009 (UTC)

Hróbjartsson and Gøtzsche

I feel some of the criticisms are a little unfounded. For example, the article states "The authors concluded that the placebo effect does not have "powerful clinical effects... Their conclusion has been criticised on several grounds. First, that did in fact find an effect for pain." They never stated they did not find an effect for pain. They just didn't consider this a "powerful clinical effect" (they stated it was small). So I have removed this criticism (I can't work out what the reference is for this either).

"They studied a highly mixed group of conditions : the placebo effect does occur with peripheral disease processes (such as Hypertension, asthma, prostatic hyperplasia, anal fissure, bronchitis) though not for processes reflecting physical disease (such as venous leg ulcers, Crohn’s disease, urinary tract infection chronic heart failure" This is valid although I'm not sure it counts as a criticism. I recall, however, that a group of authors suggesting that the placebo is more potent for psychological than physiological conditions and thus Hróbjartsson and Gøtzsche should not have analysed such a heterozygous group. The precedeeing statment seems to relate to this. At the time of Hróbjartsson and Gøtzsche's analysis, however, they did state (if not in the report, in a commentary somewhere) that people claim placebo effects for virtually everything and not just psychological conditions. Someone did a reanalysis of Hróbjartsson and Gøtzsche's work which Hróbjartsson and Gøtzsche replied to and criticized (stating the support they found is shaky or something to that effect). We should probably provide Hróbjartsson and Gøtzsche criticisms of the reanalysis so as to tell the whole story (I'll try to dig them up later). I'm leaving that part of the article text as it is for now.

"Third, that placebos do not work strongly in clinical trials because the subjects do not know whether they might be getting a real treatment or a sham one." Is valid but I have changed "strongly" to "as strongly" as the article makes relative comparisons.

"Other writers pointed to the empirical data showing that placebos can have measurable biological effects, especially in pain relief, or argued that the use of a placebo to "please the patient" fosters real healing as part of a caring doctor-patient relationship" The first part " empirical data showing that placebos can have measurable biological effects" - seems to be suppported by a BMJ letter about another article criticising the placebo effect - not Hróbjartsson and Gøtzsche's article which is implied by juxtaposition and again no one is debating the effect of the placebo in pain, including Hróbjartsson and Gøtzsche. The second part "the use of a placebo to "please the patient" fosters real healing as part of a caring doctor-patient relationship" really has nothing to do with whether or not placebo effects exist and is coverned in another section. Therfore I have changed the sentence to "Other writers have argued that the placebo effect can be reliably demonstrated under appropriate conditions" which is what the BMJ article seems to state. JamesStewart7 (talk) 08:35, 14 February 2009 (UTC)

I've also changed the title of the section to "Is it clinically significant?" to better align it with the theme of Hróbjartsson and Gøtzsche's report JamesStewart7 (talk) 08:37, 14 February 2009 (UTC)

Beliefs

I reworded the top section. But I'd like to suggest adding references to it to support the statement about a patient's beliefs. The research cited lower in the article about the percentage of people on whom the placebo effect may operate and the possibility that the mechanism is the genetic one stated may support the top better. At the moment there is no reference for it in the top. What do editors think?Mccready (talk) 01:58, 15 February 2009 (UTC)

I take it you're referring to this sentence "The patient's beliefs about the placebo may be linked to changes in the body's neurological regulatory systems." Your edits were an improvement but I think it might be difficult to find a reference for the sentence in its current state as it is quite vague. "Neurological regulatory system" in particular, could refer to several things. Maybe we could replace the sentence with "A patients expectations of recovery contribute to the placebo effect." (some reference form the expectations section. and then, and then add another sentence summarising the "the individual" or "brain and body section".

I'd be hesitant to place anything from the "Genes" section in the lead just yet because the referencing consists of primary source and two media reports. The problem is, I think the original authors seem to have interpreted their results incorrectly. Their study lacked a no treatment group so their results could just as easily be interpreted as "The TPH2 polymorphism predicts recovery from social anxiety disorder." The authors (like far too many others) failed to recognise that if someone recovers while taking a placebo they may have been just as likely to recover without taking the placebo. Given this, I'm starting to think we should just cut the Gene section but I'm going to put it up for discussion before I do anything. JamesStewart7 (talk) 08:29, 15 February 2009 (UTC)

Thanks James. I agree with your first para and see your point in the second. I don't have access to the study (only the reports) but I'd be inclined, as an inclusionist, to leave the gene study there for the moment (with reservations you've stated). The findings may be accurate and the experimental design may not suffer greatly by lack of controls. Presumably they had a reason for picking TPH2 which may be clear from a literature search. kevin Mccready (talk) 09:54, 17 February 2009 (UTC)

Ok, in that case I'll look into the study in more detail and try and verify that the summary is accurate when I have the chance. JamesStewart7 (talk) 11:38, 17 February 2009 (UTC)

Evolutionary explanations

After looking at the references for this statement, I have removed it, "These psychologically related approaches are, however, “limited to proximal causes of the placebo effect” not the “ultimate evolutionary origins of the phenomenon”,¹⁹⁸ and “Why should the brain have evolved to have such control over the immune system, and why should this control be so subject to proximal factors such as expectation?” ^{page 475}". I have done this for a few reasons.

