Placebos can ease certain mental disorders, study finds
By Kristen Rogers, CNN
(CNN) — When you’re trying to address mental health symptoms, simply the belief that you can be helped may be an important factor.
Symptoms of nine mental health disorders substantially improved under placebo treatment, according to a new review of 90 randomized controlled trials — known as a meta-analysis — totaling 9,985 adult participants largely in their 30s and 40s.
The disorders in the review, published Wednesday in the journal JAMA Psychiatry, included major depressive disorder, mania, schizophrenia, obsessive-compulsive disorder or OCD, attention-deficit/hyperactivity disorder, panic disorder, post-traumatic stress disorder and social phobia.
The placebo tablets used in the randomized controlled trials were identical in appearance and taste to the active medications but lacked the active ingredient, said Dr. Tom Bschor, first author of the study and professor of psychiatry at the University Hospital Dresden in Germany. Placebos instead contain excipients, which are the inactive ingredients in medications.
In the past, subjecting participants with mental health disorders to placebo treatment has been an ethical quandary, given that researchers would be not treating someone’s mental health condition and the potential exists for the symptoms of participants receiving placebo treatment to get worse, said Dr. Jonathan Alpert, the Dorothy and Marty Silverman Chair of the department of psychiatry and behavioral sciences at the Albert Einstein College of Medicine in New York City. But there are response plans in place for those situations.
Since the participants on placebos in this analysis experienced benefits, the findings support the use of placebo controls in studies, said Alpert, who wasn’t involved in the study.
“Otherwise, it would be very hard to make sense of the data” regarding the effects of active medication, he added. “This is the most comprehensive study of placebo effects in psychiatry.”
The results are also important for patient treatment, Bschor said.
“Firstly, the positive effect across all diagnoses shows that it can be medically and ethically justified for patients to participate in clinical trials with placebo arms in the future,” Bschor said via email. “Clinicians can encourage their patients to participate in such trials, considering the risk of being assigned to placebo.”
Additionally, the study suggests that for most of the disorders, initially forgoing prescription medications could be OK if patients have mixed feelings or anxiety about starting medication and want to see if their condition improves without it, Bschor said.
But for disorders that didn’t see as much improvement with placebos — such as OCD or schizophrenia, which is a psychotic disorder — medication may be more necessary.
Improvement in absence of medication
That mental health symptoms improved with placebo treatment may be due to a few potential influences, experts said.
First is “the placebo effect in the strict sense, i.e., the induction of hope and belief in an effective treatment,” Bschor said via email. “Placebo is administered in randomized, double-blind studies, so participants do not know if they might receive an active drug.”
Secondly, the benefit of mental health professionals inquiring about a patient’s condition is “one of the most powerful effects in all of medicine,” said Dr. Richard Keefe, professor emeritus of psychiatry and behavioral sciences, and psychology and neuroscience at Duke University Medical Center in North Carolina.
Belief that things can get better can be healing, added Keefe, who wasn’t involved in the study.
The findings may also reflect the natural courses of some disorders, experts said.
“It is well known that mental disorders are episodic, and symptoms may fluctuate over time, and a portion of people may improve partially or completely without any treatment, placebo or intervention,” said Dr. Felipe Barreto Schuch, an adjunct professor of psychiatry and mental health at Brazil’s Federal University of Santa Maria, via email. “This is what we call spontaneous remission.” Schuch wasn’t involved in the study.
The likelihood of spontaneous remission is especially true for depression and anxiety, which have the highest rates of spontaneous remission in general and were the two disorders to benefit the most from placebo treatment in this study, experts said.
“A major limitation is that for methodological reasons we cannot separate the three main influences mentioned above,” Bschor said. “Isolating the extent of the true placebo effect would require studies that include a group receiving no medication, not even a placebo, alongside the placebo arm. Such studies are virtually unavailable in the psychiatric field.”
Why is there a difference in the effectiveness of placebos for most disorders versus schizophrenia and OCD? Symptoms of certain disorders (such as the sadness that’s the result of depression) are more responsive to attention and reassurance than schizophrenia symptoms like hallucinations are, Keefe said.
Biological contributions to these disorders are another factor, Alpert said.
Genetics account for 30% to 40% of the risk for developing depression or anxiety, he said. As a result, life events “have a very important impact on whether they’re going to develop major depressive disorder or generalized anxiety disorder,” Alpert said. “Disorders like schizophrenia or OCD are more biological, (in) that 70% or 80% of the risk of developing those disorders appears to be genetic.”
If you have one of these disorders and are wondering which treatment, if any, would be best, know that medications still consistently outperform placebos, Alpert said. The study simply shows that if you’re in a therapeutic context in which people care about you and are educating you about your condition, that’s a good start, and medication adds even greater benefit, he added.
If you’ve never been on medication for your condition and are going without it to see if your symptoms improve over time, you should still do regular doctor visits and therapy, Bschor said.
“However, if no improvement occurs after several weeks,” he added, “you should openly reconsider the necessity of medication.”
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