Sham medicine works better if you care

Sham medicine works better if you care April 11, 2008

The world is full of faith healers, and witch doctors with magical cures can be found in every society. The reason for this is at least partly because the treatment works. And the reason it works is down to the power of the placebo effect. If a patient believes the treatment will work, then sometimes it does (health warning: this works better for backache than it does for cancer…)

So here’s the question: what is it about sham medicine that creates the effect? Is it the ritual and all the paraphernalia? Or is it a kind word and an understanding ear from the carer? A study in last week’s BMJ breaks sham treatment into these two aspects to try to answer this (Kaptchuk et al, 2008).

What they did was take some patients (over 260) with irritable bowel syndrome (something that’s known to respond well to placebo [ Patel et al, 2005]). A third of them were left on the waiting list (this was the control group). Another third was given fake acupuncture (using needles that retract into the shaft). The last third was given fake acupuncture and also an extended (45 minute) consultation with the practitioner, during which the practitioner did their utmost to act like the ideal doctor:

The interviewer incorporated at least five primary behaviours including: a warm, friendly manner; active listening (such as repeating patient’s words, asking for clarifications); empathy (such as saying “I can understand how difficult IBS must be for you”); 20 seconds of thoughtful silence while feeling the pulse or pondering the treatment plan; and communication of confidence and positive expectation (“I have had much positive experience treating IBS and look forward to demonstrating that acupuncture is a valuable treatment in this trial”).

The results (shown in the figure) were striking. Even the patients left on the waiting list got a little better (as you might expect, since patients usually go to the doctor when their symptoms are at their worse, so with an episodic disease like IBS time will inevitably make them better).

But patients who had the sham acupuncture got better still. And those getting the warm fuzzies from the practitioner did best of all. In other words, to get the most from your sham medicine, you need both components. Plenty of ritual (the more expensive the better) and quality personal interaction combine for the best result.

But, for any faith healers reading this, probably the most important message is that it’s the personal interaction that matters most. Kaptchuk et al write:

Placebo treatment with only limited interaction with practitioners was superior to staying on a waiting list with respect to only two of the four measures, suggesting that the supportive interaction with a practitioner is the most potent component of non-specific effects.
Kaptchuk, T.J., Kelley, J.M., Conboy, L.A., Davis, R.B., Kerr, C.E., Jacobson, E.E., Kirsch, I., Schyner, R.N., Nam, B.H., Nguyen, L.T., Park, M., Rivers, A.L., McManus, C., Kokkotou, E., Drossman, D.A., Goldman, P., Lembo, A.J. (2008). Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome. BMJ DOI: 10.1136/bmj.39524.439618.25

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