I’ve always been fascinated by the high rate of response to placebo in drug studies, not just when it has been used as a control in the treatment of ill-defined psychiatric disorders, but for other well-understood medical disorders. For example, placebo has been reported to be effective in relieving chest pain as well as correcting associated EKG abnormalities in patients with angina.
Just how does a placebo work? Well, a recent Columbia University study has attempted to answer that question. Lead researcher, Tor Wager, administered painful electric shocks to the skin of willing volunteers while they were confined inside an MRI machine. A fake analgesic cream was then applied to the subjects, and not surprisingly, half of them reported that subsequent shocks were less painful. Simultaneous imaging studies of the prefrontal cortex revealed increased inhibitory activity in the insula and anterior cingulate gyrus after the people were told they had been administered the cream. Interestingly, when the subjects were informed that the same cream would not be effective, the prefrontal cortex was quiet.
The intriguing aftermath of that study has been that scientists are now attempting to develop a drug, D-cycloserine, to simulate the effects of placebo on the brain. And if developed and approved, we’ll probably end up having to pay an inordinately high price for a prescription sugar pill.
I remember in my residency training days, it was considered an accepted practice to use placebos to safely treat a number of conditions (e.g., personality disorders, oppositional defiant disorder, adjustment disorders, somatoform disorders, etc) that were not amenable to conventional psychotropic medications, particularly in patients whose therapeutic interests were limited to medication management. Our clinic pharmacy even dispensed these for prescriptions labeled as “P-capsules”, according to dosing instructions. At some point, conventional wisdom apparently condemned this as an unethical practice, but essentially it has continued less obviously when physicians choose to prescribe subtherapeutic dosages of various psychotropics to treat these same conditions.
In view of this research, it seems to me that a compelling argument could be made to allow the unfairly maligned placebo back into our pharmaceutical membership. Often, when it comes to healing the mind, the mere expectation of improvement from any proposed remedy may be treatment enough.
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