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Predatu P, David D, Kirsch I, Florean S, Predatu R. Reciprocal relationships between positive expectancies and positive emotions during the COVID-19 pandemic: a cross-lagged panel study. Psychol Health 2024:1-23. [PMID: 38616530 DOI: 10.1080/08870446.2024.2341874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 04/04/2024] [Indexed: 04/16/2024]
Abstract
INTRODUCTION Previous research highlighted the importance of investigating distinct protective factors that predict the experience of positive emotions during stressful situations, such as the COVID-19 pandemic. In this longitudinal study, we specifically focused on positive expectancies towards the future (optimism, response expectancy, and response hope) in relation to the experience of positive emotions during the COVID-19 pandemic. Our primary objectives were to identify the best predictors for experiencing short-term and long-term positive emotions and investigate their interrelationships. METHODS Data from 271 participants (average age = 29.2 years, 84.7% female) were analyzed using four cross-lagged models. RESULTS Results showed that response expectancy was the best predictor for experiencing positive emotions in the short term, while optimism was the best predictor for experiencing positive emotions in the long term. Additionally, through further exploratory analysis, multiple bidirectional relationships were identified between positive expectancies and positive emotions. DISCUSSION Our results highlight the significant role played by positive expectancies in predicting the experience of positive emotions. Specifically, dispositional optimism emerged as a stronger predictor of longer-term positive emotions, whereas response expectancy proved to be a better predictor of shorter-term positive emotions. Thus, interventions targeting positive expectancies have the potential to enhance emotional functioning in individuals during challenging situations like the COVID-19 pandemic.
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Affiliation(s)
- Petronela Predatu
- International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health, Babeș-Bolyai University, Cluj-Napoca, Romania
- Evidence Based Psychological Assessment and Interventions Doctoral School, Babeș-Bolyai University, Cluj-Napoca, Romania
| | - Daniel David
- International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health, Babeș-Bolyai University, Cluj-Napoca, Romania
- Department of Clinical Psychology and Psychotherapy, Babeş-Bolyai University, Cluj-Napoca, Romania
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Irving Kirsch
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Stelian Florean
- International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health, Babeș-Bolyai University, Cluj-Napoca, Romania
- Department of Clinical Psychology and Psychotherapy, Babeş-Bolyai University, Cluj-Napoca, Romania
| | - Răzvan Predatu
- International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health, Babeș-Bolyai University, Cluj-Napoca, Romania
- Department of Clinical Psychology and Psychotherapy, Babeş-Bolyai University, Cluj-Napoca, Romania
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Irving AJ, Nikolova N, Robinson S, Ionita I, Kelly SW, Kirsch I, Mazzoni G, Venneri A, McGeown WJ. The relationship between transliminality, hypnotic and imaginative suggestibility, and other personality traits. Acta Psychol (Amst) 2024; 243:104125. [PMID: 38245938 DOI: 10.1016/j.actpsy.2024.104125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/20/2023] [Accepted: 01/04/2024] [Indexed: 01/23/2024] Open
Abstract
To our knowledge, no study has directly examined the link between hypnotic response and the personality trait of transliminality (which is underpinned, for example, by magical ideation, mystical experience, fantasy proneness, absorption, hyperaesthesia). In order to further understand the correlates of suggestibility, the aim of the current project was to investigate whether transliminality is associated with hypnotic and imaginative suggestibility (considering: objective response, subjective response and involuntariness). Another aim was to assess the contribution of transliminality as a predictor of suggestibility when a range of previously studied personality trait measures were considered. Participants completed: the Revised Transliminality Scale, Tellegen Absorption Scale, Creative Experiences Questionnaire, and the Dissociative Experiences Scale II. To avoid context effects, where knowledge or measurement of one trait or ability might influence measurement of another, a separate standalone study was conducted where hypnotic and imaginative (without hypnosis) suggestibility screenings were carried out in-person in small groups using the modified Carleton University Responsiveness to Suggestion Scale. The merging of these two datasets enabled the analyses. Transliminality was weakly correlated with the imaginative suggestibility subjective response measure (r = 0.19). Likewise, weak correlations were found between transliminality and the hypnotic suggestibility response measures (objective, r = 0.21, subjective, r = 0.23, involuntariness, r = 0.24). The multiple regressions (forward selection) reflected the pattern of correlations, with no model for any of the variables, retaining more than a single significant predictor. In summary, this study combination, avoiding context effects, shows transliminality to be a weak predictor of response to suggestion.
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Affiliation(s)
- Abbie J Irving
- Department of Psychological Sciences and Health, University of Strathclyde, UK
| | - Niia Nikolova
- Department of Psychological Sciences and Health, University of Strathclyde, UK
| | - Susan Robinson
- Department of Psychological Sciences and Health, University of Strathclyde, UK
| | - Iris Ionita
- Department of Psychological Sciences and Health, University of Strathclyde, UK
| | - Steve W Kelly
- Department of Psychological Sciences and Health, University of Strathclyde, UK
| | - Irving Kirsch
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| | - Giuliana Mazzoni
- Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Italy
| | - Annalena Venneri
- Department of Life Sciences, Brunel University London, UK; Department of Medicine and Surgery, University of Parma, Italy
| | - William J McGeown
- Department of Psychological Sciences and Health, University of Strathclyde, UK.
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Faria V, Talbert C, Goturi N, Borsook D, Lebel A, Kaptchuk TJ, Kirsch I, Kelley JM, Moulton EA. Placebos in pediatrics: A cross-sectional survey investigating physicians' perspectives. J Psychosom Res 2023; 172:111421. [PMID: 37354748 DOI: 10.1016/j.jpsychores.2023.111421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/07/2023] [Accepted: 06/18/2023] [Indexed: 06/26/2023]
Abstract
OBJECTIVE Placebo responses are significantly higher in children than in adults, suggesting a potential underused treatment option in pediatric care. To facilitate the clinical translation of these beneficial effects, we explored physicians' current practice, opinions, knowledge, and likelihood of recommending placebos in the future. METHODS A cross-sectional web-based survey administered by REDCap was conducted at Boston Children's Hospital between October 2021 and March 2022. Physicians (n = 1157) were invited to participate through an email containing a link to a 23-item survey designed to assess physicians' attitudes and perceptions towards the clinical use of placebo in pediatrics. RESULTS From 207 (18%) returned surveys, 109 (9%) were fully completed. Most respondents (79%) believed that enhancing the therapeutic components that contribute to the placebo response may be a way of improving pediatric care. However, whereas most (62%) found placebo treatments permissible, only one-third reported recommending them. In pediatrics, placebos are typically introduced as a medicine that "might help" (43%). The most common treatments recommended to enhance placebo effects are physical therapy, vitamins, and over-the-counter analgesics. Physicians most frequently recommend placebos for occasional pain, headaches, and anxiety disorders. Finally, the great majority of physicians (87%) stated they would be more likely to recommend placebo treatments if there were safety and ethical guidelines for open-label placebos. CONCLUSIONS Placebo treatments seem permissible to physicians in pediatric care, but the development of safety and ethical guidelines may be necessary before physicians systematically incorporate the benefits of the placebo effect in pediatrics.
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Affiliation(s)
- Vanda Faria
- Brain and Eye Pain Imaging Lab, Pain and Affective Neuroscience Center, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Psychology, Uppsala University, Uppsala, Sweden; Department of Otorhinolaryngology, Smell & Taste Clinic, TU Dresden, Dresden, Germany; Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Cameron Talbert
- Brain and Eye Pain Imaging Lab, Pain and Affective Neuroscience Center, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nathan Goturi
- Brain and Eye Pain Imaging Lab, Pain and Affective Neuroscience Center, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - David Borsook
- Departments of Psychiatry and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alyssa Lebel
- Division of Pain Medicine, Department of Anesthesiology, Boston Children's Hospital, Boston, MA, USA
| | - Ted J Kaptchuk
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Irving Kirsch
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - John M Kelley
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Psychology, Endicott College, Beverly, MA, USA
| | - Eric A Moulton
- Brain and Eye Pain Imaging Lab, Pain and Affective Neuroscience Center, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Buergler S, Sezer D, Busch A, Enzmann M, Bakis B, Locher C, Bagge N, Kirsch I, Carvalho C, Gaab J. A qualitative study of imaginary pills and open-label placebos in test anxiety. PLoS One 2023; 18:e0291004. [PMID: 37656757 PMCID: PMC10473493 DOI: 10.1371/journal.pone.0291004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 08/21/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND The efficacy of open-label placebos (OLPs) has been increasingly demonstrated and their use holds promise for applications compatible with basic ethical principles. Taking this concept one step further an imaginary pill (IP) intervention without the use of a physical pill was developed and tested in a randomized controlled trial (RCT). To explore participants' experiences and views, we conducted the first qualitative study in the field of IPs. METHODS A reflexive thematic analysis (RTA) of semi-structured interviews with test anxious students (N = 20) was nested in an RCT investigating an IP and OLP intervention. In addition, open-ended questions from the RCT were evaluated (N = 114) to corroborate the RTA and pill characteristics were included to more accurately capture the IP experience. RESULTS Four key themes were identified: (1) attitude towards the intervention, (2) applicability of the intervention, (3) experience of effects, and (4) characteristics of the imagination. The IP intervention was well-accepted, easily applicable, and various effects, pill characteristics and appearances were described. While many participants did not desire a physical pill, either due to the absence of the imagination component or aversion to pills, the approach was considered to be cognitively and time demanding, which in turn, however, encouraged the establishment of a therapeutic ritual that protected against the increase in test anxiety during the preparation phase. OLP findings were comparable, and especially the importance of a treatment rationale was stressed in both groups, counteracting an initial ambivalent attitude. The RTA findings were supported by the open-ended questions of the RCT. CONCLUSION IPs appear to be a well-accepted and easily applicable intervention producing a variety of beneficial effects. Thus, the IP approach might serve as an imaginary based alternative to OLPs warranting further investigations on its application to harness placebo effects without a physical pill.
