Placebos work even when the patient knows it's a placebo ?

Nitpick Statins treat high cholesterol, not high blood pressure
[Or maybe this mistake was deliberate to make a point, and I was just “whooshed”]
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Mommy’s kisses cure banged-up knees. It isn’t the mercurochrome, or the Donald Duck band-aid: it’s Mommy’s kiss.

My wife used to run Girl Guide camps and I went along as moral support and general dogsbody. She is a qualified first-aider and we always had a small first aid tent set up with a camp bed and all the kit.

The girls would mostly suffer from banged knees, squashed thumbs, minor burns and scalds, minor cuts, period pains and headaches. The cure for nearly all of them was a cold wet face cloth (applied to the sore area), a hug and time out on the bed away from the hustle and bustle before they were lured out by the sounds of their friends having fun.

This always happens when non-scientists start discussing the headline result from a piece of research. You thought about this for a few minutes, came up with an obvious confounding factor that would be simple to to control in the study design… but you assume that a bunch of highly intelligent people with years of training in scientific research who worked on this study for months just never thought about controlling for it? The essence of the design of scientific studies is the use of rigorous controls, to try to ensure that the only thing that varies is the factor that you want to investigate. Sometimes potentially confounding factors are subtle and/or difficult to control for, but surely not this. You would obviously design the study so that the control group are treated in exactly the same way in every possible respect except giving them the pill.

And yet moojja arrived at the same conclusions as the scientists studying the placebo effect, that it is not sugar pill based but instead part of an overall effect associated with medical treatment. The placebo effect works even if people receive no placebo.

Edzard Ernst (a former practitioner and professor of alternative medicine) had a good response to that (specifically in reference to homeopathy).

*"The empathic encounter with a homeopath, the expectation of the patient, the natural history of the disease and many other factors all provide ample explanation for the fact that patients can improve even when they receive placebos.

This leads to the vexatious question: what is wrong with giving placebos to patients as long as they help? The answer, I’m afraid, is a lot. This strategy would mean not telling the truth to patients and thus depriving them of fully informed consent. This paternalistic approach of years gone by is now considered unethical.

Also, placebo effects are unreliable and usually short-lived. Moreover, endorsing homeopathic placebos in this way would mean that people may use it for serious, treatable conditions. Furthermore, if we allow the homeopathic industry to sell placebos we should do the same for big pharmaceutical companies – and where would this take us? Crucially and somewhat paradoxically, we don’t need a placebo to generate a placebo effect. If I give my headache patient an aspirin and do this, as all good doctors should, with empathy, time and understanding, the patient will benefit from a placebo effect plus the pharmacological effect of the aspirin. If I prescribe her a homeopathic remedy, I quite simply deprive her of the latter. It is difficult to argue that this approach would be in the interest of my patient."*

It’s commonplace for alt med remedies (many if not most of which rely on placebo effect) to seem to work for a time. Then for various reasons (including the natural course of an ailment) they stop working and the patient is on to the next short-term fix. Meantime they are ignoring what could be valuable therapy and wasting their money.

Something else to note: placebos may have no effect, beneficial effects or negative effects. Look at clinical trial data for various interventions, and typically there will be a range of side effects (sometimes serious) occurring in the group that got placebo. Investigators in large-scale trials can be fairly confident that the intervention in question has an acceptable safety profile if the reported negative effects occur at the same frequency (and are of the same kind) in the placebo group as well.

I can only provide three medical treatments, I tell my students: band-aids, wet paper towels, and sympathy. But man alive do I sell those wet paper towels as a panacea.

The “professionals are taking care of me” theory makes a lot of sense. Culturally, we know that when you’re sick, you go to the office that smells like antiseptic, and the professionals talk to you and give you medicine, and you get better. You go through the dance, you’re cured by the end.

In these studies, one step in the dance is changed: you’re told the medicing you’re getting isn’t real medicine. But the rest of the dance stays the same. If you’re a pattern-seeking monkey (AND YOU ARE), there’s a pretty good chance that, seeing the rest of the pattern remains the same, you’ll expect a substantially similar outcome.

One theory is that it is a “ritual” effect. The white coats, the antiseptic as you say, a ritual of healing that has worked for shamans and doctors alike.

I had crushing depression and anxiety some years ago, it was relentless. I couldn’t stop crying and went to the doctor. I got a little pep talk and was told we would try an anti-depressant. I was given a prescription to go fill, and I walked out to the car with a lighter heart! Just the fact something was going to be DONE was uplifting.

I’m curious about the design of the study. It seems like a very unsurprising result if you aren’t thinking of placebos as triggering magical mind effects.

The main reasons for including a placebo are related to isolating the effects of the intervention being investigated. They are necessary for blinding, and when feasible, for double blinding. They also replicate as much of the process associated with the active agent as possible without including the active agent, so the effects of those processes are controlled for.