• We could just as easily write in the evolutionary explanation section "these approaches are limited to distal causes and fail to explain how the brain controls such system" or similar so I don't think it really adds anything.
• There is already an evolution section and we should probably keep the theoretical viewpoints separate.
• The writer (or at least the out of context quotation and framing) seems to suggest that the evolutionary viewpoint is more important than the cognitive one and we could argue all day about which paradigm is the most significant.
• The sentence (Moreman reference in particular) posits a very particular evolutionary viewpoint which is somewhat debatable and would again be better covered in the evolutionary section.

While I'm on the topic I think we need to find a few more references on the evolution of the placebo effect. While Humphrey seems to be a prominent figure, he didn't really support his statements in his essay with any real experimental evidence. While he definitely presents an interesting hypothesis we really need something include a journal or to present the other side of the debate (byproduct hypothesis). JamesStewart7 (talk) 12:44, 17 February 2009 (UTC)

Hi James, Well done. Would be interesting to see if Moerman interpreted his data properly. I haven't read it. Have you seen the work on different strains of H. pylori in different areas of the world? Kevin McCready (talk) 13:43, 17 February 2009 (UTC)

Study on autistic children removed - Misinterpreted

I've cut this "However, placebo effects for other conditions can last, particularly for children. One study found that three quarters of parents told their autistic child had been treated with a placebo wanted to continue that with treatment." THe authors specifically said under limitations that it was a "short-term study". I'm also fairly confident that the parents wanted to continue the treatment before they were told their child was receiving a placebo as the study refers to continuing secreting (not placebo) treatment. JamesStewart7 (talk) 12:56, 17 February 2009 (UTC)

Use?

Are placebos used in general medical practice or is that considered unethical? Are they only used in medical studies? Does the patient have to be informed that they may recieve a placebo? There needs to be more information on the use of placebos, perhaps in a separate section.

Darktangent (talk) 22:17, 17 April 2009 (UTC)

Removing the non-inline references and restoring normal display

I commonly use the Find function to search through References and see if something is already referenced before adding it. In this case, I was looking for PMID 10692902, Placebos and placebo effects in medicine: historical overview. Unfortunately I couldn't quickly do that in this article because the references were collapsed inside a box, which also makes it harder for me to scan the references at a glance. Turns out this box has a huge list of placebo publications which aren't really used in the article (based upon my use of the Find function). Some of these are also used as footnotes. I don't think Wikipedia needs to list every work on a particular subject. I'm moving them here and changing the References section to the standard. The emphasis should be on particular facts. If a reference doesn't offer any novel facts, then it probably doesn't need to be cited. If it doesn't have novel facts but offers a very good detailed description of a topic, then the reader can possibly be informed of that. II | (t - c) 07:38, 29 April 2009 (UTC)

