placebo effect

placebo effect, psychological or psychophysiological improvement attributed to therapy with an inert substance or a simulated (sham) procedure. There is no clear explanation for why some persons experience measurable improvement when given an inert substance for treatment. Research has indicated that the effect may be caused by the person’s expectations about the treatment rather than being a direct effect of the treatment itself.

One of the first doctors to deliberately prescribe placebos, or inert treatments, was Scottish physician William Cullen, who mentioned in a lecture series in 1772 having given placebos to patients to appease them, not to cure their conditions. Despite Cullen’s observations that placebos appeared to produce beneficial effects in some patients, the term placebo effect was not introduced into medicine until the early 20th century.

In modern medicine, placebos, including inert drugs and sham procedures, are frequently used in clinical trials that are designed to test new treatments, particularly those developed for neurological and psychiatric conditions. In placebo-controlled trials, enrolled patients are randomly and unknowingly (blindly) assigned to receive either the new medical intervention being tested or a placebo. This prevents patients from knowing what treatment they received, which could cause them to influence study results, and it allows researchers to determine whether the new intervention produces an effect greater than that of the placebo.

The use of placebos in clinical trials has raised important questions in medicine and bioethics. The World Medical Association’s (WMA’s) Declaration of Helsinki, which provides a set of ethical guidelines for medical experimentation on humans, traditionally prohibited the use of placebos in trials when effective therapies or interventions already existed. In 2001, however, the WMA revised its guidelines to allow placebo-controlled trials under certain circumstances, such as when scientific methodology required the use of a placebo or when a new intervention was tested for a relatively minor health condition.

A significant proportion of new treatments and interventions routinely fail to demonstrate a benefit greater than that of placebos in clinical trials. This has been most notable for certain types of antidepressants and for the application of ultrasound in the healing of soft tissue injury. In addition, investigations of inert substances have found that the colour, the size, and the price of a pill can affect expectations of drug effectiveness. For example, in a report published in 2008, researchers found that test subjects who took an inert substance labeled as a potent pain medication, marketed under a brand name, and sold at a relatively high price experienced greater pain tolerance following mild electrical shock to the wrist than people who took an inert substance marketed as a generic pain medication and sold at a comparatively low cost; the brand-name placebo and the generic placebo were the same substance.

Understanding the physiological and psychological basis of how factors such as expectations and cultural beliefs influence the placebo effect has important implications for the design of clinical trials. Studies have shown that the release of the neurotransmitter dopamine in a region of the brain known as the ventral striatum is a major determinant of expectation in the placebo effect. Patients with chronic illness who frequently experience positive outcomes from their medications often strongly anticipate therapeutic benefit, a phenomenon that has been demonstrated in research on persons with Parkinson disease. In one study researchers found that, in response to previously having taken medications such as levodopa and then being presented with these medications, Parkinson patients experienced dopamine release in the dorsal striatum of the basal ganglia. However, patients who were told that they had a 75 percent chance of receiving a new active drug, which was actually a placebo, produced significant amounts of dopamine in the ventral striatum. By comparison, patients who were told that they had a 25, 50, or 100 percent chance of receiving the new drug released relatively small amounts of dopamine in the ventral striatum. In addition to isolating the ventral striatum and dopamine as central to the placebo effect in this patient subset, the findings also suggested that a specific degree of uncertainty communicated verbally can potentially heighten the placebo effect and that by limiting this uncertainty the effect may be controlled for the purposes of clinical trials.