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Affiliation(s)
- Sarah Buergler
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Dilan Sezer
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Alexander Busch
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Marlon Enzmann
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Berfin Bakis
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Cosima Locher
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Niels Bagge
- Institute for Emotion-Focused Therapy, Roskilde, Denmark
| | - Irving Kirsch
- Program in Placebo Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States of America
| | - Claudia Carvalho
- Department of Clinical and Health Psychology, Instituto Superior de Psicologia Aplicada (ISPA), Lisbon, Portugal
| | - Jens Gaab
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
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Pigott HE, Kim T, Xu C, Kirsch I, Amsterdam J. What are the treatment remission, response and extent of improvement rates after up to four trials of antidepressant therapies in real-world depressed patients? A reanalysis of the STAR*D study's patient-level data with fidelity to the original research protocol. BMJ Open 2023; 13:e063095. [PMID: 37491091 PMCID: PMC10373710 DOI: 10.1136/bmjopen-2022-063095] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Abstract
OBJECTIVE Reanalyse the patient-level data set of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study with fidelity to the original research protocol and related publications. DESIGN The study was open label and semirandomised examining the effectiveness of up to four optimised and increasingly aggressive, antidepressant therapies in depressed adults. Patients who failed to gain adequate relief from their level 1 trial on the SSRI citalopram could receive up to three additional treatment trials in levels 2-4. SETTING 41 North American psychiatry and primary care treatment centres. PARTICIPANTS 4041 adults screened positive for major depressive disorder. In contrast to most clinical trials, STAR*D enrolled patients seeking care (vs recruited) and included patients with a wide range of common comorbid medical and psychiatric conditions to enhance the generalisability of findings to real-world clinical practice. INTERVENTIONS STAR*D evaluated the relative effectiveness of 13 antidepressants therapies in treatment levels 2-4 for depressed patients who failed to gain adequate benefit from their level 1 medication trial. MAIN OUTCOME MEASURES According to the STAR*D protocol, the primary outcome was remission, defined as a score <8 on the blinded Hamilton Rating Scale for Depression (HRSD). Response was a secondary outcome defined as ≥50% reduction in HRSD scores. STAR*D's protocol specifically excluded all non-blinded clinic-administered assessments from use as research outcome measures. RESULTS STAR*D investigators did not use the protocol-stipulated HRSD to report cumulative remission and response rates in their summary article and instead used a non-blinded clinic-administered assessment. This inflated their report of outcomes, as did their inclusion of 99 patients who scored as remitted on the HRSD at study outset as well as 125 who scored as remitted when initiating their next-level treatment. These patients should have been excluded from data analysis. In contrast to the STAR*D-reported 67% cumulative remission rate after up to four antidepressant treatment trials, the rate was 35.0% when using the protocol-stipulated HRSD and inclusion in data analysis criteria. CONCLUSION STAR*D's cumulative remission rate was approximately half of that reported.
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Affiliation(s)
| | - Thomas Kim
- Psychology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Colin Xu
- Psychology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Irving Kirsch
- Harvard Medical School, Arlington, Massachusetts, USA
| | - Jay Amsterdam
- Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Ellingsen DM, Isenburg K, Jung C, Lee J, Gerber J, Mawla I, Sclocco R, Grahl A, Anzolin A, Edwards RR, Kelley JM, Kirsch I, Kaptchuk TJ, Napadow V. Brain-to-brain mechanisms underlying pain empathy and social modulation of pain in the patient-clinician interaction. Proc Natl Acad Sci U S A 2023; 120:e2212910120. [PMID: 37339198 PMCID: PMC10293846 DOI: 10.1073/pnas.2212910120] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 04/25/2023] [Indexed: 06/22/2023] Open
Abstract
Social interactions such as the patient-clinician encounter can influence pain, but the underlying dynamic interbrain processes are unclear. Here, we investigated the dynamic brain processes supporting social modulation of pain by assessing simultaneous brain activity (fMRI hyperscanning) from chronic pain patients and clinicians during video-based live interaction. Patients received painful and nonpainful pressure stimuli either with a supportive clinician present (Dyadic) or in isolation (Solo). In half of the dyads, clinicians performed a clinical consultation and intake with the patient prior to hyperscanning (Clinical Interaction), which increased self-reported therapeutic alliance. For the other half, patient-clinician hyperscanning was completed without prior clinical interaction (No Interaction). Patients reported lower pain intensity in the Dyadic, relative to the Solo, condition. In Clinical Interaction dyads relative to No Interaction, patients evaluated their clinicians as better able to understand their pain, and clinicians were more accurate when estimating patients' pain levels. In Clinical Interaction dyads, compared to No Interaction, patients showed stronger activation of the dorsolateral and ventrolateral prefrontal cortex (dlPFC and vlPFC) and primary (S1) and secondary (S2) somatosensory areas (Dyadic-Solo contrast), and clinicians showed increased dynamic dlPFC concordance with patients' S2 activity during pain. Furthermore, the strength of S2-dlPFC concordance was positively correlated with self-reported therapeutic alliance. These findings support that empathy and supportive care can reduce pain intensity and shed light on the brain processes underpinning social modulation of pain in patient-clinician interactions. Our findings further suggest that clinicians' dlPFC concordance with patients' somatosensory processing during pain can be boosted by increasing therapeutic alliance.
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Affiliation(s)
- Dan-Mikael Ellingsen
- Department of Physics and Computational Radiology, Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo0372, Norway
- Department of Psychology, Pedagogy and Law, School of Health Sciences, Kristiania University College, Oslo0107, Norway
- Athinoula A. Martinos Center for Biomedical Imaging, Massa, chusetts General Hospital, Harvard Medical School, Charlestown, MA02129
| | - Kylie Isenburg
- Athinoula A. Martinos Center for Biomedical Imaging, Massa, chusetts General Hospital, Harvard Medical School, Charlestown, MA02129
| | - Changjin Jung
- Athinoula A. Martinos Center for Biomedical Imaging, Massa, chusetts General Hospital, Harvard Medical School, Charlestown, MA02129
- KM Research Science Division, Korea Institute of Oriental Medicine, Daejeon461-24, Republic of Korea
| | - Jeungchan Lee
- Athinoula A. Martinos Center for Biomedical Imaging, Massa, chusetts General Hospital, Harvard Medical School, Charlestown, MA02129
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA02129
| | - Jessica Gerber
- Athinoula A. Martinos Center for Biomedical Imaging, Massa, chusetts General Hospital, Harvard Medical School, Charlestown, MA02129
| | - Ishtiaq Mawla
- Athinoula A. Martinos Center for Biomedical Imaging, Massa, chusetts General Hospital, Harvard Medical School, Charlestown, MA02129
| | - Roberta Sclocco
- Athinoula A. Martinos Center for Biomedical Imaging, Massa, chusetts General Hospital, Harvard Medical School, Charlestown, MA02129
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA02129
- Department of Radiology, Logan University, Chesterfield, MO63017
| | - Arvina Grahl
- Athinoula A. Martinos Center for Biomedical Imaging, Massa, chusetts General Hospital, Harvard Medical School, Charlestown, MA02129
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA02129
| | - Alessandra Anzolin
- Athinoula A. Martinos Center for Biomedical Imaging, Massa, chusetts General Hospital, Harvard Medical School, Charlestown, MA02129
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA02129
| | - Robert R. Edwards
- Department of Anesthesiology, Brigham and Women’s Hospital, Boston, MA02115
| | - John M. Kelley
- School of Social Sciences, Communication, and Humanities, Endicott College, Beverley, MA02115
- Program in Placebo Studies & Therapeutic Encounter, Harvard Medical School, Boston, MA02215
| | - Irving Kirsch
- Program in Placebo Studies & Therapeutic Encounter, Harvard Medical School, Boston, MA02215
| | - Ted J. Kaptchuk
- Program in Placebo Studies & Therapeutic Encounter, Harvard Medical School, Boston, MA02215
| | - Vitaly Napadow
- Athinoula A. Martinos Center for Biomedical Imaging, Massa, chusetts General Hospital, Harvard Medical School, Charlestown, MA02129
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA02129
- Department of Radiology, Logan University, Chesterfield, MO63017
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Jørgensen CK, Juul S, Siddiqui F, Horowitz MA, Moncrieff J, Munkholm K, Hengartner MP, Kirsch I, Gluud C, Jakobsen JC. The risks of adverse events with venlafaxine and mirtazapine versus 'active placebo', placebo, or no intervention for adults with major depressive disorder: a protocol for two separate systematic reviews with meta-analysis and Trial Sequential Analysis. Syst Rev 2023; 12:57. [PMID: 36991504 PMCID: PMC10061867 DOI: 10.1186/s13643-023-02221-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/17/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND Major depressive disorder causes a great burden on patients and societies. Venlafaxine and mirtazapine are commonly prescribed as second-line treatment for patients with major depressive disorder worldwide. Previous systematic reviews have concluded that venlafaxine and mirtazapine reduce depressive symptoms, but the effects seem small and may not be important to the average patient. Moreover, previous reviews have not systematically assessed the occurrence of adverse events. Therefore, we aim to investigate the risks of adverse events with venlafaxine or mirtazapine versus 'active placebo', placebo, or no intervention for adults with major depressive disorder in two separate systematic reviews. METHODS This is a protocol for two systematic reviews with meta-analysis and Trial Sequential Analysis. The assessments of the effects of venlafaxine or mirtazapine will be reported in two separate reviews. The protocol is reported as recommended by Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols, risk of bias will be assessed with the Cochrane risk-of-bias tool version 2, clinical significance will be assessed using our eight-step procedure, and the certainty of the evidence will be assessed with the Grading of Recommendations Assessment, Development and Evaluation approach. We will search for published and unpublished trials in major medical databases and trial registers. Two review authors will independently screen the results from the literature searches, extract data, and assess risk of bias. We will include published or unpublished randomised clinical trial comparing venlafaxine or mirtazapine with 'active placebo', placebo, or no intervention for adults with major depressive disorder. The primary outcomes will be suicides or suicide attempts, serious adverse events, and non-serious adverse events. Exploratory outcomes will include depressive symptoms, quality of life, and individual adverse events. If feasible, we will assess the intervention effects using random-effects and fixed-effect meta-analyses. DISCUSSION Venlafaxine and mirtazapine are frequently used as second-line treatment of major depressive disorder worldwide. There is a need for a thorough systematic review to provide the necessary background for weighing the benefits against the harms. This review will ultimately inform best practice in the treatment of major depressive disorder. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022315395.
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Affiliation(s)
- Caroline Kamp Jørgensen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark.
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, J.B. Winsløws Vej 19, 3, Odense C, 5000, Odense, Denmark.
| | - Sophie Juul
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark
- Stolpegaard Psychotherapy Centre, Mental Health Services in the Capital Region of Denmark, Stolpegaardsvej 28, 2820, Gentofte, Denmark
| | - Faiza Siddiqui
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark
| | - Mark Abie Horowitz
- Division of Psychiatry, University College London, Gower Street, London, WC1E 6BT, England
- Research and Development Department, Goodmayes Hospital, North East London NHS Foundation Trust, Ilford, IG3 8XJ, London, England
| | - Joanna Moncrieff
- Division of Psychiatry, University College London, Gower Street, London, WC1E 6BT, England
- Research and Development Department, Goodmayes Hospital, North East London NHS Foundation Trust, Ilford, IG3 8XJ, London, England
| | - Klaus Munkholm
- Mental Health Centre Copenhagen, Copenhagen University Hospital - Mental Health Services CPH, Hovedvejen 17, 2000, Frederiksberg, Copenhagen, Denmark
- Open Patient Data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Michael Pascal Hengartner
- Department of Applied Psychology, Zurich University of Applied Sciences, Pfingstweidstrasse 96, 8005, Zurich, Switzerland
| | - Irving Kirsch
- Program in Placebo Studies, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, J.B. Winsløws Vej 19, 3, Odense C, 5000, Odense, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, J.B. Winsløws Vej 19, 3, Odense C, 5000, Odense, Denmark
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Kirsch I. Clinical hypnosis as a nondeceptive placebo: empirically derived techniques. Am J Clin Hypn 2023; 65:246-257. [PMID: 36638224 DOI: 10.1080/00029157.2022.2119023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Many psychological problems are maintained, in part, by dysfunctional response expectancies, and changing those expectations is an essential part of treatment. Hypnotic inductions alter response expectancies and have been shown empirically to substantially enhance the effects of psychotherapy. Therefore, hypnosis can be used therapeutically as a nondeceptive placebo. Expectancy plays a major role in hypnotic inductions and their effects. Clinical procedures suggested by these data are explored.