A long list of possible references

Books Bausell, R. Barker (2007), Snake Oil Science: The Truth About Complementary and Alternative Medicine, Oxford University Press, ISBN 978-0-19-531368-0 Has several chapters on the placebo effect. Beecher, H.K., Measurement of Subjective Responses: Quantitative Effects of Drugs, Oxford University Press, (New York), 1959. Beecher, H.K., Research and the Individual: Human Studies, Little, Brown, (Boston), 1970. [ISBN 0-7000-0168-9] Bernheim, H. (trans. by Herter C.A. from Second, revised French Edition of 1887), Suggestive Therapeutics: A Treatise on the Nature and Uses of Hypnotism, G.P. Putnam's Sons, (New York), 1889. Brody, Howard (1980). Placebos and the Philosophy of Medicine: Clinical, Conceptual, and Ethical Issues. University of Chicago Press. ISBN 978-0226075310. Brody, Howard (2000). The Placebo response. New York: Harper Collins Publishers. ISBN 0-06-019493-6. Carruthers, S.G., Hoffman, B.B., Melmon, K.L. & Nierenberg, D.W. (eds.), Melmon and Morrelli's Clinical Pharmacology: Basic Principles in Therapeutics (Fourth Edition), McGraw-Hill, (London), 2000. Evans, Dylan 2004. Placebo: Mind over Matter in Modern Medicine. HarperCollins (UK) / Oxford University Press (US). ISBN 978-0007126132 / ISBN 978-0195220544. Gauld, A., A History of Hypnotism, Cambridge University Press, (Cambridge), 1992. Guess, Harry (2002). Science of the Placebo: Toward an Interdisciplinanary Research Agenda. BMJ Books. ISBN 978-0727915948. {{cite book}}: Unknown parameter |coauthors= ignored (|author= suggested) (help) Harrington, Anne, ed. 1997. The Placebo Effect: An Interdisciplinary Exploration. Cambridge: Harvard University Press. ISBN 067466986X Haygarth, J., Of the Imagination, as a Cause and as a Cure of Disorders of the Body; Exemplified by Fictitious Tractors, and Epidemical Convulsions (New Edition, with Additional Remarks), Crutwell, (Bath), 1801. Moerman, Daniel E. (2002). Meaning, Medicine and the 'Placebo Effect'. Cambridge University Press. {{cite book}}: Unknown parameter |isbna= ignored (help) Senn SJ. 2003. Dicing with Death: Chance, Risk and Health (Cambridge University Press: Cambridge, UK. ISBN 0-521-54023-2. Wilson, I., The Bleeding Mind: An Investigation into the Mysterious Phenomenon of Stigmata, Paladin, (London), 1991. History of medicine Anonymous, "The Bottle of Medicine" [Editorial], British Medical Journal, No.4750, (19 January 1952), pp.149–150. Estimates that 40% of general practice patients receive a bottle of medicine as a placebo. Ayad, H., "Khellin in Angina Pectoris", The Lancet, Vol.251, No.6495, (21 February 1948), Page 305. Cooper, A., "Surgical Lectures", The Lancet, Vol.1, No.8, (23 November 1823), pp.253–260. Diehl, H.S., Baker, A.B. & Cowan, D.W., " Cold Vaccines: An Evaluation Based on a Controlled Study", Journal of the American Medical Association, Vol.111, No.13, (24 September 1938), pp.1168–1173. Dunn, Peter M. (1997). "James Lind (1716-94) of Edinburgh and the treatment of scurvy". Archives of Disease in Childhood Fetal & Neonatal Edition. 76: F64–5. doi:10.1136/fn.76.1.F64. PMID 9059193. Evans, W. & Hoyle, C., "The Comparative Value of Drugs Used in the Continuous Treatment of Angina Pectoris", Quarterly Journal of Medicine, No.7 (Vol.2, No.4), (July 1933), pp.311–338. Flexner, A., Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching (Bulletin Number Four), The Merrymont Press, (Boston), 1910. [3] Flint, A., "A Contribution Toward the Natural History of Articular Rheumatism, Consisting of a Report of Thirteen Cases Treated Solely with Palliative Measures", American Journal of Medical Science, Vol.46, (July 1863), pp.17–36. Gold, H., Kwit, N.T. & Otto H., "The Xanthines (Theobromine and Aminophyllin) in the Treatment of Cardiac Pain", Journal of the American Medical Association, Vol.108, No.26, (26 June 1937), pp.2173–2179. Graves, T.C., "Commentary on a Case of Hystero-Epilepsy with Delayed Puberty: Treated with Testicular Extract", The Lancet, Vol.196, No.5075, (4 December 1920), pp.1134–1135. Handfield-Jones, R.P.C., "A Bottle of Medicine from the Doctor", The Lancet, Vol.262, No.6790, (17 