Please, Please, Please Go To a Real Doctor

[Giordano]

Here is one clinical study of the placebo effect on blood pressure specifically designed to resolve prior controversies on this topic:
http://ajh.oxfordjournals.org/content/14/6/546.long

To quote its conclusion:
"In conclusion, the results of this study conclusively demonstrate the existence of the placebo effect in the treatment of mild-to-moderate hypertension, on clinic as well as ambulatory BP measurement. This effect of placebo is different from a regression to the mean phenomenon and does not depend on the method used for BP assessment. The placebo effect was observed on SBP, DBP, and MAP but not on PP or HR."

I will look for primary research literature of placebo treatment effects on other physiological measures later but I have other obligations right now.

 

[Belz...]

Placebos can produce some objective physiological changes, such as changes in heart rate, blood pressure, and chemical activity in the brain, in cases involving pain, depression, anxiety, fatigue, and some symptoms of Parkinson’s. "

Yeah but those are all psychosomatic. It's not like you can produce specific chemicals with your brain on demand, bypassing the need for the actual medecine. Heart rate you can do at home.

The reason why placebo exists is because they used to compare the medecine to nothing at all, and found that a lot of the improvement they thought should be attributed to the active ingredients instead came from the psychological effects of expecting better outcomes by the patient.

 

[Giordano]

Yeah but those are all psychosomatic. It's not like you can produce specific chemicals with your brain on demand, bypassing the need for the actual medecine. Heart rate you can do at home.

The reason why placebo exists is because they used to compare the medecine to nothing at all, and found that a lot of the improvement they thought should be attributed to the active ingredients instead came from the psychological effects of expecting better outcomes by the patient.

Highlight: But you do all the time. You and I produce specific chemicals in our brains, neurotransmitters, in response to what we perceive (on demand). I can on demand make my brain synthesize or release certain chemicals by simply thinking a scary or worrisome thought. Or other chemicals by thinking a happy thought. Or a lustful one.

Second paragraph: Placebos are used to compare potential new medicines to what should be inert chemicals; but that doesn't mean that the treatment with the inert chemical is itself inert. The knowledge that one is receiving what one believes might be an effective chemical itself exerts an effect. Call it psychosomatic but it is still a very real effect that can be measured and which has to be identified to understand if the new medicine can exert an effect beyond that of the placebo treatment effect itself.

I do fear that we are arguing definitions. As I see them, psychosomatic effects are REAL and are mediated by changes in our body chemistry (our thoughts themselves are changes in our body chemistry, so I don't see changes in our thinking as not a real effect). Some real drugs change our moods and thinking; if treatment with a sugar pill does too, then it is having a "real" effect as I view it.

 

[Belz...]

Highlight: But you do all the time. You and I produce specific chemicals in our brains, neurotransmitters, in response to what we perceive (on demand). I can on demand make my brain synthesize or release certain chemicals by simply thinking a scary or worrisome thought. Or other chemicals by thinking a happy thought. Or a lustful one.

But you can't produce the active ingredient in Advil, for example.

I do fear that we are arguing definitions.

Given that we're arguing over a word, I think that's expected.

 

[jaydeehess]

Here is one clinical study of the placebo effect on blood pressure specifically designed to resolve prior controversies on this topic:
http://ajh.oxfordjournals.org/content/14/6/546.long

To quote its conclusion:
"In conclusion, the results of this study conclusively demonstrate the existence of the placebo effect in the treatment of mild-to-moderate hypertension, on clinic as well as ambulatory BP measurement. This effect of placebo is different from a regression to the mean phenomenon and does not depend on the method used for BP assessment. The placebo effect was observed on SBP, DBP, and MAP but not on PP or HR."

I will look for primary research literature of placebo treatment effects on other physiological measures later but I have other obligations right now.

Systolic bp, diastolic bp, mean arterial presure and heart rate. What is "PP" though?

 

[Giordano]

But you can't produce the active ingredient in Advil, for example.


Given that we're arguing over a word, I think that's expected.

No, but you/I do produce the active "ingredients" that Advil acts on: the COX2 enzyme that generates the prostaglandins that are mediators of pain and inflammation. And in fact psychological stress can also alter COX-2/prostaglandin levels and thereby one's ability to sense pain. In fact a number of psychological inputs regulate pain perception through known endogenous chemicals. Another example: epinephrine/norepinephrine (produced by fear in one's own body) significantly reduces one's ability to sense pain by altering the levels of other neurotransmitters/hormones. Emotion = changes in actual chemistry of the body that in turn effects important aspects of health.

I am less interested in arguing over the meaning of a word than over the concept of if a pure psychological input, such as a "placebo" treatment represents, can actually alter the physiology/chemistry of a person. I am maintaining that it can.

 

[Giordano]

Systolic bp, diastolic bp, mean arterial presure and heart rate. What us "PP" though?

PP is pulse pressure: the difference between the systolic and diastolic bp.

 

[Belz...]

I am maintaining that it can.

At best, it would be doing so indirectly, by the "power of belief", so to speak. It would be the brain doing the actual work, not the placebo, so even if you were correct, which is far from established, you still... er... wouldn't be correct.

