“My doctor put me on this new [sugar] pill for my hypertension. You should stop taking your prescription and get on this. It works!”

( see http://alternativendhealth.wordpress.com/2010/08/22/acupuncture-novella-acts-as-judge-and-jury/ ).

I call this the ‘reverse sectarian accusation,’ whereby, the ‘dogma-bound sectarian pseudomedicalist’ accuses the ‘person following the evidence provided by medical science’ of being predetermined / dogmatic in mindset.

I’m trying to figure out the line of thinking [I'm being generous here] that ‘NAD Maloney ND’ provides:

“the only way to continue to ignore the positive acupuncture outcomes is to completely disregard everything coming out of China. Since we now outsource much of our medical production to China, it seems like we should accept them as legitimate.”

I read it this way: since China manufactures medical product materials, therefore studies coming out of China must, a priori, be of high quality and just-as-actual-as-those-materials.

As if.

-r.c.

It seems to me that you (as a practicing physician) are failing to recognize something very significant here – namely, the power of belief and its effect on health. The placebo-effect (which is based on the positive belief of the patient) provides proof-positive that faith heals. On the other hand, the nocebo-effect (which is based on the negative belief or doubt of the patient) provides proof-positive that skepticism is actually detrimental to one’s health.

First off, the “nocebo” effect is hardly limited to skeptics. Like the placebo effect, it is universal, and likely accounts for a significant (but difficult to quantify) proportion of the adverse event reports for various interventions. Especially the vague ones, like “fatigue”, which have been reported even for sugar pills as the control arm of a pharmaceutical trial. It’s a real phenomenon, and really it’s the same phenomenon as the placebo effect — expectations affect perception.

And that’s the key here. The placebo effect isn’t about actual improvement. It’s about how expectations affect perception, and yes, as one person pointed out upthread, it does affect the experimenter as well. (This, incidentally, is why animals seem to experience the placebo effect. Broadly speaking, they’re not actually getting better — their owners just think they are.)

There isn’t a “faith/skepticism” dichotomy, exactly, and even if there was, it wouldn’t map to “faith heals, skepticism hurts”. The placebo effect doesn’t care about your religious or spiritual perspective on life. It’s purely about your expectations, and these can come from anywhere. Skepticism can help a bit, but skeptics are fooling themselves if they think they are immune to it. Which, in fact, is precisely why science exists — we are all vulnerable to the placebo effect and other forms of observer bias, so we need to be very methodical to rule out the possibility that we’ve just deceived ourselves.

Second, it could be that placebo and adenosine release actually interact, so placebo + acupuncture (adenosine release) together relieves more pain that placebo alone and adenosine release considered individually. That is, nonlinear interaction between placebo and treatment is not eliminated.

So while the paper isn’t conclusive, depsite Steven’s funeral call, it is a step in the right direction, and I think with more science we’ll be able to disentangle all these factors in an evidence-driven way.

You are correct, pain is not trivial. When I write “The placebo effect is not objective, but comes from subjective self-reports, usually involving pain and perception,” I mean exactly what I have written: it is subjective (not able to be objectively measured) and requires the subject to report the intensity and any change in that intensity. For research paradigms with these measures there are typically placebo effects. When all placebo research is considered, the effect is lost.

This does not suggest (1) that pain is trivial or (2) that the placebo effect does not occur, or is not real. What it does suggest is the placebo effect is a function of the research paradigm. Sometimes we can take advantage of the effect, by incorporating placebo-control groups (especially where subjective measures are used). Sometimes we want to try to eliminate the placebo effect by using other measures.

One Washington Post article does not science make. Depression is a very poorly defined disorder. The real numbers shake out (not perfectly, certainly) like this: Major depression responds to both a statistically and clinically significant level to contemporary antidepressants. However, the definition of depression is poor. Where you seem to feel this is evidence for offering placebo treatment (correct me if I am mistaken), I see an issue with defining and diagnosing that has always plagued psychology and psychiatry. Again, we need to resolve the terms of the discussion (the operational definition of the measurement) before our research can progress.

However, let us conduct a little thought experiment. We will assume antidepressants do nothing above placebo, ever. This does not mean the placebo has done anything. It means antidepressants have done nothing. That is the power of the placebo effect; the placebo can confirm or support the null hypothesis. That is it. No special healing powers. Just the power to negate. It is, though, a very important power; not one that should be trivialized.

Everyone should keep in mind, when it comes to research, we are looking at a single, very specific social interaction. The placebo in research is not different than other possible research variables. Furthermore, such interactions are not limited to research; we see similar effects in society writ large. The power of suggestion, authority, belief, and perception (and so forth) are important in- and out-side the clinical or laboratory setting. That is why skepticism and critical thinking are important not just for the professional scientist, but all of us.

Reducing or eliminating pain is not a trivial thing, especially for the individual who is presently experiencing it.

Al Morrison: “Meta-analysis of more than one hundred placebo-controlled studies shows no statistically significant effect for the placebo across all disease types. This suggests the placebo effect is not universal, and that the placebo effect is an artifact of the research paradigm.”

This is not entirely true. You are referring to the Hróbjartsson and Peter Gøtzsche study . This research has been criticized for the following reason.

“Placebos also do not work as strongly in clinical trials because the subjects do not know whether they might be getting a real treatment or a sham one. Where studies are made of placebos in which people think they are receiving actual treatment (rather than merely its possibility) the placebo effect has been observed.[95] Other writers have argued that the placebo effect can be reliably demonstrated under appropriate conditions.[96]”

(source: Wikipedia: Placebo)

Al Morrison: “The placebo is an important tool. Research shows the effects of placebo are not as strong as treatment (see Steve Novella’s equation, TREATMENT + PLACEBO – PLACEBO = TREATMENT EFFECT). Therefore, a hypothesized treatment with an effect equal to or below that of the placebo is (if the experimental paradigm is sound) is rejected. For this reason, understanding the placebo and its role in experimentation is very important to understanding sham vs. actual treatments.”

How many medical doctors prescribe antidepressants to their patients? There is evidence that placebos perform better than antidepressants.

“A 2002 article in The Washington Post titled “Against Depression, a Sugar Pill Is Hard to Beat” summarized research as follows: “In the majority of trials conducted by drug companies in recent decades, sugar pills have done as well as — or better than — antidepressants. Companies have had to conduct numerous trials to get two that show a positive result, which is the Food and Drug Administration’s minimum for approval. The makers of Prozac had to run five trials to obtain two that were positive, and the makers of Paxil and Zoloft had to run even more”.[34]”

(source: Wikipedia: Placebo)

(This is not a trivial issue. The antidepressant drug industry is a huge business with political clout.)