THE NOCEBO EFFECT: THE POWER OF EXPECTATIONS AND OUTLOOK

The nocebo effect is the opposite of a placebo effect, so it is a negative response to a sham treatment where the person believes that they are getting the treatment but actually are not. What is amazing is how powerful expectations and outlook are as the placebo response is often close to that for those who actually received the treatment.  This has been true for studies of antidepressants used for depression. This has led some researchers to conclude that the antidepressants are not effective because the placebo response is so strong. What seems to be not understood is that for a placebo response to occur people have to believe they are getting the treatment. So, you can only have a placebo or a nocebo response if there is also treatment occuring.  

What is critical is to understand what happens in our brains when we have either a placebo or a nocebo response.  Nocebo responses are especially concerning. To understand these reponses researchers have looked at expectations and beliefs and their impact on treatment responses and overall health. Years ago a large study by the National Heart Association was conducted in Framingham, Massachusetts on 5290 men and women ages 30-62. They found that women who thought that they were "prone" to heart disease were four times more likely to die from heart disease than those women who did not feel that they were at risk for heart disease. So, is it possible that feeling prone to heart disease can kill you? It seems like it. It is as if we can create our own reality regarding our health in amazing and potentially frightening ways.

There is plenty of evidence from research that chronic stress increases negative outcomes for illnesses that we might have. Stress does not create illnesses such as heart disease or cancer but will make them worse and make for a worse prognosis. This reflects increased negative health outcomes related to the impact of chronic stress as this stress contributed to both a negative outlook and a feeling of hopelessness. This makes it similar to a nocebo effect. Turning to a positive outcome, a study by Crestwell in 2007 showed that breast cancer survivors who wrote affirming statements about their life had fewer side-effects and better overall outcomes compared to those who wrote negative statements. So, a more positive outlook as demonstrated by more positive statements without any prompts, leads to better outcomes. 

Since what we believe and expect can have significant impact on our lives why not be positive and hopeful?

PLACEBO EFFECTS AND TREATMENT RESPONSES

There has been a lot written recently about the placebo effect and how it shows that medications are ineffective because they are not more effective than placebo.  In these studies, the placebo response is often in the 30-50% range as is the response to the active treatment being studied. Placebo controlled studies are ones where if we were in the study, we would not know whether we were getting the actual treatment or are receiving everything but the active component of the treatment. Thus, we would think we were getting the treatment but we would not be.  Thus, the placebo response is the response to the belief that we are getting the treatment.  In medication studies, the treatment would be the medication.  It is quite amazing to me that believing that we are getting medication can lead to a benefit as if we wer getting the treatment. This response only occurs if we believe that we are getting the medication.

I have often heard people say that if there is a placebo response close to the response to the actual treatment [medication in this case] that the treatment is not effective.  Studies have repeatedly shown that responses to treatment are improved considerably if medication is combined with different forms of therapy and I wonder if this would also help the placebo responders to improve their outcomes. Another important fact to be aware of is the limitations of studies that involve larger numbers of people as the statistical analyses show correlations but not causations.  Also, the studies are short duration and often do not generalize to real life experience with the medications.  In fact, the placebo controlled randomized studies identify potentially useful medications that then are prescribed by your doctor and you then become part of the larger study determining the effectiveness of the medication.  This is very important as it requires more time and dosing adjustments to fine tune the use of medications to determine how effective they are.  There are two problems that prevent this from occuring.  First, it takes time with each person to assess their response to medication and to help them to determine how they are responding.  Unfortunately, it is not common for physicians to take the time that is needed. Second, there is no mechanism to feedback information about how you responded or are responding to the medication in order to update the research.  Thus, there is no way to update research with your experiences and then decisions about treatment remain limited to the initial, time limited studies.  This is another reason that treatments [like medications] are considered to be ineffective.