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Ballou S, Hassan R, Nee J, Iturrino J, Rangan V, Cheng V, Conboy L, Kirsch I, Lembo A, Kaptchuk TJ, Kelley J. Are They Side Effects? Extraintestinal Symptoms Reported During Clinical Trials of Irritable Bowel Syndrome May Be More Severe at Baseline. Clin Gastroenterol Hepatol 2022; 20:2888-2894.e1. [PMID: 35339669 PMCID: PMC9500110 DOI: 10.1016/j.cgh.2022.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 03/07/2022] [Accepted: 03/12/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Many of the reported adverse events in clinical trials of irritable bowel syndrome are extraintestinal symptoms, which typically are assessed by open-ended questions during the trial and not at baseline. This may lead to misattribution of some pre-existing symptoms as side effects to the treatment. METHODS The current study analyzed data from a 6-week clinical trial of irritable bowel syndrome. Participants were randomized to receive double-blind peppermint oil, double-blind placebo, or treatment as usual. Extraintestinal symptoms were assessed at baseline and at the end of the study. RESULTS This analysis included 173 participants (30 received double-blind peppermint oil, 72 received treatment as usual, and 71 received double-blind placebo). At baseline, each group reported approximately 5 extraintestinal symptoms per participant. The number of symptoms per participant decreased to an average of 3 by the end-of-study visit, and this change was statistically significant in all groups (P < .001 for each group). When evaluating individual extraintestinal symptoms, the majority of participants did not report new/worse symptoms. In fact, between the baseline assessment and the final assessment, the average symptom severity decreased significantly in all 3 groups (P < .001). CONCLUSIONS Our study suggests that participants with irritable bowel syndrome often experience extraintestinal symptoms at baseline and that these symptoms generally improve in severity over the course of a clinical trial, regardless of the treatment arm. Systematic assessment of extraintestinal symptoms at the beginning of a clinical trial is necessary to determine more definitively whether these symptoms may be considered an adverse event attributable to a study medication.
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Affiliation(s)
- Sarah Ballou
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts.
| | - Rafla Hassan
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Judy Nee
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Johanna Iturrino
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Vikram Rangan
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Vivian Cheng
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Lisa Conboy
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Irving Kirsch
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Anthony Lembo
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ted J Kaptchuk
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - John Kelley
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts; Department of Psychology, Endicott College, Beverly, Massachusetts
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10
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Abstract
OBJECTIVE Placebos being prescribed with full honesty and disclosure (i.e., open-label placebo [OLP]) have been shown to reduce symptom burden in a variety of conditions. With regard to allergic rhinitis, previous research provided inconclusive evidence for the effects of OLP, possibly related to a separate focus on either symptom severity or symptom frequency. Overcoming this limitation of previous research, the present study aimed to examine the effects of OLP on both the severity and frequency of allergic symptoms. METHODS In a randomized-controlled trial, patients with allergic rhinitis ( N = 74) were randomized to OLP or treatment as usual (TAU). Because of the COVID-19 pandemic, OLP was administered remotely in a virtual clinical encounter. Participants took placebo tablets for 14 days. The primary outcomes were the severity and frequency of allergic symptoms. The secondary end point was allergy-related impairment. RESULTS OLP did not significantly improve symptom severity over TAU ( F (1,71) = 3.280, p = .074, η2 = 0.044) but did reduce symptom frequency ( F (1,71) = 7.272, p = .009, η2 = 0.093) and allergy-related impairment more than TAU ( F (1,71) = 6.445, p = .013, η2 = 0.083), reflecting medium to large effects. The use of other antiallergic medication did not influence the results. CONCLUSIONS Although OLP was able to lower the frequency of allergic symptoms and allergy-related impairment substantially, its effects on symptom severity were weaker. The remote provision of OLP suggests that physical contact between patients and providers might not be necessary for OLP to work.
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Affiliation(s)
- Tobias Kube
- From the Pain and Psychotherapy Research Lab (Kube, Glombiewski), University of Koblenz-Landau, Landau, Germany; Program in Placebo Studies, Beth Israel Deaconess Medical Center (Kube, Kirsch), Harvard Medical School, Boston, Massachusetts; Department of Clinical Psychology, Psychotherapy, and Experimental Psychopathology (Witthöft, Bräscher), Johannes Gutenberg University of Mainz, Mainz, Germany
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11
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Stone MB, Yaseen ZS, Miller BJ, Richardville K, Kalaria SN, Kirsch I. Response to acute monotherapy for major depressive disorder in randomized, placebo controlled trials submitted to the US Food and Drug Administration: individual participant data analysis. BMJ 2022; 378:e067606. [PMID: 35918097 PMCID: PMC9344377 DOI: 10.1136/bmj-2021-067606] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To characterize individual participant level response distributions to acute monotherapy for major depressive disorder in randomized, placebo controlled trials submitted to the US Food and Drug Administration from 1979 to 2016. DESIGN Individual participant data analysis. POPULATION 232 randomized, double blind, placebo controlled trials of drug monotherapy for major depressive disorder submitted by drug developers to the FDA between 1979 and 2016, comprising 73 388 adult and child participants meeting the inclusion criteria for efficacy studies on antidepressants. MAIN OUTCOME MEASURES Responses were converted to Hamilton Rating Scale for Depression (HAMD17) equivalent scores where other measures were used to assess efficacy. Multivariable analyses examined the effects of age, sex, baseline severity, and year of the study on improvements in depressive symptoms in the antidepressant and placebo groups. Response distributions were analyzed with finite mixture models. RESULTS The random effects mean difference between drug and placebo favored drug (1.75 points, 95% confidence interval 1.63 to 1.86). Differences between drug and placebo increased significantly (P<0.001) with greater baseline severity. After controlling for participant characteristics at baseline, no trends in treatment effect or placebo response over time were found. The best fitting model of response distributions was three normal distributions, with mean improvements from baseline to end of treatment of 16.0, 8.9, and 1.7 points. These distributions were designated Large, Non-specific, and Minimal responses, respectively. Participants who were treated with a drug were more likely to have a Large response (24.5% v 9.6%) and less likely to have a Minimal response (12.2.% v 21.5%). CONCLUSIONS The trimodal response distributions suggests that about 15% of participants have a substantial antidepressant effect beyond a placebo effect in clinical trials, highlighting the need for predictors of meaningful responses specific to drug treatment.
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Affiliation(s)
- Marc B Stone
- Division of Psychiatry, Office of Neuroscience, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Zimri S Yaseen
- Division of Psychiatry, Office of Neuroscience, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Brian J Miller
- Division of Hospital Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kyle Richardville
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Shamir N Kalaria
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Irving Kirsch
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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12
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Abstract
Hypnosis interventions have too often failed to disseminate, in part because of the relatively few high-quality, randomized clinical trials. The Task Force proposes efficacy guidelines, which are intended to improve the quality of clinical hypnosis research and thereby increase dissemination of beneficial hypnosis interventions. However, the Task Force, in muddying the focus on efficacy with opinions about moderation and mediation, proposes guidelines that are likely to: (1) weaken efficacy findings; (2) increase participant mistrust; (3) make efficacy trials more cumbersome; and, (4) treat hypnosis as though it were something other than a time-honored form of talk therapy. While applauding the Task Force's intentions, the current recommendations could be changed to better accomplish their goal of increasing hypnosis dissemination and implementation.
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Affiliation(s)
- Guy H Montgomery
- Center for Behavioral Oncology, Icahn School of Medicine at Mount Sinai, New York City, USA
| | - Irving Kirsch
- Program in Placebo Studies, Harvard Medical School, Boston, Massachusetts, USA
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13
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Lunde SJ, Vuust P, Garza-Villarreal EA, Kirsch I, Møller A, Vase L. Music-Induced Analgesia in Healthy Participants Is Associated With Expected Pain Levels but Not Opioid or Dopamine-Dependent Mechanisms. Front Pain Res 2022; 3:734999. [PMID: 35445208 PMCID: PMC9013883 DOI: 10.3389/fpain.2022.734999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 02/21/2022] [Indexed: 01/30/2023] Open
Abstract
Music interventions accommodate the profound need for non-pharmacological pain treatment. The analgesic effect of listening to music has been widely demonstrated across studies. Yet, the specific mechanisms of action have still to be elucidated. Although the endogenous opioid and dopamine systems have been suggested to play an important role, a direct link has not been established. In addition, the involvement of placebo mechanisms is likely while largely unexplored. We examined the analgesic effect of music in healthy participants (n = 48) using a 3 × 3 within-subjects design with pharmacological manipulations and a matched, auditory control for music. Participants were exposed to thermal pain stimuli while listening to three auditory excerpts: music (active condition), nature sound (matched, auditory contextual condition), and noise (neutral control condition). The participants rated their expected and perceived pain levels in relation to each of the auditory excerpts. To investigate the involvement of the endogenous opioid and dopamine systems, the test session was performed three times on separate days featuring a double-blind randomized oral administration of naltrexone (opioid antagonist), haloperidol (dopamine antagonist), and an inactive agent (control). Our results support an analgesic effect of music. Contrary to current hypotheses, neither of the antagonists attenuated the effect of music. Yet, the participants' expectations for pain relief predicted their perceived pain levels during the auditory excerpts—even when controlling for a gradual learning effect. In conclusion, we demonstrate that the analgesic effect of music is at least partially mediated by expectations of an analgesic effect—a core mechanism in placebo effects—but not by opioid and dopamine-dependent mechanisms.
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Affiliation(s)
- Sigrid Juhl Lunde
- Division for Psychology and Neuroscience, Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
- *Correspondence: Sigrid Juhl Lunde
| | - Peter Vuust
- Center for Music in the Brain, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- The Royal Academy of Music Aarhus/Aalborg, Aarhus, Denmark
| | - Eduardo A. Garza-Villarreal
- Laboratorio Nacional de Imagenología por Resonancia Magnética, Institute of Neurobiology, Universidad Nacional Autonoma de Mexico Campus Juriquilla, Queretaro, Mexico
- Center of Functionally Integrative Neuroscience, Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Irving Kirsch
- Program in Placebo Studies and Therapeutic Encounter, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Arne Møller
- Center of Functionally Integrative Neuroscience, Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Nuclear Medicine and PET Center, Institute of Clinical Medicine, Aarhus University and University Hospital, Aarhus, Denmark
| | - Lene Vase
- Division for Psychology and Neuroscience, Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
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14
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Rosenkjær S, Lunde SJ, Kirsch I, Vase L. Expectations: How and when do they contribute to placebo analgesia? Front Psychiatry 2022; 13:817179. [PMID: 36147975 PMCID: PMC9488555 DOI: 10.3389/fpsyt.2022.817179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 08/16/2022] [Indexed: 11/20/2022] Open
Abstract
In placebo research, expectations are highlighted as one of the most influential subjective factors. While some studies have shown a relationship between expectations and pain relief, others have not. However, little is known about how methods of assessment of expectations may affect these conclusions. One of the fundamental considerations is that participants in placebo trials rate their expectations when prompted to rate them on scales in advance, but are less likely to report their prior expectations, when asked to report their experience retroactively in an unprompted manner, often expressing, for example, prior hope or wishes of recovery. This article presents previously unpublished data to elucidate and explore the concepts highlighted by individuals in a placebo analgesia trial when assessed in a prompted and unprompted manner. The data corroborates the role of expectations involved in placebo effects, particularly in placebo analgesia. Thus, the question may be a matter of how and when expectations contribute to placebo effects, rather than if.
