Psychiatrists should consider incorporating into their daily practice ideas learned from studying placebo treatment. "The placebo has a powerful healing effect on many people," said Jerome Frank, M.D., Ph.D., professor emeritus of psychiatry at John Hopkins University and a coauthor of the book Persuasion and Healing.

"Placebo treatment changes the meaning of the patients’ syndrome from pessimistic to hopeful, and in doing so, it induces a very powerful therapeutic effect," he observed. "This effect can induce physiological changes. The placebo is not considered respectable, but it is respectable, and it should be studied and taken seriously."

Two researchers whose curiosity has driven them to wonder just how the placebo effect works and how its power may someday be harnessed are Walter A. Brown, M.D., clinical professor of psychiatry at Tufts and Brown universities, and Irving Kirsch, Ph.D., a professor of psychology at the University of Connecticut.

Brown has found that between 30 percent and 40 percent of moderately depressed patients and close to 70 percent of mildly depressed patients in the acute phase get better with placebo treatment. Patients with generalized anxiety disorder also show a high placebo response rate, he noted, and 40 percent to 50 percent of those with panic disorder get a lot better.

Brown based his conclusions on an analysis of the literature and three studies of placebo response in which he was a coinvestigator.

Similarly, Kirsch found that patients with moderate depression receiving placebo treatment had 75 percent of the improvement of those who were prescribed medication. Kirsch derived this finding from a meta-analysis he coauthored, analyzing data from 19 clinical studies with 2,318 patients, most of whom had moderate depression. The study was published in the June 1998 issue of the online journal Prevention and Treatment.

"I am not saying that antidepressants don’t work; in fact, there is a tremendous improvement with the antidepressants," Kirsch explained. "However, there is a similar improvement with the placebo."

Besides determining the percentage of people who benefit from placebo treatment, Brown derived two other conclusions from his research and the literature. First, patients with milder and shorter depression were more likely to respond to placebo treatment than those with more severe, longer lasting depression. Kirsch cautioned that there are not enough data to know whether this is also true of severe depression.

Second, Brown said that in his study of moderately depressed subjects who received the dexamethasone suppression test, only 10 percent of subjects with elevated levels of cortisol responded to placebo treatment; in contrast, 50 percent of those with normal cortisol levels responded positively. This physiological difference could help clinicians decide which patients might benefit from placebo treatment and which would likely do better with antidepressants.

"Placebo treatment is not the same as no treatment: What patients probably get from placebo treatment are the effective elements of psychotherapy," observed Brown, who will discuss the placebo effect in the symposium "Doctor-Patient Relationship: Past, Present, and Future" at APA’s 2000 annual meeting on Thursday, May 18, at 2 p.m.

Frank agreed. In fact, Frank promulgated the idea that there are important similarities between elements of psychotherapy and placebo treatment.

One reason placebo treatment works is because of a conditioning effect. Patients who have previously taken active medications become conditioned to associate the effects of these medications with the placebo pill, said Brown.

Another reason placebo treatment works is that patients’ anxiety and distress are reduced when they are in the hands of a healing authority offering "enhanced treatment," he noted. One element of this enhanced treatment is that patients develop an "expectation of wellness." And research has shown that patients who expect to feel better are more likely to feel better than those without this expectation, said Brown

The bottom line? This enhanced treatment reduces anxiety and distress in patients with generalized anxiety disorder, panic disorder, and moderate depression, thereby often ameliorating the patient’s symptoms.

"Why not harness the power of what we have learned about why placebo treatment works to offer enhanced treatment in [our daily practice]? asked Brown. Doing this would require adopting three key measures.

"First, it’s very important to patients that [they are] treated by a recognized healing authority who uses the rituals and symbols of healing: Psychiatrists should dress in a psychiatrist’s outfit," have credentials on display, do a thorough patient examination, and instead of just telling patients their suggestions, should write them on a prescription form. Also, psychiatrists should offer a diagnosis, treatment alternatives, and a prognosis, he said.

"Second, psychiatrists should be suitably optimistic when giving medicine to patients. In other words, they should say something definitive like, ‘This medicine will take the anxiety away and you will feel better in a few days.’ "

Third, Brown said, "the patient should be encouraged to ask questions, but the psychiatrist should remain in charge. For example, psychiatrists should actively guide patients’ medication choice. Why? Patients expect the psychiatrists’ expert advice."

When Kirsch was asked about prescribing placebo pills, he replied, "This would involve the patient knowing they were taking a placebo, and there isn’t enough research as to the efficacy of using placebos that patients know are placebos." There is only one study on this topic, but it had only 13 subjects and no control group, added Kirsch.

In contrast, Brown said, "There may be certain circumstances with patients who have mild depression in which I would prescribe a placebo pill with the patient’s consent."

In fact, he said, many psychiatrists already use placebo treatment. "They prescribe antidepressants and anxiolytics to mildly depressed or anxious patients. Because most of these patients will get better on their own, isn’t this medication really being prescribed as placebo treatment?"

David Hellerstein, M.D., agreed that placebo treatment works because patients in clinical trials receive enhanced treatment—including full workups and frequent doctor visits. He also agreed with Brown’s statement that placebo treatment often works for patients with mild depression and some anxiety disorders. Hellerstein is the chief of outpatient psychiatry and director of Mood Disorders Research Unit at New York’s Beth Israel Medical Center.

He noted, however, that "research on placebo treatment generally comes from short-term clinical trials, [and] many patients initially respond to placebo but then relapse, whereas medication responses are generally maintained over time."

He said that studies evaluating how placebo effects are maintained over time are needed.

Hellerstein also questioned whether he and other psychiatrists would be as "convincing" when prescribing placebo pills as they are when prescribing active medication.

Despite these questions, he thinks that studying the placebo response is important. "It is crucial that we understand the different components of healing," he said. "We need to mobilize people’s innate capacities for recovery and to get optimal pharmacological effects. A good clinician tries to use both components in order to get the best clinical outcome. The effects of expectation of recovery are often crucial to success in treatment."