From the Editor
The most powerful placebo is not a pill
The psychiatrist’s verbal and nonverbal cues can have a positive or negative placebo effect on the patient
The placebo effect—when a patient’s symptoms improve with an inert pill—is widely recognized in medicine. Placebo has an especially important role in psychiatry, especially given the fact that a substantial proportion of patients with mood, anxiety, or psychotic disorders improve and experience some side effects with placebo in double-blind studies conducted by drug manufacturers as part of FDA registration trials.
On the other hand, non-psychiatric medical disorders such as pneumonia and diabetes are unlikely to improve with placebo. Thus, psychiatric brain disorders appear to be particularly susceptible to the placebo effect, which implies it could be harnessed in psychiatric care. A component of every medication prescribed in psychiatry is a variable placebo effect in addition to the actual pharmacodynamic effects.
Some physicians (including non-psychiatrists) openly admit to using placebo—which is sold as Obecalp capsules—to treat patients with vague aches, pains, insomnia, or low energy. Some published studies have shown patients respond to inert pills even when the physician tells them in advance they will be receiving a placebo!1 This reflects the power of the placebo effect programmed in the human brain, which may have an evolutionary advantage of instilling hope and sustaining faith things will get better despite serious physical or psychological adversity.
What health care professionals often overlook is that the placebo effect transcends the pill itself. The most powerful placebo is the psychiatrist or nurse practitioner who prescribes the pill. In fact, the placebo effect of a clinician occurs even without prescribing any medication.
The shape and color of a placebo pill may endow it with a greater effect (eg, a red and blue striped placebo caplet looks more impressive and may project an aura of being more effective than a plain white tablet). Similarly, a patient is influenced positively or negatively by a range of attributes that characterize his or her psychiatrist, and the totality of the impressions (positive or negative) the psychiatrist “projects” may enhance or detract from whatever treatment is administered, including medication or psychotherapy. This is why different prescribers may achieve disparate results when prescribing the same psychotropic.
Many subtle and not-so-subtle verbal and nonverbal aspects of a clinician can project an “aura” of competence and trust for the patient, which will contribute to a better treatment outcome because of the patient’s stronger unconscious expectation of improvement. These include the psychiatrist’s grooming and clothing, his facial expression and demeanor, the neatness of his desk, the décor of his office, the cleanliness of the waiting room, even the appearance of the neighborhood where his clinic is located. Wearing a white coat instead of street clothes can evoke the image of a physician/healer, which is a strong positive placebo effect that can be exploited for many patients. Direct eye contact an open body posture, a firm, reassuring voice, and a handshake or caring pat on the back at the end of the session when appropriate all contribute to patient improvement even before he or she ingests any pills. A psychiatrist can enhance the response and tolerability of a drug by expressing confidence in the medication and assuring the patient if taken as prescribed the medication will help and will be tolerable according to published studies. Even slight uncertainty by the psychiatrist about the potential usefulness of a medication—even if realistic—may compromise the patient’s response.
Take the following extreme illustration of a psychiatrist whose image projects a powerful negative placebo effect that could undermine therapeutic outcome and even patient adherence: Dr. X works in a dilapidated building in a downtrodden neighborhood. Several furniture pieces in his waiting room are torn or broken. The carpet is worn and features several stains. His office is poorly lit and reeks of mildew and stale cigarette butts. He barely looks at the patient but types on a laptop as the patient speaks. Dr. X is dressed in a casual sports shirt and blue jeans. His hair is disheveled. The floor of his office is littered with piles of journals and books. Dr. X speaks in a hurried, impatient tone and often interrupts the patient to ask a barrage of questions unrelated to what the patient was talking about. Occasionally, Dr. X stops typing, leans back in his worn creaky chair, crosses his arms, and just stares at the patient. He then abruptly ends the session because “there are many other patients waiting.” He scribbles a prescription, slides it over the desk to the patient, and says “Here, take this until next visit and we’ll see if it works for you.” The psychiatrist never leaves his chair and keeps typing as the patient dejectedly leaves the office.
Dr. X clearly has squandered the valuable placebo effect inherent in his role that not only can enhance the medication efficacy but also usually bolsters the therapeutic alliance. The many negative aspects of his demeanor, behavior, relatedness, and office probably will decrease the likelihood of a good outcome in his patient
Every clinician can achieve better treatment results by creating a set of positive personal and environmental cues to reinforce that powerful and intangible force that expedites the relief of psychiatric symptoms. It would be folly to squander the remarkable placebo inherent in us “healers.”
1. Kaptchuk TJ, Friedlander E, Kelley JM, et al. Placebos without deception: a randomized controlled trial in irritable bowel syndrome. PLoS One. 2010;5(12):1-7.