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Affiliation(s)
- Sophie Rosenkjær
- Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - Sigrid Juhl Lunde
- Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - Irving Kirsch
- Program in Placebo Studies, Beth Israel Deaconess Medical Center Harvard Medical School, Boston, MA, United States
| | - Lene Vase
- Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
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15
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Evers AWM, Colloca L, Blease C, Gaab J, Jensen KB, Atlas LY, Beedie CJ, Benedetti F, Bingel U, Büchel C, Bussemaker J, Colagiuri B, Crum AJ, Finniss DG, Geers AL, Howick J, Klinger R, Meeuwis SH, Meissner K, Napadow V, Petrie KJ, Rief W, Smeets I, Wager TD, Wanigasekera V, Vase L, Kelley JM, Kirsch I. What Should Clinicians Tell Patients about Placebo and Nocebo Effects? Practical Considerations Based on Expert Consensus. Psychother Psychosom 2021; 90:49-56. [PMID: 33075796 DOI: 10.1159/000510738] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 07/23/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Clinical and laboratory studies demonstrate that placebo and nocebo effects influence various symptoms and conditions after the administration of both inert and active treatments. OBJECTIVE There is an increasing need for up-to-date recommendations on how to inform patients about placebo and nocebo effects in clinical practice and train clinicians how to disclose this information. METHODS Based on previous clinical recommendations concerning placebo and nocebo effects, a 3-step, invitation-only Delphi study was conducted among an interdisciplinary group of internationally recognized experts. The study consisted of open- and closed-ended survey questions followed by a final expert meeting. The surveys were subdivided into 3 parts: (1) informing patients about placebo effects, (2) informing patients about nocebo effects, and (3) training clinicians how to communicate this information to the patients. RESULTS There was consensus that communicating general information about placebo and nocebo effects to patients (e.g., explaining their role in treatment) could be beneficial, but that such information needs to be adjusted to match the specific clinical context (e.g., condition and treatment). Experts also agreed that training clinicians to communicate about placebo and nocebo effects should be a regular and integrated part of medical education that makes use of multiple formats, including face-to-face and online modalities. CONCLUSIONS The current 3-step Delphi study provides consensus-based recommendations and practical considerations for disclosures about placebo and nocebo effects in clinical practice. Future research is needed on how to optimally tailor information to specific clinical conditions and patients' needs, and on developing standardized disclosure training modules for clinicians.
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Affiliation(s)
- Andrea W M Evers
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, The Netherlands, .,Erasmus University Rotterdam & Delft University of Technology, Rotterdam/Delft, The Netherlands,
| | - Luana Colloca
- Departments of Pain Translational Symptoms Science and Anesthesiology, School of Nursing and Medicine, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Charlotte Blease
- General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jens Gaab
- Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Karin B Jensen
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Lauren Y Atlas
- National Center for Complementary and Integrative Health, National Institute of Mental Health, and National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland, USA
| | - Chris J Beedie
- School of Psychology, University of Kent, Canterbury, United Kingdom
| | - Fabrizio Benedetti
- Physiology and Neuroscience, University of Turin Medical School, Turin, Italy
| | - Ulrike Bingel
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Christian Büchel
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jet Bussemaker
- Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Ben Colagiuri
- School of Psychology, University of Sydney, Sydney, New South Wales, Australia
| | - Alia J Crum
- Department of Psychology, Stanford University, Stanford, California, USA
| | | | - Andrew L Geers
- Department of Psychology, University of Toledo, Toledo, Ohio, USA
| | - Jeremy Howick
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Regine Klinger
- Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefanie H Meeuwis
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, The Netherlands
| | - Karin Meissner
- Division of Health Promotion, University of Applied Sciences, Coburg, Germany
| | - Vitaly Napadow
- Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, Massachusetts, USA
| | - Keith J Petrie
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany
| | - Ionica Smeets
- Science Communication and Society, Institute of Biology, Leiden University, Leiden, The Netherlands
| | - Tor D Wager
- Department of Psychological and Brain Sciences, Dartmouth College, Hanover, New Hampshire, USA
| | | | - Lene Vase
- Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
| | - John M Kelley
- Beth Israel Deaconess Medical Center, Harvard Medical School, Program in Placebo Studies, Boston, Massachusetts, USA
| | - Irving Kirsch
- Beth Israel Deaconess Medical Center, Harvard Medical School, Program in Placebo Studies, Boston, Massachusetts, USA
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16
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Evers AWM, Colloca L, Blease C, Gaab J, Jensen KB, Atlas LY, Beedie CJ, Benedetti F, Bingel U, Büchel C, Bussemaker J, Colagiuri B, Crum AJ, Finniss DG, Geers AL, Howick J, Klinger R, Meeuwis SH, Meissner K, Napadow V, Petrie KJ, Rief W, Smeets I, Wager TD, Wanigasekera V, Vase L, Kelley JM, Kirsch I. "Consensus on Placebo and Nocebo Effects Connects Science with Practice:" Reply to "Questioning the Consensus on Placebo and Nocebo Effects". Psychother Psychosom 2021; 90:213-214. [PMID: 33631769 DOI: 10.1159/000514435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 12/23/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Andrea W M Evers
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, The Netherlands, .,Erasmus University Rotterdam & Delft University of Technology, Rotterdam/Delft, The Netherlands,
| | - Luana Colloca
- Departments of Pain Translational Symptoms Science and Anesthesiology, School of Nursing and Medicine, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Charlotte Blease
- General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jens Gaab
- Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Karin B Jensen
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Lauren Y Atlas
- National Center for Complementary and Integrative Health, National Institute of Mental Health, and National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland, USA
| | - Chris J Beedie
- School of Psychology, University of Kent, Canterbury, United Kingdom
| | - Fabrizio Benedetti
- Physiology and Neuroscience, University of Turin Medical School, Turin, Italy
| | - Ulrike Bingel
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Christian Büchel
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jet Bussemaker
- Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Ben Colagiuri
- School of Psychology, University of Sydney, Sydney, New South Wales, Australia
| | - Alia J Crum
- Department of Psychology, Stanford University, Stanford, California, USA
| | | | - Andrew L Geers
- Department of Psychology, University of Toledo, Toledo, Ohio, USA
| | - Jeremy Howick
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Regine Klinger
- Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefanie Helena Meeuwis
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, The Netherlands
| | - Karin Meissner
- Division of Health Promotion, University of Applied Sciences, Coburg, Germany
| | - Vitaly Napadow
- Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, Massachusetts, USA
| | - Keith J Petrie
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany
| | - Ionica Smeets
- Science Communication and Society, Institute of Biology, Leiden University, Leiden, The Netherlands
| | - Tor D Wager
- Department of Psychological and Brain Sciences, Dartmouth College, Hanover, New Hampshire, USA
| | | | - Lene Vase
- Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
| | - John M Kelley
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Irving Kirsch
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Lembo A, Kelley JM, Nee J, Ballou S, Iturrino J, Cheng V, Rangan V, Katon J, Hirsch W, Kirsch I, Hall K, Davis RB, Kaptchuk TJ. Open-label placebo vs double-blind placebo for irritable bowel syndrome: a randomized clinical trial. Pain 2021; 162:2428-2435. [PMID: 33605656 PMCID: PMC8357842 DOI: 10.1097/j.pain.0000000000002234] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/02/2021] [Indexed: 12/19/2022]
Abstract
ABSTRACT It is commonly believed that blinding to treatment assignment is necessary for placebos to have an effect. However, placebos administered without concealment (ie, open-label placebos [OLPs]) have recently been shown to be effective in some conditions. This study had 2 objectives: first, to determine whether OLP treatment is superior to no-pill control (NPC) in irritable bowel syndrome (IBS) and, second, to compare the efficacy of OLP against double-blind placebo (DBP). In a 6-week, 3-arm, randomized clinical trial, participants were randomized in equal proportions to 3 arms: OLP, DBP, or NPC. Two hundred sixty-two adults (72.9% women), with a mean age of 42.0 (SD = 18.1) years, participated in the primary study. The mean improvement on the IBS Severity Scoring System from baseline to the 6-week end point was significantly greater in OLP compared with that in NPC (90.6 vs 52.3, P = 0.038). Open-label placebo and DBP did not differ significantly on IBS Severity Scoring System improvement (100.3 vs 90.6, P = 0.485). Standardized effect sizes were moderate for OLP vs NPC (d = 0.43) and small for OLP vs DBP (d = 0.10). Participants treated with OLP reported clinically meaningful improvements in IBS symptoms that were significantly greater than those on NPC. Open-label placebo and DBP had similar effects that did not differ significantly, suggesting that blinding may not be necessary for placebos to be effective and that OLP could play a role in the management of patients with refractory IBS.
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Affiliation(s)
- Anthony Lembo
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - John M. Kelley
- Department of Psychology, Endicott College, Beverly, MA, USA
- Program in Placebo Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Judy Nee
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Sarah Ballou
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Johanna Iturrino
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Vivian Cheng
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Vikram Rangan
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Jesse Katon
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - William Hirsch
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Irving Kirsch
- Program in Placebo Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Kathryn Hall
- Program in Placebo Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
- Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Roger B. Davis
- Program in Placebo Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ted J. Kaptchuk
- Program in Placebo Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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18
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Jørgensen CK, Juul S, Siddiqui F, Barbateskovic M, Munkholm K, Hengartner MP, Kirsch I, Gluud C, Jakobsen JC. Tricyclic antidepressants versus 'active placebo', placebo or no intervention for adults with major depressive disorder: a protocol for a systematic review with meta-analysis and Trial Sequential Analysis. Syst Rev 2021; 10:227. [PMID: 34389045 PMCID: PMC8361619 DOI: 10.1186/s13643-021-01789-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 08/02/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Major depressive disorder is a common psychiatric disorder causing great burden on patients and societies. Tricyclic antidepressants are frequently used worldwide to treat patients with major depressive disorder. It has repeatedly been shown that tricyclic antidepressants reduce depressive symptoms with a statistically significant effect, but the effect is small and of questionable clinical importance. Moreover, the beneficial and harmful effects of all types of tricyclic antidepressants have not previously been systematically assessed. Therefore, we aim to investigate the beneficial and harmful effects of tricyclic antidepressants versus 'active placebo', placebo or no intervention for adults with major depressive disorder. METHODS This is a protocol for a systematic review with meta-analysis that will be reported as recommended by Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols, bias will be assessed with the Cochrane Risk of Bias tool-version 2, our eight-step procedure will be used to assess if the thresholds for clinical significance are crossed, Trial Sequential Analysis will be conducted to control random errors and the certainty of the evidence will be assessed with the Grading of Recommendations Assessment, Development and Evaluation approach. To identify relevant trials, we will search both for published and unpublished trials in major medical databases and trial registers, such as CENTRAL, MEDLINE, EMBASE and ClinicalTrials.gov from their inception to 12 May 2021. Clinical study reports will be applied for from regulatory authorities and pharmaceutical companies. Two review authors will independently screen the results from the literature searches, extract data and perform risk of bias assessment. We will include any published or unpublished randomised clinical trial comparing tricyclic antidepressants with 'active placebo', placebo or no intervention for adults with major depressive disorder. The following interventions will be assessed: amineptine, amitriptyline, amoxapine, butriptyline, cianopramine, clomipramine, desipramine, demexiptiline, dibenzepin, dosulepin, dothiepin, doxepin, imipramine, iprindole, lofepramine, maprotiline, melitracen, metapramine, nortriptyline, noxiptiline, opipramol, protriptyline, tianeptine, trimipramine and quinupramine. Primary outcomes will be depressive symptoms, serious adverse events and quality of life. Secondary outcomes will be suicide or suicide-attempts and non-serious adverse events. If feasible, we will assess the intervention effects using random-effects and fixed-effect meta-analyses. DISCUSSION Tricyclic antidepressants are recommended by clinical guidelines and frequently used worldwide in the treatment of major depressive disorder. There is a need for a thorough systematic review to provide the necessary background for weighing the benefits against the harms. This review will ultimately inform best practice in the treatment of major depressive disorder. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021226161 .