 

[Pixel42]

I think a lot of the confusion stems from the different meanings assigned to the word 'works'. For me a medical treatment only works if it has an effect over and above placebo, which is why we need to eliminate the placebo effect with a double blind trial in order to find out if a treatment works. I mean, if we could get exactly the same effect by giving someone a sugar pill and telling them it was an aspirin as we do by giving them an actual aspirin most people would agree that means that aspirin does not work. But the placebo effect does exist, it does have a measureable effect. That doesn't mean that a placebo 'works' in the same sense that an aspirin 'works'.

 

[steenkh]

There is also some confusion because most are talking about the placebos that are used to test active treatments against. The placebos that Giordano is talking about is from those studies that pitch a form of placebo against really nothing at all, thus hopefully measuring the effect of the placebo itself - or what was called placebo in the other studies.

This placebo effect is real and can be measured, but it is not stable. Distrust can eliminate the effect, and a bad reputation can even turn it into a negative effect, a nocebo.

 

[Giordano]

At best, it would be doing so indirectly, by the "power of belief", so to speak. It would be the brain doing the actual work, not the placebo, so even if you were correct, which is far from established, you still... er... wouldn't be correct.

That is exactly what I have been maintaining all along- that it works, but indirectly through the brain doing the actual work. I've used the words indirectly through the brain in a number of my posts. And where we appear to disagree is whether this counts as the placebo treatment really "working" or not. I don't see why this doesn't count as really working. A treatment has a demonstrable effect. Why it working through the brain makes it somehow not count as "real" eludes me. Lots of clinically used drugs work through actions on the brain: in fact I believe that aspirin lowers fevers by acting on sites in the brain- isn't this an indirect effect?

I am not slinging some form of woo here about the awesome mystical power of belief- just the obvious- the brain controls or influences our physical body in many powerful and well understood ways, from directing our muscles to releasing important hormones to regulating our body temperature (the last usually beyond voluntary control). The brain is itself a flux of chemicals and electrical/ionic signals that give rise to what we call a consciousness. And our conscious perceptions, in turn, alter the chemistry and physics of the brain. Targeting the brain to achieve a result, even through deception, is very much fully within normal physics and chemistry- not supernaturalism.

In any case thanks to steenkh and Pixel42 for helping to clarify these points of disagreement, why placebos are nonetheless not desirable medical treatments, but why they are important in testing potentially new medication.

 

[Lithrael]

I don't know, it seems to me that whatever effect placebo can have (on things like stress levels, blood pressure, heart rate etc) is too finicky to really try to use as an intentional effect - as has been mentioned, it arises from things like trust and expectations, so until we have some kind of standardized way to measure and predict, to create, etc, those predispositions in individual people, placebo cannot be useful in the way that actual medicine is useful.

And that sounds more like a job for mentalists than for doctors.

In the meantime, harnessing 'the power of placebo' is essentially what all that crystal waving stuff is - and I'm guessing that the people most inclined to have the sort of trust and expectations that allow the placebo effect to make anyone feel better are already participating in those sorts of, er, therapies.

 

[Giordano]

I don't know, it seems to me that whatever effect placebo can have (on things like stress levels, blood pressure, heart rate etc) is too finicky to really try to use as an intentional effect - as has been mentioned, it arises from things like trust and expectations, so until we have some kind of standardized way to measure and predict, to create, etc, those predispositions in individual people, placebo cannot be useful in the way that actual medicine is useful.

And that sounds more like a job for mentalists than for doctors.

In the meantime, harnessing 'the power of placebo' is essentially what all that crystal waving stuff is - and I'm guessing that the people most inclined to have the sort of trust and expectations that allow the placebo effect to make anyone feel better are already participating in those sorts of, er, therapies.

Absolutely true- part of the reason I am not advocating using placebo treatments as substitutions for directly acting drugs- too unpredictable, uncertain, and tricky (as well as the immorality of relying on a deception by the doctor on the patient). My only point is that they can have real effects; not that they are reliable or even useful in practice.

I will mention two points though:

1. I do think that directly active treatments have better response rates and fewer side effects when presented in a positive, optimistic manner (and yet stay within the truth: "We've had good success with this drug in cases such as yours, and although you should let us know if you have these possible side effects, most people we see haven't experienced more than a few minor ones").

2. Even directly active drugs show a lot of variability in their effectiveness from person to person. Placebos having variable efficiency is not unique. But certainly the ability of aspirin to lower a fever is less variable than that of a placebo treatment to yield a useful effect.

Finally- crystal waving can indeed produce a placebo effect. But that doesn't mean that placebo effects are unreal or supernatural- only that they (and crystal waving) can influence how people think (by deception in both cases) and how people think can act through known mechanisms to influence their emotions and their physiology.

 

[Lithrael]

Hm, your first point sounds completely reasonable. I know patients at the very least often feel ill-treated and stressed if their doctor doesn't bother to give them a good impression of their treatment options.