October 1953), pp.823–825. Jellinek, E. M. "Clinical Tests on Comparative Effectiveness of Analgesic Drugs", Biometrics Bulletin, Vol.2, No.5, (October 1946), pp.87–91. Pepper, O.H.P., "A Note on the Placebo", American Journal of Pharmacy, Vol.117, (November 1945), pp.409–412. Platt, R., "Two Essays on the Practice of Medicine", The Lancet, Vol.250, No.6470, (30 August 1947), pp.305–307. Steele, Dr., "The Charitable Aspects of Medical Relief", Journal of the Royal Statistical Society, Vol.54, No.2, (June 1891), pp.263–310. Wolf, S., "Effects of Suggestion and Conditioning on the Action of Chemical Agents in Human Subjects; The Pharmacology of Placebos", Journal of Clinical Investigation, Vol.29, No.1, (January 1950), pp.100–109. Modern research Barfod TS. 2005. Placebos in medicine: placebo use is well known, placebo effect is not. BMJ. 330:45. PMID 15626817. Beecher, H.K., "Experimental Pharmacology and Measurement of the Subjective Response", Science, Vol.116, No.3007, (15 August 1952), pp.157–162. Beecher, H. K. 1955. "The powerful placebo". Journal of the American Medical Association, 159:1602–1606. PMID 13271123. Original article describing a widespread placebo effect. Beecher, H.K., Keats, A.S., Mosteller, F. & Lasagna, L., "The Effectiveness of Oral Analgesics (Morphine, Codeine, Acetylsalicylic Acid) and the Problem of Placebo "Reactors" and "Non-Reactors"", Journal of Pharmacology and Experimental Therapeutics, Vol.109, No.4, (December 1953), pp.393–400. Benedetti, Fabrizio (2005). "Neurobiological mechanisms of the placebo effect". Journal of Neuroscience. 25: 10390–402. doi:10.1523/JNEUROSCI.3458-05.2005. PMID 16280578. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help) Benedetti, Fabrizio (2003). "Conscious expectation and unconscious conditioning in analgesic, motor, and hormonal placebo/nocebo responses". Journal of Neuroscience. 23: 4315–23. PMID 12764120. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help) Benson, Herbert (1996). "Harnessing the power of the placebo effect and renaming it "remembered wellness"". Annual Review of Medicine. 47: 193–9. doi:10.1146/annurev.med.47.1.193. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help) Carter, A.B., "The Placebo: Its Use and Abuse", The Lancet, Vol.262, No.6790, (17 October 1953), p.823. Chambless, D.L. & Hollon, S.D., "Defining Empirically Supported Therapies", Journal of Consulting and Clinical Psychology, Vol.66, No.1, (February 1998), pp.7–18. Coronary Drug Project (1980). "Influence of adherence to treatment and response of cholesterol on mortality in the coronary drug project". New England Journal of Medicine. 303: 1038–41. Di Blasi Z, Reilly D. 2005. Placebos in medicine: medical paradoxes need disentangling. BMJ. 330:45. PMID 15626818. Evans D. 2005. Suppression of the acute-phase response as a biological mechanism for the placebo effect. Med Hypotheses. 64:1–7. PMID 15533601. Findley, T., "The Placebo and the Physician", Medical Clinics of North America, Vol.37, (November 1953), pp.1821–1826. Finniss, Damien G. (2005). "Mechanisms of the placebo response and their impact on clinical trials and clinical practice". Pain. 114: 3–6. doi:10.1016/j.pain.2004.12.012. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help) Gaddum, F.M., "Walter Ernest Dixon Memorial Lecture: Clinical Pharmacology", Proceedings of the Royal Society of Medicine, Vol.47, No.3, (March 1954), pp.195–204. Gallagher, E. J. (1993). "The relationship of treatment adherence to the risk of death after myocardial infarction in women". Journal of the American Medical Association. 270: 742–4. doi:10.1001/jama.270.6.742. PMID 8336377. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help) Geers AL et al. 2005. Goal activation, expectations, and the placebo effect. J Pers Soc Psychol. 89:143–159. PMID 16162050. Green, S.A., "The Origins of Modern Clinical Research", Clinical Orthopaedics and Related Research, Vol.405, (December 2002), pp.311–319. Harman, W.W., McKim, R.H., Mogar, R.E., Fadiman, J. & Stolaroff, M.J., "Psychedelic Agents in Creative Problem-Solving: A Pilot Study, Psychological Reports, Vol.19, No.1, (August 1966), pp.211–227. Herbert, James D. (2005). "Introduction to the special issue on the placebo concept in psychotherapy". Journal of Clinical Psychology. 