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Affiliation(s)
- Caroline Kamp Jørgensen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital – Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Sophie Juul
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital – Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
- Stolpegaard Psychotherapy Centre, Mental Health Services in the Capital Region of Denmark, Stolpegaardsvej 28, 2820 Gentofte, Denmark
- Department of Psychology, University of Copenhagen, Østre Farimagsgade 2A, 1353 Copenhagen K, Denmark
| | - Faiza Siddiqui
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital – Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital – Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Klaus Munkholm
- Cochrane Denmark, Centre for Evidence-Based Medicine Odense, Department of Clinical Research, University of Southern Denmark, JB Winsløwsvej 9b, 5000 Odense, Denmark
| | - Michael Pascal Hengartner
- Department of Applied Psychology, Zurich University of Applied Sciences, Pfingstweidstrasse 96, 8005 Zurich, Switzerland
| | - Irving Kirsch
- Program in Placebo Studies, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital – Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital – Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, J.B. Winsløws Vej 19, 5000 Odense C, Denmark
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Peerdeman KJ, Geers AL, Della Porta D, Veldhuijzen DS, Kirsch I. Underpredicting pain: an experimental investigation into the benefits and risks. Pain 2021; 162:2024-2035. [PMID: 33470747 DOI: 10.1097/j.pain.0000000000002199] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/21/2020] [Indexed: 11/25/2022]
Abstract
ABSTRACT Expectancies can shape pain and other experiences. Generally, experiences change in the direction of what is expected (ie, assimilation effects), as seen with placebo effects. However, in case of large expectation-experience discrepancies, experiences might change away from what is expected (ie, contrast effects). Previous research has demonstrated contrast effects on various outcomes, but not pain. We investigated the effects of strong underpredictions of pain on experienced pain intensity. In addition, we assessed related outcomes including (certainty of) expectations, fear of pain, pain unpleasantness, autonomic responses, and trust. Healthy participants (study 1: n = 81 and study 2: n = 123) received verbal suggestions that subsequent heat stimuli would be moderately or highly painful (correct prediction), mildly painful (medium underprediction; study 2 only), or nonpainful (strong underprediction). Both studies showed that participants experienced less intense pain upon strong underprediction than upon correct prediction (ie, assimilation). Expected pain, fear of pain, and pain unpleasantness were generally also lowered. However, strong underprediction simultaneously lowered certainty of expectations and trust in the experimenter. Study 2 indicated that the effects of strong underprediction vs medium underprediction generally did not differ. Moreover, study 2 provided some indications for reduced heart rate and skin conductance levels but increased skin conductance responses upon strong underprediction. In conclusion, even strong underpredictions of pain can reduce pain (ie, cause assimilation), although not significantly more than medium underpredictions. However, strong underpredictions can cause uncertainty and undermine trust. These findings suggest that healthcare providers may wish to be cautious with providing overly positive information about painful medical procedures.
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Affiliation(s)
- Kaya J Peerdeman
- Unit Health, Medical and Neuropsychology, Leiden University, Leiden, the Netherlands
- Leiden Institute for Brain and Cognition, Leiden University, Leiden, the Netherlands
| | - Andrew L Geers
- Department of Psychology, University of Toledo, Toledo, OH, United States
| | - Delia Della Porta
- Unit Health, Medical and Neuropsychology, Leiden University, Leiden, the Netherlands
| | - Dieuwke S Veldhuijzen
- Unit Health, Medical and Neuropsychology, Leiden University, Leiden, the Netherlands
- Leiden Institute for Brain and Cognition, Leiden University, Leiden, the Netherlands
| | - Irving Kirsch
- Program in Placebo Studies, Harvard Medical School, Boston, MA, United States
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Kube T, Hofmann VE, Glombiewski JA, Kirsch I. Correction: Providing open-label placebos remotely-A randomized controlled trial in allergic rhinitis. PLoS One 2021; 16:e0252850. [PMID: 34077482 PMCID: PMC8171944 DOI: 10.1371/journal.pone.0252850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
[This corrects the article DOI: 10.1371/journal.pone.0248367.].
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21
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Juul S, Gluud C, Simonsen S, Frandsen FW, Kirsch I, Jakobsen JC. Blinding in randomised clinical trials of psychological interventions: a retrospective study of published trial reports. BMJ Evid Based Med 2021; 26:109. [PMID: 32998993 DOI: 10.1136/bmjebm-2020-111407] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2020] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To study the extent of blinding in randomised clinical trials of psychological interventions and the interpretative considerations if randomised clinical trials are not blinded. DESIGN Retrospective study of trial reports published in six high impact factor journals within the field of psychiatry in 2017 and 2018. SETTING Trial reports published in World Psychiatry, JAMA Psychiatry, Lancet Psychiatry, American Journal of Psychiatry, British Journal of Psychiatry, or Psychotherapy and Psychosomatics. MAIN OUTCOME MEASURES Blinding status of participants, treatment providers, outcome assessors, data managers, the data safety and monitoring committee, statisticians and conclusion makers, if trialists rejected the null hypothesis on the primary outcome measure, and if trialists discussed the potential bias risk from lack of blinding in the published trial report. RESULTS 63 randomised clinical trials of psychological interventions were identified. None (0%; 95% CI 0% to 5.75%) of the trials reported blinding of all possible key persons. 37 (58.7%; 95% CI 46.42% to 70.04%) trials reported blinding of outcome assessors. Two (3.2%; 95% CI 0.87% to 10.86%) trials reported blinding of participants. Two (3.2%; 95% CI 0.87% to 10.86%) trials reported blinding of data managers. Three (4.8%; 95% CI 1.63% to 13.09%) trials reported blinding of statisticians. None of the trials reported blinding of treatment providers, the data safety and monitoring committee, and conclusion makers. 45 (71.4%; 95% CI 59.30% to 81.10%) trials rejected the null hypothesis on the primary outcome(s). 13 (20.7%; 95% CI 12.48% to 32.17%) trials discussed the potential bias risk from lack of blinding in the published trial report. CONCLUSIONS Blinding of key persons involved in randomised clinical trials of psychological interventions is rarely sufficiently documented. The possible interpretative limitations are only rarely considered. There is a need of randomised clinical trials of psychological interventions with documented blinding attempts of all possible key persons.
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Affiliation(s)
- Sophie Juul
- Stolpegaard Psychotherapy Centre, Mental Health Services in the Capital Region of Denmark, Gentofte, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Copenhagen Ø, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Copenhagen Ø, Denmark
| | - Sebastian Simonsen
- Stolpegaard Psychotherapy Centre, Mental Health Services in the Capital Region of Denmark, Gentofte, Denmark
| | - Frederik Weischer Frandsen
- Stolpegaard Psychotherapy Centre, Mental Health Services in the Capital Region of Denmark, Gentofte, Denmark
| | - Irving Kirsch
- Program in Placebo Studies, Harvard Medical School, Boston, Massachusetts, USA
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Copenhagen Ø, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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22
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Juul S, Siddiqui F, Barbateskovic M, Jørgensen CK, Hengartner MP, Kirsch I, Gluud C, Jakobsen JC. Beneficial and harmful effects of antidepressants versus placebo, 'active placebo', or no intervention for adults with major depressive disorder: a protocol for a systematic review of published and unpublished data with meta-analyses and trial sequential analyses. Syst Rev 2021; 10:154. [PMID: 34034811 PMCID: PMC8152051 DOI: 10.1186/s13643-021-01705-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 05/14/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Major depressive disorder is one of the most common, burdensome, and costly psychiatric disorders worldwide. Antidepressants are frequently used to treat major depressive disorder. It has been shown repeatedly that antidepressants seem to reduce depressive symptoms with a statistically significant effect, but the clinical importance of the effect sizes seems questionable. Both beneficial and harmful effects of antidepressants have not previously been sufficiently assessed. The main objective of this review will be to evaluate the beneficial and harmful effects of antidepressants versus placebo, 'active placebo', or no intervention for adults with major depressive disorder. METHODS/DESIGN A systematic review with meta-analysis will be reported as recommended by Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), bias will be assessed with the Cochrane Risk of Bias tool-version 2 (ROB2), our eight-step procedure will be used to assess if the thresholds for clinical significance are crossed, Trial Sequential Analysis will be conducted to control for random errors, and the certainty of the evidence will be assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. To identify relevant trials, we will search both for published and unpublished trials in major medical databases from their inception to the present. Clinical study reports will be obtained from regulatory authorities and pharmaceutical companies. Two review authors will independently screen the results of the literature searches, extract data, and perform risk of bias assessment. We will include any published or unpublished randomised clinical trial comparing one or more antidepressants with placebo, 'active placebo', or no intervention for adults with major depressive disorder. The following active agents will be included: agomelatine, amineptine, amitriptyline, bupropion, butriptyline, cianopramine, citalopram, clomipramine, dapoxetine, demexiptiline, desipramine, desvenlafaxine, dibenzepin, dosulepin, dothiepin, doxepin, duloxetine, escitalopram, fluoxetine, fluvoxamine, imipramine, iprindole, levomilnacipran, lofepramine, maprotiline, melitracen, metapramine, milnacipran, mirtazapine, nefazodone, nortriptyline, noxiptiline, opipramol, paroxetine, protriptyline, quinupramine, reboxetine, sertraline, trazodone, tianeptine, trimipramine, venlafaxine, vilazodone, and vortioxetine. Primary outcomes will be depressive symptoms, serious adverse events, and quality of life. Secondary outcomes will be suicide or suicide attempt, suicidal ideation, and non-serious adverse events. DISCUSSION As antidepressants are commonly used to treat major depressive disorder in adults, a systematic review evaluating their beneficial and harmful effects is urgently needed. This review will inform best practice in treatment and clinical research of this highly prevalent and burdensome disorder. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020220279.
