Nocibo Effect

NYT Illustration by Scott Balmer

"Beware the Nocibo Effect," a short piece in today's Sunday Review Section of the New York Times, points again to one of the most mysterious areas of modern medicine; the effect of expectation on outcome. Usually examined through the well documented placebo effect, this piece instead examines the "nocibo effect," or the harm done by the expectation that a medication will have side bad effects.

The authors, Paul Enck, a professor psychology at the University of Boblingen and Winfried Hauser, an associate professor of psychosomatic medicine at the University of Munich, reviewed 31 studies of the nocibo effect. Their review concludes that nocibo has a potent effect on patient experience and treatment outcome. For instance, eleven percent of patients in a drug trial for a fibromyalsia drug dropped out of the study because they experienced strong dizziness and/or nausea after being warned that the sugar pills they were taking may cause those symptoms.
In another study of an anti-depressant medication, one desperate patient swallowed 26 harmless placebo tablets in an attempt to kill himself. The patient's blood pressure "dropped perilously low," the researchers report.
The point of the piece is that doctors should be mindful when describing the potential side effects of medications they are prescribing. Fair enough. But more interesting by far is the tacit acknowledgement that there is a potent and hugely influential psycho-biological mechanism at play here that we really don't understand at all.

Placebo: Buy Shares Now!

Please don’t ever say “just the placebo effect.” Placebos are potent treatments that kick the butts of many billion-dollar drugs. And their price can’t be beat.

In his wide-ranging New Yorker piece, “Head Case,” about the state of psychopharmacology (is it evil or merely useless?), Louis Menand reviews Irving Kirsch’s book The Emperor’s New Drugs (Basic; $23.95). Kirsch, a psychologist in the UK, argues that antidepressants are just (I hate that!) expensive placebos. While they usually do a little better than placebos in drug trials, Kirsh argues that there is no good way to protect the double-blind nature of such trials; most antidepressants have side effects such as nausea, restlessness, and dry mouth. Once a patient detects those, he knows he’s on the drug side of the trial. A patient feeling no side effects may assume he’s taking sugar pills and may get more depressed than he was to begin with, amplifying the minimal statistical gap. Great point, but...

Well, read the whole piece. It’s fascinating. I certainly don’t want to minimize the importance of hucksterism and venality in the psychopharmacology business, and I want to write more about it soon,  but I just want to say here what I always do when I hear about billion-dollar drugs that don’t beat placebos in trials: Let’s invest in the placebo effect! It helps at least a third of severely depressed patients. And it also helps patients with Parkinson’s, and chronic pain, some kinds of epilepsy, and many, many other serious conditions. When we figure out what’s going on with placebos, doctors--or clerks for that matter-- may be able to prescribe them honestly, inexpensively, and in good conscience and make millions of people better. And a little side benefit: we’ll begin to map the current no-man’s land extending the broad distance between neurology (the science of the brain) and psychology (the science of the mind). That should bring with it some other exciting (anti-depressing!) philosophical benefits, too.