61: 787–90. doi:10.1002/jclp.20125. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help) Hyland, M. E. (2003). Using the placebo response in clinical practice. Clinical Medicine (London, England), 3, 347–350. Jewson, N.D., "Medical Knowledge and the Patronage System in 18th Century England", Sociology, Vol.8, No.3, (1974), pp.369–385. Jewson, N.D., "The Disappearance of the Sick Man from Medical Cosmology, 1770–1870", Sociology, Vol.10, No.2, (1976), pp.225–244. Kaptchuk, Ted J. (1998a). "Intentional ignorance: A history of blind assessment and placebo controls in medicine". 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PMID 16014592. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help) Perlman, L, "Nonspecific, Unintended, and Serendipitous Effects in Psychotherapy", Professional Psychology: Research and Practice, Vol.32, No.3, (June 2001), pp.283–288. Ploghaus, Alexander (2003). "Neural circuitry underlying pain modulation: expectation, hypnosis, placebo". Trends in Cognitive Sciences. 7: 197–200. doi:10.1016/S1364-6613(03)00061-5. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help) Price DD et al. 1999. An analysis of factors that contribute to the magnitude of placebo analgesia in an experimental paradigm. Pain. 83:147–156. PMID 10534585. Ross, Sherman (1962). "Drugs and placebos: A model design". Psychological Reports. 10: 383–92. doi:10.2466/PR0.10.2.383-392. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help) Sauro MD. 2005. Endogenous opiates and the placebo effect: a meta-analytic review. J Psychosom Res. 58:115–120. PMID 15820838. Shapiro, A.K., "Semantics of the Placebo", Psychiatric Quarterly, Vol.42, No.4, (December 1968), pp.653–695. Spiegel D. 2004. Placebos in practice. BMJ. 329:927–928. PMID 15499085. Wager TD, Rilling JK, Smith EE et al. 2004. Placebo-induced changes in FMRI in the anticipation and experience of pain. Science. 303:1162–1167. PMID 14976306 Zubieta JK, Bueller JA et al. 2005. Placebo effects mediated by endogenous opioid activity on mu-opioid receptors. J Neurosci. 25:7754–7762. PMID 16120776. General audience Brooks, Michael. New Scientist Space. March 19, 2005. 13 Things that do not make sense. URL accessed April 25, 2008. Dodes, John E (January/February 1997). "The Mysterious Placebo". Skeptical Inquirer. Retrieved 2006-05-08. {{cite news}}: Check date values in: |date= (help) An overview of the placebo effect and how it influences the study of alternative medicines. Donaldson James, Susan (August 1, 2007). "People need both drugs and faith to get rid of pain". ABC News. McQuay, H. J. (2005). "Placebo". Postgraduate Medical Journal. 81: 155–60. doi:10.1136/pgmj.2004.024737. PMID doi:[https://doi.org/10.1136%2Fpgmj.2004.024737 10.1136/pgmj.2004.024737 15749790 '"`UNIQ--templatestyles-0000003E-QINU`"'[[doi (identifier)|doi]]:[https://doi.org/10.1136%2Fpgmj.2004.024737 10.1136/pgmj.2004.024737]]. {{cite journal}}: Check |pmid= value (help); External link in |pmid= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help); templatestyles stripmarker in |pmid= at position 10 (help) Mayo Clinic (2003-12-31). "Placebo effect: Harnessing your mind's power to heal". ScienceDaily. Retrieved 2008-04-26. {{cite news}}: Check |url= value (help); soft hyphen character in |url= at position 28 (help) Nordenberg, Tamar (January–February 2000). "The healing power of placebos". FDA Consumer Magazine. Retrieved 2006-05-08.{{cite news}}: CS1 maint: date format (link) Pavlus, John (2006-03-01). "Mystery Painkiller". ScienCentral News. Retrieved 2008-04-26. Includes video. Reilly, David (2002). "Creative consulting: what modifies a healing response". Student BMJ. 10: 1–44. Stetka, Bret (2007-04-16). "Descartes' Nightmare: The Convergence of Mind and Matter, and the State of Psychosomatic Medicine". Litmus. Retrieved 2008-04-26. Talbot, Margaret (January 9, 2000). "The Placebo Prescription". The New York Times Magazine. Retrieved 2006-05-08.

