Pills & Ills
In our culture, the pill is a symbol of healing. As such, the pill and the rituals surrounding it create powerful expectations of relief. And this expectation probably accounts for part of a pill's or capsule's therapeutic power.
As a result, placebos in pill form are remarkably effective. For example, propranolol is a drug often prescribed after a heart attack to regulate the heartbeat and prevent further damage. In a study headed by Ralph Horwitz, M.D., at the Yale University School of Medicine, patients who took propranolol regularly for a year had half the death rate of those who took it less regularly. But in the same study, those who took a placebo regularly also had half the death rate of those who took the placebo less regularly—even though the two groups of placebo users were similar medically and psychologically.
Placebo pills may also get their therapeutic power from the learning process known as conditioning. Just as Pavlov's dogs learned to salivate upon hearing a bell because the sound of a bell had accompanied food, a medically neutral substance or procedure associated with drug administration may eventually elicit the same response as the drug. For example, after a rat has been given several injections of amphetamine, an injection of saltwater alone produces a temporarily hyperactive rodent, just as the amphetamine had.
A similar process may well occur in humans. People who have experienced relief after taking a pill may unconsciously learn through conditioning that various characteristics of the pill—for example, its shape or color—and the context in which the pill is given, bring relief. A careful study by Eugene Laska, Ph.D., and Abraham Sunshine, M.D., has shown that the degree to which a placebo relieves pain is directly related to the potency of the pain medication taken the previous day. In other words, a placebo will relieve your headache more effectively if you took two codeine tablets yesterday than if you took a single children's aspirin. Clearly, previous experiences with treatment influence the response to placebo treatment, and a placebo is most effective when it follows active treatment.
All of this raises a provocative question: Might doctors someday openly use placebos as part of everyday treatment? Robert Ader, Ph.D., a psychologist at the University of Rochester and an expert on conditioned drug responses, suggests that in some treatment regimens placebo pills could be periodically substituted for drug-containing pills without losing the desired response to the drug. For example, someone taking codeine for a chronic pain problem could substitute placebo pills half or more of the time and as a result of conditioning get adequate pain relief. This approach would reduce the dose of "real" medicine, reduce the cost of treatment, and probably reduce toxicity and side effects as well. Like other research findings on placebo treatment, however, this approach has yet to be thoroughly tested and applied.
Distress Factors
In considering how placebos may work, the distinction between disease and illness is worth noting. Disease can be defined as an abnormal state of the body—a broken leg, cancer, a lung infection—whereas illness is the suffering that accompanies disease. More succinctly, disease is what a physician sees; illness is what the patient feels. The misery of illness is a mixture of unpleasant symptoms, fear, and demoralization. Often people who are ill don't know what's wrong or what will happen to them. They feel at the mercy of the body that has betrayed them.
Placebo treatment may or may not benefit disease, but it always benefits illness. The decision to seek treatment restores some sense of control. The symbols and rituals of healing—the doctor's office, stethoscope, physical exam—offer reassurance; the prognosis, when favorable, reduces fear and uncertainty, and even when unfavorable reduces the distress of uncertainty; and a plausible treatment mobilizes hope and creates the expectation of improvement.
Since placebos may work in part by reducing the distress of illness, it comes as little surprise that placebo treatment seems most effective for afflictions in which distress directly affects the symptoms. In certain forms of depression and anxiety, for example, distress is the illness, and placebos are remarkably effective. Pain often improves with placebo treatment, as do asthma and moderate high blood pressure; in these conditions distress is one of the symptoms, or contributes directly to the symptoms.
There is no direct evidence that placebo treatment influences the course of diseases like cancer or bacterial infection. But distress does reduce the efficiency of the immune system, and it affects the secretion of hormones important in disease resistance. It is conceivable that by reducing distress, placebo treatment could influence countless diseases, including some we don't usually think of as subject to psychological influence.
Neglected and Rejected
Given its effectiveness, why is the placebo response ignored and often disparaged by the medical community? Some of the negativity surrounding the placebo comes from the term itself. Placebo is Latin for "I shall please." Because it is the first word of the Catholic vespers for the dead, these vespers were commonly referred to in the 12th century as "placebos." By the 14th century, placebo had become a secular and pejorative term; it meant flatterer, today. This usage probably stemmed from the derision felt toward professional mourners, who were paid to sing placebos. When placebo entered medical terminology, the pejorative connotation stuck: It was defined as a medicine given to please patients rather than to benefit them. In the 20th century the word took on its current definition, referring to a lack of pharmacologic activity.
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