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Affiliation(s)
- Sophie Juul
- Stolpegaard Psychotherapy Centre, Mental Health Services in the Capital Region of Denmark, Stolpegaardsvej 28, 2820, Gentofte, Denmark. .,Department of Psychology, University of Copenhagen, Østre Farimagsgade 2A, København K, 1353, Copenhagen, Denmark. .,Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital -- Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Faiza Siddiqui
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital -- Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital -- Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Caroline Kamp Jørgensen
- Stolpegaard Psychotherapy Centre, Mental Health Services in the Capital Region of Denmark, Stolpegaardsvej 28, 2820, Gentofte, Denmark.,Department of Psychology, University of Copenhagen, Østre Farimagsgade 2A, København K, 1353, Copenhagen, Denmark.,Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital -- Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Michael Pascal Hengartner
- Department of Applied Psychology, Zurich University of Applied Sciences, Pfingstweidstrasse 96, 8005, Zurich, Switzerland
| | - Irving Kirsch
- Program in Placebo Studies, Harvard Medical School, 330 Brookline Avenue, Boston, Massachusetts, 02215, USA
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital -- Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, J.B. Winsløws Vej 19, 3, 5000, Odense C, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital -- Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, J.B. Winsløws Vej 19, 3, 5000, Odense C, Denmark
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23
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Carvalho C, Pais M, Cunha L, Rebouta P, Kaptchuk TJ, Kirsch I. Open-label placebo for chronic low back pain: a 5-year follow-up. Pain 2021; 162:1521-1527. [PMID: 33259459 DOI: 10.1097/j.pain.0000000000002162] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 11/18/2020] [Indexed: 12/15/2022]
Abstract
ABSTRACT Long-term follow-up of patients treated with open-label placebo (OLP) are nonexistent. In this article, we report a 5-year follow-up of a 3-week OLP randomized controlled trial (RCT) in patients with chronic low back pain. We recontacted the participants of original RCT and reassessed their pain, disability, and use of pain medication. We obtained follow-up data from 55 participants (82% of those who took OLP during the parent RCT), with a mean elapsed time between the end of the 3 weeks placebo trial and the follow-up interview of 55 months (SD = 7.85). We found significant reductions in both pain and disability between the baseline assessment immediately before the 3 weeks trial with placebo pills and the original trial endpoint (P < 0.00001 for the 2 primary outcomes of pain and disability). At the 5-year follow-up, we found no significant differences in either outcome between original trial endpoint and follow-up. Improvements persisted after 5 years and were accompanied by substantial reductions compared with baseline in the use of pain medication (from 87% to 38%), comprising analgesics (from 80% to 31%), antidepressants (from 24% to 11%), and benzodiazepines (from 15% to 5%). By contrast, the use of alternative approaches to pain management increased (from 18% to 29%). Although the reduction in pain and medication is comparable with the improvements that occurred in the original study, a major limitation of this long-term follow-up is the absence of controls for spontaneous improvement and new cointerventions. Nonetheless, our data suggest that reductions in pain and disability after OLP may be long lasting.
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Affiliation(s)
- Claudia Carvalho
- ISPA-Instituto Universitário de Ciências Psicológicas, Sociais e da Vida, Rua Jardim do Tabaco, Lisbon, Portugal
| | - Maria Pais
- Santa Casa da Misericórdia de Lisboa, Largo Trindade Coelho, Lisbon, Portugal
| | - Lidia Cunha
- Unidade de Terapia de Dor do Hospital de Egas Moniz/Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Paula Rebouta
- Unidade de Terapia de Dor do Hospital de Egas Moniz/Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Ted J Kaptchuk
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Irving Kirsch
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
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24
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Kube T, Hofmann VE, Glombiewski JA, Kirsch I. Providing open-label placebos remotely-A randomized controlled trial in allergic rhinitis. PLoS One 2021; 16:e0248367. [PMID: 33705475 PMCID: PMC7951912 DOI: 10.1371/journal.pone.0248367] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/23/2021] [Indexed: 12/12/2022] Open
Abstract
Background Placebos can reduce physical symptoms even when provided with full honesty and disclosure. Yet, the precise mechanisms underlying the effects of “open-label placebos” (OLPs) have remained subject of debate. Furthermore, it is unclear whether OLPs are similarly effective when provided remotely, as is sometimes required e.g. in the current COVID-19 pandemic. Methods In a randomized-controlled trial, we examined the effects of OLP plus treatment as usual (TAU) compared to TAU alone on symptom reduction in people with allergic rhinitis (N = 54) over the course of two weeks. Due to the COVID-19 pandemic, OLP was provided remotely (i.e. sent via postal service). To investigate the potential influence of the clinical encounter on the effects of OLP, we manipulated the perception of the virtual clinical encounter, both with respect to verbal and nonverbal factors (augmented vs. limited encounter). Results The results of the manipulation check confirmed that the augmented clinical encounter was evaluated more positively than the limited encounter, in terms of perceived warmth of the provider. Participants from all treatment groups showed significant symptom reduction from baseline to two weeks later, but OLP had no incremental effect over TAU. Participants benefitted more from OLP when they did not take any other medication against allergic symptoms than when taking medication on demand. When controlling for baseline symptoms, a significant treatment by encounter interaction was found, pointing to greater symptom improvement in the OLP group when the encounter was augmented, whereas the control group improved more when the encounter was limited. Discussion The study demonstrates that providing OLP and enhancing the encounter remotely is possible, but their effectiveness might be lower in comparison to previous studies relying on physical patient-provider interaction. The study raises questions for future research about the potential and challenges of remote placebo studies and virtual clinical encounters. The study has been registered as a clinical trial at ISRCTN (record number: 39018).
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Affiliation(s)
- Tobias Kube
- Pain and Psychotherapy Research Lab, University of Koblenz-Landau, Landau, Germany
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Verena E. Hofmann
- Pain and Psychotherapy Research Lab, University of Koblenz-Landau, Landau, Germany
| | - Julia A. Glombiewski
- Pain and Psychotherapy Research Lab, University of Koblenz-Landau, Landau, Germany
| | - Irving Kirsch
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
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Abstract
This article explores the reaction when an article challenging received wisdom is published and covered extensively by the media (1). The article in question was a meta-analysis of antidepressant clinical trials indicating that for most patients, difference between drug and placebo was not clinically significant. Reactions ranged from denial that the effects of antidepressants are so small to criticisms of the clinical trials that were analyzed. Each of these reactions is explored and countered.
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26
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Nitzan U, Carmeli G, Chalamish Y, Braw Y, Kirsch I, Shefet D, Krieger I, Mendlovic S, Bloch Y, Lichtenberg P. Open-Label placebo for the treatment of unipolar depression: Results from a randomized controlled trial. J Affect Disord 2020; 276:707-710. [PMID: 32871704 DOI: 10.1016/j.jad.2020.07.077] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 06/01/2020] [Accepted: 07/05/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND The response to placebo is robust in studies of various antidepressant treatments. The strong placebo response, combined with the absence of side-effects, has prompted suggestions to use the ethically sound open-label placebo (OLP) as a treatment for depression. The aim of the present study was to assess the efficacy of OLP as an adjunct to treatment as usual (TAU) in the setting of a randomized controlled trial for the treatment of unipolar depression. METHODS Thirty-eight patients (age: 50 ± 17.1; 73.7% females) were randomized to either eight-week OLP treatment (n = 18) or four weeks of TAU followed by four weeks of OLP (n = 20). Clinical and socio-demographic measures were assessed at baseline, after four weeks, and at the end of the trial. Response to treatment was determined using the QIDS SR-16. RESULTS There was an overall decrease in depression levels over time, F(2,35) = 3.98, p = .028. A significant group x time interaction was found only among non-geriatric patients (<65years) with an early onset of depression (<50years), F(2,22) = 3.89, p = .036. Post-hoc tests indicated a significant decrease during the first four weeks, but only in the OLP group, t(11) = 2.29, p = .043. LIMITATIONS Small sample size and the use of a self-report questionnaire to assess depressive symptoms. CONCLUSIONS Our findings support the possibility that OLP is an effective treatment for the relatively young population of depressed patients. Additional studies are warranted to explore the use of OLP in clinical practice.
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Affiliation(s)
- Uri Nitzan
- Shalvata Mental Health Center, P.O.B 94, Hod-Hasharon, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Gal Carmeli
- Shalvata Mental Health Center, P.O.B 94, Hod-Hasharon, Israel
| | | | - Yoram Braw
- Department of Psychology, Ariel University, Israel
| | - Irving Kirsch
- Program in Placebo Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MS, USA
| | - Daphna Shefet
- Shalvata Mental Health Center, P.O.B 94, Hod-Hasharon, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Israel Krieger
- Shalvata Mental Health Center, P.O.B 94, Hod-Hasharon, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shlomo Mendlovic
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yuval Bloch
- Shalvata Mental Health Center, P.O.B 94, Hod-Hasharon, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Pesach Lichtenberg
- Department of Psychiatry, Faculty of Medicine, Hebrew University of Jerusalem, Israel
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27
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Ellingsen DM, Isenburg K, Jung C, Lee J, Gerber J, Mawla I, Sclocco R, Jensen KB, Edwards RR, Kelley JM, Kirsch I, Kaptchuk TJ, Napadow V. Dynamic brain-to-brain concordance and behavioral mirroring as a mechanism of the patient-clinician interaction. Sci Adv 2020; 6:eabc1304. [PMID: 33087365 PMCID: PMC7577722 DOI: 10.1126/sciadv.abc1304] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/25/2020] [Indexed: 06/02/2023]
Abstract
The patient-clinician interaction can powerfully shape treatment outcomes such as pain but is often considered an intangible "art of medicine" and has largely eluded scientific inquiry. Although brain correlates of social processes such as empathy and theory of mind have been studied using single-subject designs, specific behavioral and neural mechanisms underpinning the patient-clinician interaction are unknown. Using a two-person interactive design, we simultaneously recorded functional magnetic resonance imaging (hyperscanning) in patient-clinician dyads, who interacted via live video, while clinicians treated evoked pain in patients with chronic pain. Our results show that patient analgesia is mediated by patient-clinician nonverbal behavioral mirroring and brain-to-brain concordance in circuitry implicated in theory of mind and social mirroring. Dyad-based analyses showed extensive dynamic coupling of these brain nodes with the partners' brain activity, yet only in dyads with pre-established clinical rapport. These findings introduce a putatively key brain-behavioral mechanism for therapeutic alliance and psychosocial analgesia.
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Affiliation(s)
- Dan-Mikael Ellingsen
- Department of Psychology, University of Oslo, Oslo, Norway.