It seems like it would be nice to bring the number of footnotes down if possible. There's not a lot that can be trimmed, but both the first two footnotes are used for the same facts and appear similar. Does anyone have a preference? II | (t - c) 08:29, 29 April 2009 (UTC)

Section using incomprehensible jargon

Article was on the whole understandable until I hit the following sentence:

"upon the N2–P2, a biphasic negative–positive complex response, the N2 peak of which is at about 230 ms, and the P2 one at about 380 ms."

I don't have the background to know where to start fixing it... —Preceding unsigned comment added by 195.241.102.95 (talk) 22:11, 7 June 2009 (UTC)

New RS article

This article gives excellent coverage of the whole subject:

• The Placebo Effect by Harriet Hall, MD

It is the feature article in the May 20, 2009 issue of Skeptic, and is also featured as a link in the "Articles of Note" section of the June 26, 2009 edition of "Arts & Letters Daily, A service of The Chronicle of Higher Education".

-- Brangifer (talk) 03:35, 27 June 2009 (UTC)

Newman and deception in placebos in the intro

I will remove the following statement from the intro --"The deceptive nature of the placebo creates tension between the Hippocratic Oath and the honesty of the doctor-patient relationship." -- unless someone can come up with a compelling reason why it should remain. It is unsourced, and there is no sourced text in the article to justify it. There are situations where it is patently ethical for a physician to use placebo as a diagnostic tool, for the benefit of the patient and faithful to the Hippocratic Oath. A google search would help the naysayers. Comments? Kaiwhakahaere (talk) 23:58, 21 April 2009 (UTC)

The conflict the sentence tries to convey is important enough to be pointed out in the introduction. To some degree the problem of dishonesty is expressed in the body of the article (see doctor-patient relationship) and may need further elaboration. It is also right that there are legitimate uses for a placebo (i.e. a prospective drug study where the subject is aware that either the drug or a placebo is given). I would leave out the Hippocratic Oath part and propose to rephrase the sentence perhaps this way:-"The use of a placebo in a deceptive manner creates a conflict with the honesty of the doctor-patient relationship."(cite book |author=David H. Newman |title=Hippocrates' Shadow |publisher=Scribner (2008)| page=154-7 |isbn=1-4165-5153-0). Ekem (talk) 02:56, 23 April 2009 (UTC)

The sentence is basically correct, although it is misleading to cherrypick this sentence from Newman. Newman's chapter on placebos comes off as ambivalent about placebos, and he makes a strange distinction between "meaning responses" and "placebo effects". On page 156 he says "while antibiotics are no more effective than placebo pills [for sore throat], what if you compare antibiotic pills to nothing"? He says they're often effective in such cases and says "it seems unethical not to use something that heals". Then later he says that "we may as well be handing patients an inert pill and all the deceptions, moral compromises, and long-term harms that come with it". His main point is against using active drugs which don't really work for the condition they're purported to treat. Ultimately he concludes that the "meaning response" can be gained without deception (ie ineffective drugs or homeopathy) through "listening and doctoring". Basically he seems to say that if the doctors explain that things will go away with time, they will resolve. He doesn't seem to support this contention with data all that well though. II | (t - c) 08:14, 27 April 2009 (UTC)

I think it's important that the sentence stay in something close to its original form. It's worded pretty well: any kind of deception of the patient creates a tension for the physician. That doesn't mean the physician believes he/she is doing something wrong, just that he/she feels a bit uncomfortable about it. Looie496 (talk) 16:20, 27 April 2009 (UTC)

The issue about deception in this context while present is fairly complex. Medicine has an element of theater and play acting. Nurses often distract patients attention while giving injections so they do not focus upon the needle when it is inserted. Doctors are aware people come to be reassured and will give a full examination even if they do not think it is necessary because that is what is expected. Doctors will tell minor lies so that they can tell a patient "bad news" when there is sufficient time to properly explain the situation, or with a relative with who they can then discuss it. Deception is not itself wrong, it is deception with bad intent. The tension is medicine is what might be considered good intent: in the past (and presently in countries such as Japan) that included lies that reassured patients when they had cancer, for example.

One additional problem is that even clinically effective treatment has a placebo effect (see below): should a doctor warn a patient that while a drug has an active effect a large part of the positive effects that will happen to them is due to an additional effect of their own expectation that it will work. Should they tell the patient this in such a way to remove that additional placebo effect or just leave it as a bonus? What when a drug can have a clinical effect but that in half the cases it will not but still have that expectation effect? And what then a quarter of the time or less? The issue is about what is appropriate good "intent" and that is a very complex topic in the way it intermixes with deception.

The introduction has shrunk in the last few months and no longer mentions that the placebo effect also applies as an additional enhancement of treatments with real clinical effects. for example, Eccles R, Eccles, K.S.J. Placebo effect (2007) Encyclopedia of life sciences . John Wiley & Sons doi:10.1038/npg.els.0004114 ISBN 978-0470066515

The therapeutic response to any medicine is made up of several components (Eccles, 2003) including a perceived placebo effect (see Figure 1). The figure shows that the active medicine has three components that contribute to the overall effect of the medicine on the disease (pharmacological, true placebo and nonspecific components).

I suggest lead starts with the Placebo effect rather than Placebos so that can be mentioned. I suggest it reverts to something like: The Placebo effect is the medical phenomena in which a person’s beliefs about an inert substance or a sham therapy results in that treatment having the expected consequences of those beliefs upon health. The placebo effect can also be an additional boost for a real therapy or drug beyond that warranted solely by its actual physiological action. --LittleHow (talk) 03:58, 28 April 2009 (UTC)

