The Germans are happier than we are. The average German also enjoys better health and lives longer than the average American, all of which raise the possibility that their medical system is better than ours. One has to keep this in mind when evaluating a recent move by the German Medical Association that will sound insane—or worse—to many Americans. Based on study published in early March, this venerable body advised German doctors to prescribe more placebos to their patients.
If this doesn’t sound earth shattering to you, would it be more compelling if I said, “German doctors are being told to give their patients fake medications that do not contain any active ingredients.” And to make matters worse, they are being advised not to tell their patients that they are receiving a fake treatment (most placebos are made of sugar, flour or dust), only that they are receiving a “unique” remedy. The fact that the German Medical Association recommends placebo treatments only for conditions with a psychological, or subjective, component, such as chronic pain asthma, inflammatory diseases and depression, softens the blow a little (the group suggests avoiding placebos for things like broken bones), but only a little.
Before we pass judgment on the Germans, however, let me talk a bit more about placebos, because you are unlikely to know much about them unless you’ve been in a drug study. That’s because in the U.S. placebos are used only in such studies as a means of examining whether a particular medication has specific effects, some type of activity that transcends the potent healing powers of hope, expectation and the therapeutic relationship (for more on the importance of hope for heart health see my previous post ).
In a typical clinical trial, patients are given a medication and told that this medication may be an active drug or an inactive substance and that neither they nor the researchers will know which they’ve gotten until the study is over (the active drug and placebo are designed to look exactly alike). This design seems ridiculous on first hearing to many research subjects, because (obviously) if you get a drug that’s active you’ll get better, and if you get a “sugar pill” which has no effectiveness you’ll either stay the same or get worse. It’s a classic self-fulfilling prophecy. All the subjects who improve during a study believe they’ve received the real deal and everyone who doesn’t benefit curses his luck at being randomized to the placebo arm of the study.
And then—as we say in investigator land—the “blind is broken,” who got what is made known and the amazement begins, for both the researchers and their erstwhile subjects. Whenever we study the types of conditions for which the Germans want to prescribe placebos we find that even if the study medication is effective, many patients who got better during the study took placebo and many who didn’t respond took the active drug. When examined on a group level these differences reveal the power of placebo. For example, in studies of antidepressants, the placebo effect accounts for 2/3s of the medication efficacy. Said differently, although antidepressants can be lifesavers for individuals, in groups of patients they only add one-third more effectiveness than taking a sugar pill.
How can this be? There are only two possibilities. Either our active medications aren’t really active, or placebos aren’t really placebos. Fortunately for all of us, the second possibility is the true one. Just because a sugar pill has no power itself, says nothing about the power it has when placed in a medical context, where it becomes a tangible talisman for a patient’s hope, expectations and belief in his or her doctor.
Let’s do a thought experiment. Mothers, would you be happy if a hospital emergency room gave your wheezing child an inactive treatment for his asthma? Would it make a difference if the doctor told you she was going to give your little boy a sham treatment? Whether you answered this second question yes or no, I’m sure your first thought was something like, “Well if the doctor told us it was a placebo, it would lose its power and wouldn’t work.”
Remarkably, however, a recent study from Harvard shows that this isn’t true at all. Patients with irritable bowel syndrome were randomly assigned to receive a placebo or nothing. Those who got the placebo were told point blank by their doctors that they were receiving “a sugar pill with no active ingredients.” Even with this information, the patients who received the fake pill had significantly greater improvements in their bowel symptoms than those who got nothing.
So, apparently, the placebo effect taps into parts of us deeper than our common sense. So how do they do this? The short—and amazing—answer is that they do this by behaving like active medications do. Moreover, what is even more remarkable is the fact that the same inert sugar pill placebo will have very different physiological effects depending on the condition for which it is being given. For example, when a placebo to works in a depressed patient it causes many of the same brain changes that are seen with antidepressants. However, if that little sugar pill could hop out of the depressed person’s body and dive into someone with chronic back pain it would behave completely differently, this time mimicking the effects of opioid analgesics. Placebos have also been shown to work in Parkinson’s disease, but for this condition they don’t behave as they do in depression or pain. This time they work by causing damaged neurons in the brain to squeeze out more dopamine, the neurotransmitter needed to restore the rapid and smooth movements lost in the disease.
So what should we say about the Germans? If we combine what we know about the power of the placebo effect with the fact that Germans are medically healthier than we are, would it surprise you to learn that 50% of German doctors are prescribing placebos already?