- Norwegian Centre for Mental Disorders Research (NORMENT), Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Kylie Isenburg
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Changjin Jung
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
- KM Fundamental Research Division, Korea Institute of Oriental Medicine, Daejeon, The Republic of Korea
| | - Jeungchan Lee
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Jessica Gerber
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Ishtiaq Mawla
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Roberta Sclocco
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Radiology, Logan University, Chesterfield, MO, USA
| | - Karin B Jensen
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Robert R Edwards
- Department of Anesthesiology, Brigham and Women's Hospital, Boston, MA, USA
| | - John M Kelley
- Endicott College, Beverly, MA, USA
- Program in Placebo Studies and Therapeutic Encounter (PiPS), Harvard Medical School, Boston, MA, USA
| | - Irving Kirsch
- Program in Placebo Studies and Therapeutic Encounter (PiPS), Harvard Medical School, Boston, MA, USA
| | - Ted J Kaptchuk
- Program in Placebo Studies and Therapeutic Encounter (PiPS), Harvard Medical School, Boston, MA, USA
| | - Vitaly Napadow
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Radiology, Logan University, Chesterfield, MO, USA
- Department of Anesthesiology, Brigham and Women's Hospital, Boston, MA, USA
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Affiliation(s)
- Steven Jay Lynn
- Department of Psychology Binghamton University (SUNY) Binghamton New York
| | - Irving Kirsch
- Program in Placebo Studies Harvard Medical School Boston Massachusetts
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Mitsikostas DD, Blease C, Carlino E, Colloca L, Geers AL, Howick J, Evers AWM, Flaten MA, Kelley JM, Kirsch I, Klinger R, MaassenVanDenBrink A, Moerman DE, Sfikakis PP, Vase L, Wager TD, Benedetti F. European Headache Federation recommendations for placebo and nocebo terminology. J Headache Pain 2020; 21:117. [PMID: 32977761 PMCID: PMC7519524 DOI: 10.1186/s10194-020-01178-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 08/26/2020] [Indexed: 12/31/2022] Open
Abstract
Background and aim Despite recent publications, practitioners remain unfamiliar with the current terminology related to the placebo and nocebo phenomena observed in clinical trials and practice, nor with the factors that modulate them. To cover the gap, the European Headache Federation appointed a panel of experts to clarify the terms associated with the use of placebo in clinical trials. Methods The working group identified relevant questions and agreed upon recommendations. Because no data were required to answer the questions, the GRADE approach was not applicable, and thus only expert opinion was provided according to an amended Delphi method. The initial 12 topics for discussion were revised in the opinion of the majority of the panelists, and after a total of 6 rounds of negotiations, the final agreement is presented. Results/recommendations Two primary and mechanism-based recommendations are provided for the results of clinical trials: [1] to distinguish the placebo or nocebo response from the placebo or nocebo effect; and [2] for any favorable outcome observed after placebo administration, the term “placebo response” should be used, and for any unfavorable outcome recorded after placebo administration, the term “nocebo response” should be used (12 out of 17 panelists agreed, 70.6% agreement). The placebo or nocebo responses are attributed to a set of factors including those that are related to the medical condition (e.g. natural history, random comorbidities, etc.), along with idiosyncratic ones, in which the placebo or nocebo effects are attributed to idiosyncratic, or nonspecific mechanisms, exclusively (e.g. expectation, conditioning, observational learning etc.). To help investigators and practitioners, the panel summarized a list of environmental factors and idiosyncratic dynamics modulating placebo and nocebo effects. Some of them are modifiable, and investigators or physicians need to know about them in order to modify these factors appropriately to improve treatment. One secondary recommendation addresses the use of the terms “placebo” and “nocebo” (“placebos” and “nocebos” in plural), which refer to the triggers of the placebo/nocebo effects or responses, respectively, and which are inert agents or interventions that should not be confused with the placebo/nocebo responses or effects themselves (all panelists agreed, 100% agreement). Conclusion The working group recommends distinguishing the term response from effect to describe health changes from before to after placebo application and to distinguish the terms placebo(s) or nocebo(s) from the health consequences that they cause (placebo/nocebo responses or effects).
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Affiliation(s)
- Dimos D Mitsikostas
- 1st Neurology Department, Aeginiton Hospital, Medical School, National and Kapodistrian University of Athens, 72-72 Vas. Sofia's Avenue, 11528, Athens, Greece.
| | - Charlotte Blease
- General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Elisa Carlino
- Physiology and Neuroscience, University of Turin Medical School, Turin, Italy
| | - Luana Colloca
- Departments of Pain Translational Symptoms Science and Anaesthesiology, School of Nursing and Medicine, University of Maryland Baltimore, Baltimore, MD, USA
| | - Andrew L Geers
- Department of Psychology, University of Toledo, Toledo, OH, USA
| | - Jeremy Howick
- Faculty of Philosophy, University of Oxford, Oxford, UK
| | - Andrea W M Evers
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, The Netherlands
| | - Magne A Flaten
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| | - John M Kelley
- Beth Israel Deaconess Medical Center, Program in Placebo Studies, Boston, MA, USA
| | - Irving Kirsch
- Beth Israel Deaconess Medical Center, Program in Placebo Studies, Boston, MA, USA
| | - Regine Klinger
- Department of Anesthesiology University Medical Center Hamburg-Eppendorf, Center for Anesthesiology and Intensive Care Medicine, Hamburg, Germany
| | | | | | - Petros P Sfikakis
- 1st Department of Propedeutic and Internal Medicine, National and Kapodistrian University Medical School, Athens, Greece
| | - Lene Vase
- Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
| | - Tor D Wager
- Department of Psychological and Brain Sciences, Dartmouth College, Hanover, NH, USA
| | - Fabrizio Benedetti
- Physiology and Neuroscience, University of Turin Medical School, Turin, Italy
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Blease CR, Delbanco T, Torous J, Ponten M, DesRoches CM, Hagglund M, Walker J, Kirsch I. Sharing clinical notes, and placebo and nocebo effects: Can documentation affect patient health? J Health Psychol 2020; 27:135-146. [PMID: 32772861 DOI: 10.1177/1359105320948588] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
This paper connects findings from the field of placebo studies with research into patients' interactions with their clinician's visit notes, housed in their electronic health records. We propose specific hypotheses about how features of clinicians' written notes might trigger mechanisms of placebo and nocebo effects to elicit positive or adverse health effects among patients. Bridging placebo studies with (a) survey data assaying patient and clinician experiences with portals and (b) randomized controlled trials provides preliminary support for our hypotheses. We conclude with actionable proposals for testing our understanding of the health effects of access to visit notes.
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Affiliation(s)
| | - Tom Delbanco
- Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - John Torous
- Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Catherine M DesRoches
- Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Maria Hagglund
- Beth Israel Deaconess Medical Center, Boston, MA, USA.,Uppsala University, Uppsala, Sweden
| | - Jan Walker
- Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Irving Kirsch
- Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Abstract
BACKGROUND Major depressive disorder is estimated by the WHO to affect more than 300 million people globally, making depression the leading cause of disability worldwide. Antidepressants are commonly used to treat depression. OBJECTIVE The study aimed to provide an update on the evidence on the effects of antidepressants compared with placebo. Should antidepressants be used for adults with major depressive disorder? STUDY SELECTION We searched the Cochrane Library, BMJ Best Practice and PubMed up to June 2019 with the search terms 'depression' and 'antidepressants' targeting reviews published in English since 1990. FINDINGS Several reviews have assessed the effects of antidepressants compared with placebo for depression. Generally, all the previous reviews show that antidepressants seem to have statistically significant effects on depressive symptoms, but the size of the effect has questionable importance to most patients. Antidepressants seem to have minimal beneficial effects on depressive symptoms and increase the risk of both serious and non-serious adverse events. CONCLUSIONS The benefits of antidepressants seem to be minimal and possibly without any importance to the average patient with major depressive disorder. Antidepressants should not be used for adults with major depressive disorder before valid evidence has shown that the potential beneficial effects outweigh the harmful effects.
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Affiliation(s)
- Janus Christian Jakobsen
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Cardiology, Holbaek Hospital, Holbaek, Denmark
- Department of Regional Health Research, The Faculty of Heath Sciences, University of Southern Denmark, Denmark
| | - Christian Gluud
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Irving Kirsch
- Program in Placebo Studies, Harvard Medical School, Boston, Massachusetts, USA
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Read J, Kirsch I, McGrath L. Electroconvulsive Therapy for Depression: A Review of the Quality of ECT versus Sham ECT Trials and Meta-Analyses. ACTA ACUST UNITED AC 2020. [DOI: 10.1891/ehpp-d-19-00014] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BackgroundElectroconvulsive therapy (ECT) is still being administered to approximately a million people annually. There have been no ECT versus simulated ECT (SECT) studies since 1985. The five meta-analyses of ECT versus SECT studies all claim that ECT is more effective than SECT for its primary target, severe depression. This review assesses the quality of those meta-analyses and of the 11 studies on which they are based.MethodsThe meta-analyses were evaluated primarily in terms of whether they considered the quality of the studies they included, but also in terms of whether they addressed efficacy beyond end of treatment. The methodological rigor of the 11 studies included by one or more of the meta-analyses was assessed using a 24-point Quality scale developed for this review.ResultsThe five meta-analyses include between 1 and 7 of the 11 studies. The meta-analyses pay little or no attention to the multiple limitations of the studies they include. The 11 studies have a mean Quality score of 12.3 out of 24. Eight scored 13 or less. Only four studies describe their processes of randomization and testing the blinding. None convincingly demonstrate that they are double-blind. Five selectively report their findings. Only four report any ratings by patients. None assess Quality of Life. The studies are small, involving an average of 37 people. Four of the 11 found ECT significantly superior to SECT at the end of treatment, five found no significant difference and two found mixed results (including one where the psychiatrists reported a difference but patients did not). Only two higher Quality studies report follow-up data, one produced a near-zero effect size (.065) in the direction of ECT, and the other a small effect size (.299) in favor of SECT.ConclusionsThe quality of most SECT–ECT studies is so poor that the meta-analyses were wrong to conclude anything about efficacy, either during or beyond the treatment period. There is no evidence that ECT is effective for its target demographic—older women, or its target diagnostic group—severely depressed people, or for suicidal people, people who have unsuccessfully tried other treatments first, involuntary patients, or children and adolescents. Given the high risk of permanent memory loss and the small mortality risk, this longstanding failure to determine whether or not ECT works means that its use should be immediately suspended until a series of well designed, randomized, placebo-controlled studies have investigated whether there really are any significant benefits against which the proven significant risks can be weighed.
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Stridh A, Pontén M, Arver S, Kirsch I, Abé C, Jensen KB. Placebo Responses Among Men With Erectile Dysfunction Enrolled in Phosphodiesterase 5 Inhibitor Trials: A Systematic Review and Meta-analysis. JAMA Netw Open 2020; 3:e201423. [PMID: 32196105 PMCID: PMC7084170 DOI: 10.1001/jamanetworkopen.2020.1423] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
IMPORTANCE Placebo responses in the treatment of erectile dysfunction (ED) are poorly described in the literature to date. OBJECTIVE To quantify the association of placebo with ED outcomes among men enrolled in placebo-controlled, phosphodiesterase 5 inhibitor (PDE5I) trials. DATA SOURCES For this systematic review and meta-analysis, a database search was conducted to identify double-blind, placebo-controlled studies using PDE5Is for the treatment of ED published from January 1, 1998, to December 31, 2018, within MEDLINE, Embase, Cochrane Library, and Web of Science. Only articles published in the English language were included. STUDY SELECTION Double-blind, placebo-controlled randomized clinical trials of PDE5Is for ED were included. Studies were excluded if they did not provide distribution measures for statistical analysis. Study selection review assessments were conducted by 2 independent investigators. A total of 2215 studies were identified from the database search, and after review, 63 studies that included 12 564 men were analyzed. DATA EXTRACTION AND SYNTHESIS Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in abstracting data and assessing validity. Data were extracted from published reports by 2 independent reviewers. Quality assessment was performed using the Jadad scale. Data were pooled using a random-effects model. MAIN OUTCOMES AND MEASURES The main outcome was improvement in the erectile function domain of the International Index of Erectile Function questionnaire in the placebo arm of the included studies. Effect size was reported as bias-corrected standardized mean difference (Hedges g). The hypothesis was formulated before data extraction. RESULTS A total of 63 studies that included 12 564 men (mean [SD] age, 55 [7] years; age range, 36-68 years) were included. Erectile function was significantly improved among participants in the placebo arm, with a small to moderate effect size (Hedges g [SE], 0.35 [0.03]; P < .001). Placebo effect size was larger among participants with ED associated with posttraumatic stress disorder (Hedges g [SE], 0.78 [0.32]; P = .02) compared with the overall analysis. No significant difference was found between placebo and PDE5Is for ED after prostate surgery or radiotherapy (Hedges g [SE], 0.30 [0.17]; P = .08). CONCLUSIONS AND RELEVANCE In this study, placebo was associated with improvement of ED, especially among men with ED-related posttraumatic stress disorder. No difference was found between placebo and PDE5I among men treated for ED after prostate surgery.