So what was the design of the OP study? What exactly were they investigating, and how could they control for it?

Cite, please? What are you referring to? The original research is not cited in the blog article linked in the OP, but the article says:

From research I have seen, there is certainly an effect associated with just generally receiving care and attention, I’m not disputing that. But if you control for that, there is (for some conditions) an additional effect solely from the administration of an open-label placebo, and the blog post linked in the OP appears to be talking about that.

I think this is the study the OP’s article is talking about. From the abstract:

(Emphasis mine)

Actually, it is my understanding (admittedly second-hand) that most of what we know about placebos comes from “real pill vs placebo” studies, making every factor except the contents of the pill as identical as possible for both groups. Studying “placebo vs. no pill” is a recent development.

A no-treatment control is a significant difference that is questionable as a control. It eliminates blinding, and there can be a nocebo effect when patients know they took on the burden of being in a study and are receiving no treatment. The article I cited also points out that you need to very carefully examine the claims and results (of any study) as well as what they claim to be looking specifically for, and whether they changed the latter after seeing some data.

Yes. Though you’ll have to make sure that the revelation can be done double blind, so you’ll need some way to make sure the doctor doesn’t know. Maybe hand out envelopes with information, and some say it’s a placebo, and some don’t.

That said, double-blind isn’t always required. If you’re testing what effects besides medications can improve symptoms, then simply “no treatment” can be useful. I’ve seen it mentioned in studies as an additional control.

For instance, one was some sort of talk therapy. One group got the therapy being studied. One got just talking to them normally. And one group got nothing. They used the nothing group to identify what aspects were just part of the doctors taking an interest and talking to the patient.

The reality of the study in the OP is that patients were told placebos could have powerful effects.

Patients were randomly assigned either to open-label placebo treatment or to the no-treatment control. Prior to randomization, patients from both groups met either a physician (AJL) or nurse-practitioner (EF) and were asked whether they had heard of the “placebo effect.” Assignment was determined by practitioner availability. The provider clearly explained that the placebo pill was an inactive (i.e., “inert”) substance like a sugar pill that contained no medication and then explained in an approximately fifteen minute a priori script the following “four discussion points:” 1) the placebo effect is powerful, 2) the body can automatically respond to taking placebo pills like Pavlov’s dogs who salivated when they heard a bell, 3) a positive attitude helps but is not necessary, and 4) taking the pills faithfully is critical. Patients were told that half would be assigned to an open-label placebo group and the other half to a no-treatment control group. Our rationale had a positive framing with the aim of optimizing placebo response.

[Bolding mine.]

So if you tell if you induce people to believe that a placebo can have powerful effects, you’re basically inducing the placebo effect.

I’m not a medico of any sort, but it seems to me that most medical studies I’ve seen have been double-controlled: One control group which (unknowingly) received a placebo, and another control group that got no treatment at all.

There was another study recently that claimed to be the first to ever study the placebo effect itself, and which said that the placebo effect didn’t exist at all. That one was just as flawed in its assumption that this sort of study is a new thing.

Another possibility is that one is getting care of another and that is helpful in itself. Taking of the known placebo is also taking comfort in the care and trusting it, and the person providing it, even at a subconsciencious level.

There is a placebo response that can affect things with subjective measures, like pain. It may have to do with the body releasing its own pain reducing substances, and it may be a change in pain reporting based on expectation.

But telling people that “placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes” is not testing whether the placebo effect is lessened by telling people they are getting a placebo – as in being honest with people. It is BS being fed to people to make them have the same response they would if they were in a blinded study.

There is not a magical “mind-body self-healing process.” Telling people that is not the same as telling them they are receiving an inert substance rather than the active agent in a study, because they are in the control group, e.g.

A placebo response can include (and might primarily be) things that have nothing to do with subjective measures or mind-body anything. For example, if you test an herbal cream that is supposed to speed bruise healing, you need an inert cream placebo to compare it to, because there could be a benefit from rubbing the bruised area when the cream is applied. Likewise, with controls for something like arthroscopic surgery, making the same incisions and requiring the same after care isolates the procedure being tested. So you would know any benefits over placebo are not based on the body’s healing response to the incisions, or the after care protocols.

Why should it be the case that being told it’s a placebo eliminates the effect? This would require that the placebo effect is due to a patient’s conscious knowledge, which seems rather dubious.

Compare: here, you see two lines of clearly different length. Now, I tell you (or, of course, you already know) that these lines are in fact the same length. Does this new knowledge suddenly cause you to perceive them as the same length? If you’re anything like me, it doesn’t: despite that knowledge, they still seem just as different as before. Your physiological, bodily response to the stimulus remains despite the difference in context.

The placebo effect is similarly a bodily response to a certain stimulus, or set of stimuli. Being told that these stimuli don’t represent what the body experiences them as doesn’t necessarily eliminate this response, and thus, it shouldn’t be surprising that the effect persists.