In a recent post, Dr. Gorski criticized two articles by Jo Marchant on placebos and alternative medicine. He mentioned that she had a book coming out and suggested I might want to review it. The title is Cure: A Journey into the Science of Mind Over Body.
I don’t know of any evidence that the mind has ever cured a disease, so I would have been prejudiced against this book just from its title, and Dr. Gorski’s post prejudiced me even more. But I was willing to give it a fair trial. The publisher sent me a review copy of the book and I read it. I was expecting to hate it, but I was pleasantly surprised. I enjoyed reading it. I found it fascinating. I found myself agreeing with much of what Marchant says, and I was intrigued by some of the recent research she reports that I was not yet aware of. Preliminary studies, to be sure, but thought-provoking. The book challenged me to think more deeply about placebos, alternative medicine, and patient comfort.
Moving the line in the sand
In the introduction, she mentions Dr. Gorski as one of the scientists who are fighting back against the tide of irrationality, who have drawn “anti-woo” lines in the sand. She suggests that those lines might be relaxed a bit to the benefit of both sides. Before you have a knee-jerk reaction to that suggestion, I encourage you to read her book for yourself to try to understand the nuances of her position. She is saying what I think frequent SBMcommenter Peter Moran may have been driving at, but she expresses herself much more clearly and tries to support her claims with evidence. I think he might like this book.
She clearly understands and supports science. She starts by giving examples of how people have been misled into believing that bogus treatments were effective, and how controlled studies are the only way to determine whether a treatment really works. She explains that while placebos influence how we feel, they don’t influence objective measures like cancer survival. But she points out that survival time is not the only thing that matters to a cancer patient: pain control and quality of life are important too. If doctors lose sight of that, patients suffer. Alternative medicine has filled the gap with methods that are honed to maximize placebo responses; the treatments themselves do nothing but patients experience real relief. She argues for reinstating the doctor’s role as healer so that patients can benefit from both personal caring and scientifically proven treatments.
Placebos and Kaptchuk
One doctor wants to change the name of the placebo effect to “the meaning response.” The most important factor is the meaning that is attached to and surrounds any medical treatment, fake or otherwise. Instead of focusing on sugar pills, we should turn our attention to the trappings of medicine that make us expect to feel better, things like the white coat and stethoscope of a doctor or the incense and incantations of a traditional healer.
She covers Ted Kaptchuk’s placebo research and explains how he became interested in it. While practicing acupuncture, he noticed that some patients experienced improvement before they even got the treatment, and he wanted to understand why. It is common for patients in the placebo arm of a trial to experience a dramatic improvement and to want to keep taking the placebo after the trial even after they’ve been told it was a placebo. But Kaptchuk puts a damper on Marchant’s enthusiasm by reminding her that there’s nothing in the research to suggest that positive expectations can do anything to change the underlying physiology of the disease.
Marchant buys some placebo pills online and takes one for a headache. 20 minutes later, her pain subsides. She knows it isn’t a scientific trial, but she feels empowered because her own mind was able to make her feel better. There is an argument for trying a placebo before trying a drug that could have side effects; but she also presents the other side of the argument, quoting Edzard Ernst, who explains why he is against using placebos in clinical practice.
The nocebo effect
She delves into the dark side of placebos, the nocebo effect. Suggestion accounts for all those cases of mass psychogenic illnesses in schools. She describes a patient in a clinical trial of antidepressants who tried to overdose and collapsed with a racing heart and low blood pressure; after 4 hours of resuscitation in the hospital and six liters of IV fluids, the trial organizers divulged that he was in the placebo group. His symptoms disappeared within 15 minutes. When doctors warn patients about potential side effects of a drug, they are more likely to get those side effects. In one study of men on the drug atenolol, patients who didn’t know it could cause erectile dysfunction had an ED rate of 3.1%; those who were told it could cause ED had a rate of 31.2%. Many if not most of the side effects of drugs may be due to nocebo effects. I can’t help wondering what that implies for informed consent: if we fully inform patients about the pros and cons of a treatment, it makes some of the “cons” more likely.
Benedetti’s placebo research
I have written about Fabrizio Benedetti’s placebo research here and here. Marchant visits his high-altitude lab in the Alps and describes some of his recent studies. They are fascinating stuff. For instance, they hint that placebos might sometimes work by removing pre-existing nocebo effects.
Placebo-controlled dose reduction
Researchers are studying whether the effect of a treatment can be enhanced by creating a ritual around pill-taking or by getting someone else to administer it. They are studying classical conditioning and other ways to utilize placebo responses to reduce the dosage of drugs that have side effects, ranging from anti-rejection drugs for transplant recipients to medications for ADHD in children. It’s called placebo controlled dose reduction (PCDR). The results are encouraging but they are preliminary and can’t yet be recommended for clinical practice.
Even the doctor’s beliefs make a difference: in one study the doctor’s beliefs about whether they were prescribing a painkiller or a placebo dramatically altered the amount of pain felt by the patient, even though what they told the patient didn’t change.
The mind even determines the limits of physical performance and fatigue. Cyclists given a pill that they believed was a performance enhancer cycled 2-3% faster. Chronic fatigue syndrome (CFS) patients who believe that exercise will harm them are less likely to recover.