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Affiliation(s)
- Alexander Stridh
- Department of Clinical Neuroscience, Karolinska Institute, Solna, Sweden
| | - Moa Pontén
- Department of Clinical Neuroscience, Karolinska Institute, Solna, Sweden
| | - Stefan Arver
- Department of Medicine, Karolinska Institute, Solna, Sweden
| | - Irving Kirsch
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christoph Abé
- Department of Clinical Neuroscience, Karolinska Institute, Solna, Sweden
| | - Karin B. Jensen
- Department of Clinical Neuroscience, Karolinska Institute, Solna, Sweden
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Abstract
INTRODUCTION Recent evidence suggests that for certain clinical conditions, placebos can improve clinical outcomes even without deception. These so-called open-label placebos (OLPs) bear the advantage of a significant lower risk of adverse events and comply with ethical principles. Although premenstrual syndrome (PMS) seems to be considerably susceptible to placebo effects, no study has examined open-OLP responses on PMS. METHODS AND ANALYSIS To test the efficacy of OLPs in women suffering from PMS, a clinical randomised controlled trial including two OLP study groups (with and without treatment rationale) was designed to investigate on the effect on PMS. PMS symptoms are monitored on a daily basis via a symptom diary, adverse events are monitored intermittently. The study started in spring 2018 and patients will be included until a maximum of 150 participants are randomised. Besides the primary outcome PMS symptom intensity and interference, an array of further variables is assessed. Multilevel modelling will be used for data analyses. ETHICS AND DISSEMINATION Ethics approval was obtained from the Ethics Committee Northwest and Central Switzerland. Results of the main analysis and of secondary analyses will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBERS: (1) ClinicalTrials.gov (NCT03547661); (2) Swiss national registration (SNCTP000002809).
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Affiliation(s)
- Antje Frey Nascimento
- Division of Clinical Psychology and Psychotherapy, Department of Psychology, University of Basel, Basel, Switzerland
| | - Jens Gaab
- Division of Clinical Psychology and Psychotherapy, Department of Psychology, University of Basel, Basel, Switzerland
| | - Irving Kirsch
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Joe Kossowsky
- Division of Clinical Psychology and Psychotherapy, Department of Psychology, University of Basel, Basel, Switzerland
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea Meyer
- Division of Clinical Psychology and Epidemiology, Department of Psychology, University of Basel, Basel, Switzerland
| | - Cosima Locher
- Division of Clinical Psychology and Psychotherapy, Department of Psychology, University of Basel, Basel, Switzerland
- School of Psychology, University of Plymouth, Plymouth, UK
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Kirsch I. Re: "The Impact of Placebo Response Rates on Clinical Trial Outcome: A Systematic Review and Meta-Analysis of Antidepressants in Children and Adolescents with Major Depressive Disorder" by Li Y, Huang J, He Y, Yang J, Lv Y, Liu H, Liang L, Zheng Q, and Li L (J Child Adolesc Psychopharmacol 29:712-720, 2019). J Child Adolesc Psychopharmacol 2020; 30:55-56. [PMID: 31603715 DOI: 10.1089/cap.2019.0127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Irving Kirsch
- Program in Placebo Studies, Harvard Medical School, Boston, Massachusetts
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Kirsch I, Ness AR, Appleton KM. Treatments for depression: Side-effects, adverse events and health risks. J Affect Disord 2019; 259:38-39. [PMID: 31437699 DOI: 10.1016/j.jad.2019.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 08/08/2019] [Accepted: 08/12/2019] [Indexed: 11/16/2022]
Affiliation(s)
- I Kirsch
- Program in Placebo Studies, Harvard Medical School, Boston, US
| | - A R Ness
- NIHR Bristol Biomedical Research Centre, University of Bristol, Bristol, UK
| | - K M Appleton
- Research Centre for Behaviour Change, Psychology Department, Bournemouth University, Bournemouth, UK.
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Fernandez A, Kirsch I, Noël L, Rodondi PY, Kaptchuk TJ, Suter MR, Décosterd I, Berna C. A test of positive suggestions about side effects as a way of enhancing the analgesic response to NSAIDs. PLoS One 2019; 14:e0209851. [PMID: 30605458 PMCID: PMC6317829 DOI: 10.1371/journal.pone.0209851] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 12/12/2018] [Indexed: 12/12/2022] Open
Abstract
Side effects are frequent in pharmacological pain management, potentially preceding analgesia and limiting drug tolerability. Discussing side effects is part of informed consent, yet can favor nocebo effects. This study aimed to test whether a positive suggestion regarding side effects, which could act as reminders of the medication having been absorbed, might favor analgesia in a clinical interaction model. Sixty-six healthy males participated in a study "to validate pupillometry as an objective measure of analgesia". Participants were unknowingly randomized double-blind to positive vs control information about side effects embedded in a video regarding the study drugs. Sequences of moderately painful heat stimuli applied before and after treatment with diclofenac and atropine served to evaluate analgesia. Atropine was deceptively presented as a co-analgesic, but used to induce side effects. Adverse events (AE) were collected with the General Assessment of Side Effects (GASE) questionnaire prior to the second induced pain sequence. Debriefing fully informed participants regarding the purpose of the study and showed them the two videos.The combination of medication led to significant analgesia, without a between-group difference. Positive information about side effects increased the attribution of AE to the treatment compared to the control information. The total GASE score was correlated with analgesia, i.e., the more AEs reported, the stronger the analgesia. Interestingly, there was a significant between-groups difference on this correlation: the GASE score and analgesia correlated only in the positive information group. This provides evidence for a selective link between AEs and pain relief in the group who received the suggestion that AEs could be taken as a sign "that help was on the way". During debriefing, 65% of participants said they would prefer to receive the positive message in a clinical context. Although the present results cannot be translated immediately to clinical pain conditions, they do indicate the importance of testing this type of modulation in a clinical context.
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Affiliation(s)
- Aurore Fernandez
- Pain Center, Department of Anesthesiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Irving Kirsch
- Program in Placebo Studies, Harvard Medical School, Boston, MA, United States of America
| | - Louis Noël
- Pain Center, Department of Anesthesiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Pierre Yves Rodondi
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
- Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Ted J. Kaptchuk
- Program in Placebo Studies, Harvard Medical School, Boston, MA, United States of America
| | - Marc R. Suter
- Pain Center, Department of Anesthesiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Isabelle Décosterd
- Pain Center, Department of Anesthesiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Chantal Berna
- Pain Center, Department of Anesthesiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
- Program in Placebo Studies, Harvard Medical School, Boston, MA, United States of America
- * E-mail:
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Bernstein MH, Magill M, Weiss AP, Kaptchuk TJ, Blease C, Kirsch I, Rich JD, Becker S, Mach S, Beaudoin FL. Are Conditioned Open Placebos Feasible as an Adjunctive Treatment to Opioids? Results from a Single-Group Dose-Extender Pilot Study with Acute Pain Patients. Psychother Psychosom 2019; 88:380-382. [PMID: 31563914 PMCID: PMC6868304 DOI: 10.1159/000503038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 08/29/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Michael H. Bernstein
- Department of Behavioral and Social Sciences, Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA,Corresponding Author: Michael H. Bernstein, Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main Street, Providence RI, 0288, Tel: 4018637688,
| | - Molly Magill
- Department of Behavioral and Social Sciences, Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA
| | - Arnold-Peter Weiss
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Ted J. Kaptchuk
- Program in Placebo Studies, General Medicine and Primary Care, Beth Israel Deaconess Medical Center/ Harvard Medical School Program, Boston, MA, USA
| | - Charlotte Blease
- Program in Placebo Studies, General Medicine and Primary Care, Beth Israel Deaconess Medical Center/ Harvard Medical School Program, Boston, MA, USA,School of Psychology, University College Dublin, Dublin, Ireland
| | - Irving Kirsch
- Program in Placebo Studies, General Medicine and Primary Care, Beth Israel Deaconess Medical Center/ Harvard Medical School Program, Boston, MA, USA
| | - Josiah D. Rich
- Medicine and Epidemiology, Warren Alpert Medical School of Brown University, Providence, RI, USA,The Center for Prisoner Health and Human Rights, Providence, RI, USA
| | - Sara Becker
- Department of Behavioral and Social Sciences, Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA
| | - Steven Mach
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Francesca L. Beaudoin
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University,Department of Health Services Policy and Practice, Brown University School of Public Health, Providence, RI, USA
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Abstract
The aim of this review is to evaluate the placebo effect in the treatment of anxiety and depression. Antidepressants are supposed to work by fixing a chemical imbalance, specifically, a lack of serotonin or norepinephrine in the brain. However, analyses of the published and the unpublished clinical trial data are consistent in showing that most (if not all) of the benefits of antidepressants in the treatment of depression and anxiety are due to the placebo response, and the difference in improvement between drug and placebo is not clinically meaningful and may be due to breaking blind by both patients and clinicians. Although this conclusion has been the subject of intense controversy, the current article indicates that the data from all of the published meta-analyses report the same results. This is also true of recent meta-analysis of all of the antidepressant data submitted to the Food and Drug Administration (FDA) in the process of seeking drug approval. Also, contrary to previously published results, the new FDA analysis reveals that the placebo response has not increased over time. Other treatments (e.g., psychotherapy and physical exercise) produce the same benefits as antidepressants and do so without the side effects and health risks of the active drugs. Psychotherapy and placebo treatments also show a lower relapse rate than that reported for antidepressant medication.
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Kirsch I, Huedo-Medina TB, Pigott HE, Johnson BT. Do outcomes of clinical trials resemble those of “real world” patients? A reanalysis of the STAR*D antidepressant data set. Psychology of Consciousness: Theory, Research, and Practice 2018. [DOI: 10.1037/cns0000164] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Affiliation(s)
- Irving Kirsch
- Program in Placebo Studies, Harvard Medical School, Boston, MA, USA
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen DK-2100, Denmark.
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Evers AW, Colloca L, Blease C, