Evidence-Based Reviews

Words to the wise: 4 secrets of successful pharmacotherapy

Author and Disclosure Information

Put to good use the placebo effect, conditioned responses, and the power of suggestion


 

References

Any medication’s therapeutic success depends on the interaction between its specific biochemical effects and nonspecific factors.1 Thus, clinical trial designers may view the placebo effect as undesirable, but it can be a valuable response that improves treatment outcomes in clinical practice. As Freud stated, “Expectation colored by hope and faith is an effective force with which we have to reckon…in all our attempts at treatment and cure.”2

This article describes how experienced clinicians make use of the placebo effect and 3 other powerful, nonspecific elements of successful pharmacotherapy.

The placebo effect

The placebo effect is any effect attributable to a pill or potion that does not originate from its specific pharmacologic properties.3 Its clinical value has been trivialized, in part because of misconceptions (Table 1). For example, the placebo effect is commonly believed to be short-lived, whereas in fact it can last a long time.4

In clinical practice, our goal is to enhance the placebo effect to maximize a desirable therapeutic outcome (Table 2).5 Therefore, before I prescribe a medication, I tell my patient that I have selected a particular medication because I have had good results with it in many other patients and I believe it will work well for him or her, too.

Too often, doctors feel pessimistic about a medication’s potential therapeutic result and communicate this pessimism. What the patient hears is, “There’s nothing else I can do for you; why not try this medication, even though I don’t believe it’s going to work.” This may create a negative placebo effect6—termed the “nocebo” effect—which gives the patient a negative expectation about the treatment’s outcome. The patient internalizes the doctor’s words and lives out this negative expectation.

Table 1

Correcting misconceptions about the placebo effect

MisconceptionWhat the evidence shows
Placebo effects are short-livedThe placebo effect has been documented to last for a long time
Only complaints that are psychologically originated respond to placeboChanges after placebo have been documented for most symptoms, including those originating from somatic diseases
Placebo responders are distinctly different from nonrespondersThere is no difference between placebo responders and nonresponders
The placebo effect is only about one-third of the total therapeutic effectThe placebo effect can be up to 100% of the total therapeutic effect
Only about one-third of the population responds to placeboThe placebo response is context-dependent and may include >90% of the patient population
Source: Reference 4
Table 2

Clinical strategies to enhance the placebo effect

  • Develop a sustained therapeutic partnership with the patient
  • Listen effectively and verify that the patient feels listened to
  • Provide comprehensible explanations of health problems therapeutically tailored for each patient’s needs and personality style
  • Show empathy, care, and concern for the patient as a person
  • Enhance patients’ sense of control and mastery over their predicament
Source: Reference 5

CASE REPORT: Predicting positive results

Mr. B, age 42, has a history of recurrent depression associated with severe insomnia, poor appetite, significant weight loss, and psychosocial withdrawal with feelings of hopelessness. After I take a detailed history and do a mental status examination, I suggest that he be treated with cognitive-behavioral therapy (CBT) and mirtazapine.

I tell Mr. B this antidepressant has excellent potential to help him recover from depression. I also inform him that improved sleep and appetite may be the first effects he experiences. I give Mr. B an appointment for 1 week later, and when he comes in he reports improved sleep and appetite, as expected.

Even though studies of antidepressants rarely show mood improvements within the first 7 days, it is not unusual to hear patients report feeling less depressed within days after they start a new antidepressant. Although the drug’s specific chemical effects on the brain may not be sufficient to explain this phenomenon, the explanation probably lies in nonspecific effects—such as the patient expecting that this medication will make him feel better.

The placebo effect can occur as soon as a patient starts a medication. Experienced clinicians understand the placebo effect’s power and harness it to benefit their patients.

Conditioned responses

Many biological responses can be associated with visual, auditory, tactile, olfactory, or gustatory stimuli. Nonconditioned physiologic responses paired with conditioned stimuli induce the same biological effects of a drug. Evidence supporting this phenomenon includes successful conditioning of the immune system.7-10 Conditioned responses—as demonstrated in glycemia regulation10 and with psychopharmacology11—also can enhance the desirable results of pharmacotherapy.

CASE REPORT: A soothing drink

Ms. L, a 22-year-old college student, suffers from obsessive-compulsive disorder associated with anxiety and depression. She arrives at the appointment hurried and worried that she might be late. She is short of breath and looks stressed. The nurse offers Ms. L a cup of tea or water. She chooses a glass of water and is asked to bring it into her session.

Pages

Recommended Reading

Antipsychotics Tied to Adverse Metabolic Events
MDedge Psychiatry
Undertreated Pain Can Spark Pseudoaddiction
MDedge Psychiatry
School-Based Intervention Improves Anger Control in Black Teens
MDedge Psychiatry
Tarenflurbil Shows 'No Efficacy' for Alzheimer's
MDedge Psychiatry
Prayer Helps Enhance Quality of Life in Dementia
MDedge Psychiatry
Exercise Protective for Mild Memory Impairment
MDedge Psychiatry
Phase II Findings in AD Drug Trial 'Not All Bad'
MDedge Psychiatry
Blacks May Be at Greater Risk for Alcoholism
MDedge Psychiatry
Medicaid Substance Abuse Funds Going Unused
MDedge Psychiatry
Let's End Health Disparities
MDedge Psychiatry