I think a lot of good points have been made. Newman struggled with the placebo dilemma and so it seems do we. I expanded the "Motivation and meanings section" a little bit, but feel that this dilemma should not be avoided in the introduction. Also Eccles' point can be introduced in the intro showing that the placebo effect is an integral part of the effect of "active medicine". When I came to the "Placebo" article I found it jarring that it started at that time with "The placebo effect..." and changed it to begin with "The placebo...", to have the horse in front of the cart so to speak. The Placebo effect may deserve its own article, though, but that is a tall order.Ekem (talk) 14:08, 28 April 2009 (UTC)

There's no such thing as a placebo without a placebo effect. This article should probably be retitled to the placebo effect. II | (t - c) 21:28, 29 April 2009 (UTC)

Hróbjartsson and Norup indicate that about "30% (28-36) of the clinicians believed in an effect of placebo interventions" (see ref #2 of article) and you are saying placebo interventions always have an objective outcome? Ekem (talk) 12:06, 30 April 2009 (UTC)

Hmm. How did you get that from what I said? A placebo is just an inert substance which, through some manner of expectation, deception or promotion, exerts a placebo effect. Without that effect, it's just an inert substance ... actually, thinking about this a bit more maybe I'm wrong. Maybe a placebo is just an inert substance used as a control, which just happens to exert a placebo effect. Even if there was no placebo effect, there would still be a placebo. On the other hand, under a definition of placebo as a "control procedure" non-placebos can obviously have a placebo effect; for example, Moerman's example of expensive swimsuits. II | (t - c) 16:39, 30 April 2009 (UTC)

The statement is an important indication on what is the general philosophical/ethical trouble with exploiting the "placebo effect" 100% if that is possible, and maybe also an indication on why the effect is not very well understood. By my gut-feelings, it is some kind of "instantiation" of a general "tailbiter paradox" (where the statement over a thing affects the truth of the same thing) related to self-fulfilling prophecies and possibly also Heisenberg's uncertainty principle (measurement of things affects the truth of the same things). ... said: Rursus (bork²) 08:32, 8 July 2009 (UTC)

Chronic Fatigue Syndrome

Previous wording was misleading, citation PMID15784798 full text concludes:

"In contrast with the conventional wisdom, the placebo response in CFS is low."

"In contrast with the initial hypothesis, the pooled placebo response was substantially lower than the usually reported one third response in other medical conditions."

"This comparison of like with like enabled us to conclude that contrary to the received wisdom, the summary placebo response in CFS was actually lower compared with the comparison disorders." Ward20 (talk) 07:14, 3 June 2009 (UTC)

I agree about the problem but not about the solution. A "list of medical conditions" with no further comment beyond references makes no sense to me. Depending on how this is fixed it probably makes sense to include CFS again; after all the low placebo response is unexpected.

I don't remember this section from the last time I worked on the article, and I am not sure what to do about it. --Hans Adler (talk) 08:21, 3 June 2009 (UTC)

Hans, if it can be fixed without the reader the assuming wrong information that's great. AFAIK there is a placebo response for almost all diseases, why pick these few out? I spot checked some conditions to the sources and several talked about substantial or elevated placebo response. The Crohn's disease citation talked about a variable placebo response. IMO the section needs a lot of work to make sense. Maybe present an elevated placebo response illness, a lowered placebo response illness such as CFS, a variable placebo response condition such as Crohn's disease, and whatever other permutations there may be to illustrate different types of responses? Ward20 (talk) 08:54, 3 June 2009 (UTC)

Take list that has no explanation or reason for inclusion in article and park it here for now. The list appears to be placebo studies of illnesses but they can't be inclusive as most studies have placebo controls. Ward20 (talk) 00:55, 2 July 2009 (UTC)

List of medical conditions

The placebo is an inert pill unless otherwise stated

• ADHD:adult, child
• Amalgam fillings: attributed symptoms (inert "chelation" therapy)
• Anxiety disorders
• Asthma (water aerosol inhalant)
• Asthma^{table 1}
• Autism: language and behavior problems
• Benign prostatic enlargement
• Binge eating disorder
• Bipolar mania
• Cough
• Crohn's disease

• Depression (Light treatment; low red light placebo)
• Depression
• Dyspepsia and gastric motility
• Epilepsy
• Erectile dysfunction
• Food allergy: ability to eat ill-making foods ^{p. 54}
• Gastric and duodenal ulcers
• Headache
• Heart failure, congestive
• Herpes simplex
• Hypertension: mild and moderate
• Irritable bowel syndrome
• Migraine prophylaxis
• Multiple sclerosis
• Nausea: gastric activity
• Nausea: chemotherapy
• Nausea and vomiting: postoperative (sham acupuncture)

• Pain
• Panic disorders
• Parkinson’s disease
• Pathological gambling
• Premenstrual dysphoric disorder.
• Psoriatic arthritis
• Reflux esophagitis
• Restless leg syndrome
• Rheumatic diseases
• Sexual dysfunction: women
• Social phobia
• Third molar extraction swelling (sham ultra-sound)
• Ulcerative colitis
• Vulvar vestibulitis

---

The list is interesting and provides an useful source of studies and papers that discuss the placebo effect in diverse conditions and should be kept.

