The Power of the Placebo

Depression is an extremely distressing experience.  Individuals can feel unbearably miserable and chronically anxious and sometimes suicidal.  They endure deep feelings of worthlessness, despair and either suffer from not sleeping enough or sleeping too much.  Getting out of bed in the morning is tortuous for they feel they have nothing to get up for.  What is often not appreciated by health care professionals that depression is unconsciously created by the person to draw attention to repressions that occurred in childhood in response to painful violations of one’s person and a hypercriticism of one’s behaviour.

In Ireland the HSE annually spends 67 million Euros on anti-depressants in the belief that these pharmacological compounds relieve depression.  The figure of 67 million Euros does not include the larger majority of those who are not on medical cards.  According to the drug companies who manufacture these anti-depressants over 80 per cent of individuals who are diagnosed can be treated successfully.  These companies also claim – even though there is damning evidence that is contrary – that the effectiveness of anti-depressants are significantly more effective than placebos (best known as ‘dummy pills’).  There are annual global sales of 15 billion Euros of anti-depressants.  

A new book by Irving Kirsch, The Emperor’s New Drugs, Exploding the Antidepressant Myth, seriously questions the claims of the drug companies and presents convincing research evidence that any improvements shown by individuals who experience depression is not due to the anti-depressants but to the placebo effect.  Kirsch admits that whilst there is a slight non-significant difference between the use of anti –depressants and placebos, this difference is due to what he calls an ‘enhanced placebo effect’.  Basically, when drug companies do their clinical trials they employ what is known as a double-blind research design.  In these trials neither the individuals who have a diagnosis of clinical depression nor the researchers know who is taking what pill – the anti-depressant or the placebo pill.  However, because, inevitably, individuals on the anti-depressants experience distressing side-effects – not so those on the placebo pills – the former group’s expectations are heightened – leading to the slight difference between the two groups – an ‘enhanced placebo’!

Kirsch’s findings – and he is not alone – raises a very important question:  how can we harness the power of the placebo to benefit individuals who are feeling depressed without having to employ expensive anti-depressants that actually have no therapeutic effect in themselves but do act as powerful placebos?

Despair and hopelessness are strong accompaniments of depression and it now appears that the provision of hope lies at the core of the placebo effect – whether you prescribe pharmacologically constituted drugs or sugar pills.  When any treatment is received by the client with the internalisation of the medical doctor’s expressed belief and conviction in it, a placebo effect immediately comes into play.  In other words, when the promise of improvement evokes hope, it counters the overwhelming aspect of depression – hopelessness.

Kirsch is not saying that anti-depressants don’t work.  Like him I believe that anti-depressants are genuinely prescribed.  But what he is saying is that these drugs are not any more powerful than a placebo!  Following on from the latter he invites his readers to consider how to employ the placebo effect without having to use anti-depressants whose chemical ingredients have no active therapeutic effect but have serious side effects.  Kirsch points out several factors that bring about the placebo effect:

Relationship between doctors and clients

Clients’ beliefs and expectations

Socially held associations of pills and injections with therapeutic effects

The most powerful factor appears to lie in the therapeutic relationship.  To what degree do individuals who seek help for their depression find that their doctor engages with them, makes eye-contact, actively listens, gives space and time to describe how they are feeling and the story that lies behind the symptoms being experienced, asks relevant questions, is kind, comforting, empathic, supportive and empowering?  Furthermore, does the doctor’s surgery provide privacy, physical comfort and is it tastefully decorated with a window with a view of nature?  All of these factors have been shown to produce improvements, not only in people who experience depression, but with many physical illnesses as well.

In my opinion Kirsch misses out an important aspect of the placebo effect – and that is the client’s creativity.  Depression is a creation that seeks to draw attention to deep-seated, unresolved childhood emotional conflicts that become increasingly distressing as a person gets older and the urgent need to find some mature individual – health professional – that will provide the relationship through which resolution of one’s sense of worthlessness can be finally resolved.  All the evidence indicates that psychotherapy –which is essentially about relationship – is the most beneficial therapy for depression.  However, there are people who are not ready to go to psychotherapists and doctors are left with the alternative of prescribing anti-depressants.  In such a situation ,does it really matter little if the person responds because of the placebo effect of the anti-depressant as long as improvement occurs?  The problem with this attitude is that many anti-depressants have harmful side effects and that many people stop taking anti-depressants due to finding these side effects intolerable.  Surely the way forward is harnessing the power of the placebo effect – which is largely due to the inner actions of the person who is depressed coupled with the power of the therapeutic relationship.

A final note of caution; any person on anti-depressants who wishes to discontinue taking them need to discuss it with his or her doctor.

Dr. Tony Humphreys is a Consultant clinical psychologist, author and national and international speaker. He is also Director of several UCC courses and his course on Interpersonal communication is due to re- start on Wednesday, Oct. 5th, 5.15-9.30  until mid-May, 2012.  All other courses are mid-cycle.  Details from Margaret 021-4642394.