anti-Causality


Tuesday, January 18, 2011

Placebos in therapy

It is widely known that antidepressants are extremely effective for depression.  It is also widely reported in clinical studies that placebos are nearly as effective, typically 10 to 15% behind the medications being tested; this placebo effect has grown in recent years (Hougaard, 2010).  This phenomena has raised speculation as to why this occurs and critical inquiry into the effectiveness of antidepressants (DeMarco, 1998).  Strictly speaking, a placebo is an inert version of a medication (or other therapy), but the placebo is not necessarily inert.  Extending this is an inquiry into psychotherapy:  perhaps psychotherapy is, in a sense, a placebo for the supports provided by family and society for those suffering from depression.

An attempt to lower the placebo effect is the use of a run-in phase, or test, to find and eliminate participants who respond to placebos (Hougaard, 2010).  But a meta-study found that studies that used a run-in phase were not significantly different from those that didn't.  Some find fault in the nature of antidepressant efficacy trials, showing that a majority of the depressed would not qualify to participate in the trials (Zimmerman, 2005).  Eliminating factors include comorbid anxiety, previous episodes, a possibility of suicide, or social impairments.

Two likely explanations for the placebo effect are an expectation for improvement by participants (that may be supported by industry advertising), and that the interaction between participants and clinicians initiates a healing phase (Hagen, 2010).  Explanations like these imply that efficacy trials themselves are therapy, and for this reason, psychotherapy should first be attempted, followed by medication.  The greatest efficacy for depression combines counseling and medicine; the combination shows 15-20% improved efficacy for chronic severe depression.  Counseling is the better long-term therapy as it helps prevents relapse.

There is temptation to use the placebo effect as it has fewer side effects than medications (Kirsch, 2002).  But their deceptive nature inhibits their use.  The best approach to the placebo effect is to attempt to understand why it is beneficial and to apply its components in ways that clients can accept.

References

DeMarco, C. (1998, June). On the impossibility of placebo effects in psychotherapy. Philosophical Psychology, p. 207. Retrieved from Academic Search Premier database.

Dimidjian, S., Hollon, S., Dobson, K., Schmaling, K., Kohlenberg, R., Addis, M., et al. (2006). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology, 74(4), 658-670. doi:10.1037/0022-006X.74.4.658.

Hagen, B., Wong-Wylie, G., & Piji-Zieber, E. (2010). Tablets or Talk? A critical review of the literature comparing antidepressants and counseling for treatment of depression. Journal of Mental Health Counseling, 32(2), 102-124. Retrieved from Academic Search Premier database.

Hougaard, E. (2010). Placebo and antidepressant treatment for major depression: Is there a lesson to be learned for psychotherapy?. Nordic Psychology, 62(2), 7-26. doi:10.1027/1901-2276/a000008.

Kirsch, I., Moore, T., Scoboria, A., & Nicholls, S. (2002). The emperor's new drugs: An analysis of antidepressant medication data submitted to the U.S. Food and Drug Administration. Prevention & Treatment, 5(1), 23. doi:10.1037/1522-3736.5.1.523a.

Zimmerman, M. (2005). Generalizability of antidepressant efficacy trials: Differences between depressed psychiatric outpatients who would or would not qualify for an efficacy trial. American Journal of Psychiatry 162, pp. 1370-1372, July 2005.  Retrieved October 24, 2010 from http://ajp.psychiatryonline.org/cgi/content/full/162/7/1370

No comments:

Post a Comment