Placebo controls it should always be noted are not placebos because those taking them do not know whether their treatment is "active" or not. (Placebo controls are given for methodological reasons in trial design not to explore the placebo effect). Such uncertainty about receiving an "active" or inactive treatment could effect whether or not a placebo effect occurs. This list contains studies and metastudies that seem to look at the question whether the placebo effect actually applies to a wide range of symptoms and conditions. That makes it relevant in an article upon the placebo effect.--LittleHow (talk) 04:10, 2 July 2009 (UTC)

I don't understand how the reader is expected to know what the studies and metastudies represent since there is no explanation in the article. Is it a see also section in disguise? Then there is a problem of presenting how the group of studies and metastudies are relevant in the article without getting into original research. I will ask for input at Wikipedia talk:WikiProject Medicine here. Ward20 (talk) 05:49, 2 July 2009 (UTC)

These don't seem to be all about studying the effect of placebo. The first[4] one, for ADHD, was actually comparing drugs to placebo . If you're studying placebo, you need an untreated group. The second [5], oddly enough, found that kids openly administered placebo with lowered stimulant doses maintained their status compared to those who weren't given placebo. So the first is not really what we're looking for. We're looking for studies like the second, which study the placebo rather than use placebo as a control. II | (t - c) 05:29, 3 July 2009 (UTC)

However if a reader had a prior interest in ADHD, these papers would seem the kind of literature to which they would appreciate a pointer. The first though lacking a no treatment arm found that 46% of the placebo takers had a 30% improvement on the adult ADHD rating scale -- the comparison drugs at 34% and 49% were not statistically different. That is not marginal and given the surprising finding of the second study of an effect for open-label placebo treatment in ADHD suggests ADHD is a condition that in which there exists placebo findings of interest.

The question about this list seems to me to bewhether there is a general "placebo effect" or a lot of different "placebo effects" each tied to different conditions. If the latter there is a need to provide at least some indications of the conditions to which it might be relevant. --LittleHow (talk) 09:37, 3 July 2009 (UTC)

That's one of the reasons I believe the list is questionable. What does the list represent? The footnote,¹³³ which IMO is original research (I haven't seen a footnote before that is an editorial opinion), states, "In many of these citations concern research that show active treatments are effective. The point is that they also show placebo effects exist as well. It should not therefore be inferred that more effective active treatments for these conditions do not exist, only that placebo effects have been shown." There are other problems with the list. Several small placebo controlled studies are represented. How are those selected over others. A pubmed search of "placebo controlled study" has 88574 articles and 7799 reviews. What is the list inclusion criteria, and why are these medical conditions significant over others? Ward20 (talk) 13:11, 3 July 2009 (UTC)

Also, in the section Gastric and duodenal ulcers the article talks about a meta-study but reference¹³² doesn't seem to be a meta-study nor support the material. Anyone know what is going on there? Ward20 (talk) 13:19, 3 July 2009 (UTC)

• The list exists because many readers will have an interest in a particular condition and might want further information upon research relevant to them. It may or may not achieve that--but that is a valid reason for its existence. Being imperfect is not a reason for deletion: one of the key ideas behind Wikipedia is "Wikipedia is a work in progress" and that "Preserve information: fix problems if you can, flag them if you can't.".
• I do not see in what way the footnote is expressing an opinion or original research. It seems to me to written to warn the reader not to infer that because a treatment is mentioned to show a placebo effect that it might not also show an active effect as well. One responsibility in any discussion of placebos is noting that even if a drug shows a placebo effect it still might have an active one as well--without such a warning a person might mistakenly discontinue treatment.
• Rereading the titles, abstracts and some of the pdfs the list seems to be made up articles that have either focused upon the placebo effect in these conditions or found something unusual. There may be lots of "placebo controlled studies" but few such placebo effect focused articles.
• The section Gastric and duodenal ulcers cites a book reference¹³² as meta-study. Moerman discusses in that book his meta-study that was published earlier in Moerman DE. (2000) Cultural variations in the placebo effect: ulcers, anxiety, and blood pressure. Med Anthropol Q. 14:51-72.(A paper cited elsewhere in the article)
• What is happening is a discussion.--LittleHow (talk) 14:04, 4 July 2009 (UTC)