Focused attention: hypnosis and virtual reality
Hypnosis has been largely discredited, but there are studies suggesting that hypnosis improves outcomes in irritable bowel syndrome (IBS) and other conditions. Hypnosis is basically a way to focus attention, and another fascinating way to focus attention is virtual reality (VR). Burn patients tolerate painful treatments better while they are flying through a VR ice canyon and throwing virtual snowballs at virtual snowmen. The Snow World program is already being used in 15 hospitals and has been very helpful at Brooke Army Medical Center for treating soldiers burned in combat. VR home units are becoming less expensive, and the gaming industry might be a source of funding for pain relief trials.
Other things that might help
Being accompanied by one caregiver throughout labor has been shown to decrease the need for C-sections. Hospice patients given only comfort care not only have a better quality of life than patients getting aggressive treatment, but they live longer! A program called Comfort Talk reduced pain scores during invasive medical procedures from 7.5 out of 10 to 2.5, and reduced anxiety scores to zero. Instead of saying “Now this may hurt a bit” they go over all the details ahead of time and during the procedure they simply say “Now I’m injecting the contrast.” Something so simple can make a big difference to patient comfort, and it could be so easily implemented everywhere. Isn’t it better to harness patients’ psychological resources than to medicate them?
We are learning that the stress of poverty in early life has lasting health consequences, because stress rewires our brains. Meditation can rewire the brain too. A program called Mindfulness-Based Cognitive Behavioral Therapy (MCBT) makes depressed patients 24% less likely to relapse. But Marchant quotes David Gorski’s warning that the benefits of meditation are being oversold, and that it is impossible to carry out double-blind trials.
There is good evidence that social support is important to health. Just interacting with other people can be therapeutic. A program called Experience Corps sends elderly volunteers into deprived elementary schools to help kids learn to read; there is preliminary evidence suggesting that it reverses age-related changes in their brains. Marchant asks, “What if we reshaped care for the elderly not around managing their decline, but harnessing their abilities?” Attitudes matter. Research suggests that “seeing ourselves as part of something bigger, or having a meaning or purpose beyond ourselves, helps us to do better physically.”
In the chapter on heart rate variability, I think Marchant oversells the benefits of HRV biofeedback, even after she quotes Steven Novella’s warning in an SBM article that it is nothing but “bad tracings, technical artifacts and noise.” She also reports preliminary evidence of benefit from vagal nerve stimulation in various disorders.
Marchant visits Lourdes and is impressed by how much comfort patients experience just from visiting there, even if there is no change in their physical condition. She speculates that it might be because at Lourdes they are treated as people rather than as cases of a disease. She doesn’t believe in miracles. She describes how a “best case” miracle cure of a patient with an apparently incurable osteosarcoma turned out to be based on a misdiagnosis: re-examination of the histology slides showed that the patient actually had lymphoma and may even have been treated with chemotherapy.
Is alternative medicine worth trying?
Edzard Ernst did a controlled study of faith healing using actors as therapists, and while there was no difference between the real and fake therapy, there were patients in both groups who improved dramatically and abandoned their wheelchairs. So should we give alternative medicine a try, even obviously fake therapies like homeopathyand Reiki?
Marchant doesn’t argue that we should replace conventional treatment with alternative medicine. She points out that alternative medicine can have bad outcomes. Patients can be made to feel they are responsible for their illness. Patients who eschew conventional cancer therapy die unnecessarily. People who consult homeopaths reject effective malaria prophylaxis in favor of nonsensical remedies that “make it so your energy doesn’t have a malaria-shaped hole in it.” Physical complications from alternative medicine are rare, but they do occur (infections from acupuncture needles, adverse effects from unlicensed herbal medicines).
She got some things wrong
I can’t wholeheartedly recommend the book. Overall, it gives the impression that we know much more than we do. The studies described are very preliminary and far from ready for prime time; we know that preliminary studies are often overturned by larger, better-designed studies. I found some things in the book disturbing. I don’t condone her use of the term “Western medicine;” there is only one medicine. I was appalled that after a C-section she had a VBAC at home, giving birth to her second baby underwater with the assistance of a non-NHS midwife who she believed was less likely to transfer her to a hospital if something went wrong. In my opinion, that showed very poor judgment. She misrepresents the safety of home births. She even trots out the old “death by medicine” canard. She claims that statins may only benefit 1 in 50 patients (true, but misleadingly alarmist when taken out of context as statins do save lives).
Conclusion: Marchant has interesting ideas, but a bad title
The title of this book, Cure, is simply wrong: Marchant does not claim that placebos cure disease in any objective sense. Rather, they comfort. And the subtitle, A Journey into the Science of Mind Over Body, is equally misleading. Marchant does not believe mind and body are separate. In fact, she says “What is psychological is physical and what is physical has a psychological perception to it.”
The role of a doctor is “To cure sometimes, to relieve often, to comfort always.” In modern medicine, doctors don’t always do a good job of comforting. Research on placebos and on why patients are attracted to alternative medicine and derive comfort from can it lead to practical applications within the practice of science-based medicine. This book describes cutting edge research that may lead to methods that don’t require lying to patients or providing alternative medicine treatments. There are exciting developments, but still in their early days. We need more research. We need to learn how to incorporate things like empathy, social support, and hope into better patient care. It’s not just about curing; it’s about caring and comforting when we can’t cure.
This article was originally published in the Science-Based Medicine Blog.