I wonder whether the positive effects of someone feeling confident about their treatment because their doctor is good at inspiring trust is best described as placebo, though? While it does seem like the same effect to me, it still feels strange to call a good and positive bedside manner an invocation of the placebo effect. Does medicine have a term for this aspect of good health care already?

 

[steenkh]

It seems appropriate to draw attention to the Smack the Pony placebo sketch at this point:

 

[Giordano]

Hm, your first point sounds completely reasonable. I know patients at the very least often feel ill-treated and stressed if their doctor doesn't bother to give them a good impression of their treatment options.

I wonder whether the positive effects of someone feeling confident about their treatment because their doctor is good at inspiring trust is best described as placebo, though? While it does seem like the same effect to me, it still feels strange to call a good and positive bedside manner an invocation of the placebo effect. Does medicine have a term for this aspect of good health care already?

I agree that the two effects are almost certainly related- I don't really know if they are (or should) be called the same or not.

One of the things I've observed in the USA is that doctors are increasingly expected to provide just the facts to their patients, avoid revealing their personal opinion (even though it would be an expert opinion) and let the patient decide what to do. As a result upbeat, positive, confident presentations are more rare (IMO) and the patient is left with a big list of what to them is techno-babel and a lot of uncertainty as to the possible efficacy of the treatment and the possible scary side effects.

 

[Lithrael]

Yeah, this is true. It sounds to me like doctors wanted to avoid the pitfall of over-recommending the treatment they themselves felt most comfortable with, knowing that that's a form of bias tied to their own comfort levels and knowledge and could easily end up failing to give proper weight to whatever the most up-and-coming treatment is... Or perhaps in the USA they didn't want to risk being sued for giving a good impression of treatment x over treatment y if treatment x ended up failing for the patient... so they just backed off entirely and try to act like human wikipedia articles to their patients. But many, if not most, patients are not prepared to be their own advocate in this way and would probably on balance be happier and better off with their treatment options presented positively by their doctor.

Only a very few people are actually happier with a cantankerous doctor who acts like they'd rather not tell you anything at all. The type who likes rudeness from an authority figure because that means the authority figure is so good at what they do and so damn busy doing it that it'd be better if everyone would just shut up and follow orders.

 

[Darwin123]

I seriously hope they go after the chiropractor.

Correlation is not cause. So I hope not.

The chiropractor did not cause the disease. No one knows if the patient would have gone to a real doctor if there was no chiropractor. We don't even know if a real doctor could have treated the disease effectively.

We don't even know precisely why the patient went to the chiropractor. Maybe he didn't want any treatment at all. Maybe the chiropractor was a friend or relative of the patient that he wanted to give money too. Maybe the but wanted to appease superstitious relatives and friends.

The plea expresses a false dichotomy that can be misused. The plea implies that a treatment can either cure the disease or cause harm. Some treatments do nothing at all. It provides a straw man theory that can be exploited by con men.

The plea is irrational. I despise most 'alternative medicine'. So I sympathize with OP. However, I think the fundamental danger is in irrational thinking.

Suppose the OP is a Christian Scientists. Christian Science is a cult which forbids all treatments whatsoever. Christian Scientists reject scientific medicine as well as alternative treatment in the belief that all medicine is inconsistent with faith. They believe that chiropractic medicine is a scientific method, which reject as being contrary to Gods will. So the OP could be saying, don't do anything at all.

Suppose the OP is a homeopathic physician. There is no requirement for a homeopath to believe chiropractic medicine, though many do. The OP could want patients to go the him rather than a chiropractor.

Suppose the OP is a mad scientist trying to test his brain washing narcotic on an unsuspecting patient. He wants to recruit volunteers from chiropractic believers. This would be scientific medicine. If so, it would probably be effective for aches and pains. However, the treatment in this case is still a con. It has undisclosed side effects that the patient may not desire.

So I reject all emotional pleas that are bare of reason. Such pleas are polemic, usually intended to mislead. Irrational pleas often lead to a loss of freedom. The loss of a few superstitious idiots are a small price to pay for freedom.

Let the patient choose his treatment based on what he believes. Insist on showing him the scientific alternatives, by all means. Use the true believers as a control for the scientific studies. Real science needs control groups. Patients who refuse real treatments and die should be applauded as volunteer martyrs of real science.

 

[RecoveringYuppy]

Correlation is not cause. So I hope not.

The chiropractor did not cause the disease. No one knows if the patient would have gone to a real doctor if there was no chiropractor. We don't even know if a real doctor could have treated the disease effectively.

Has there been a change to the coroner's conclusion? The coroner concluded the adjustment caused the injury that lead to death.

 

[Dave Rogers]

Correlation is not cause. So I hope not.

The chiropractor did not cause the disease. No one knows if the patient would have gone to a real doctor if there was no chiropractor. We don't even know if a real doctor could have treated the disease effectively.

Missing the point by a mile. The finding was not that the chiropractor failed to treat an existing condition effectively. The finding was that the chiropractor, while attempting to treat the existing condition, performed a spinal manipulation that directly caused death. Whether or not a real doctor could have treated the original injury correctly is irrelevant, because that wasn't what killed her; it was what the chiropractor did to her that killed her.

Dave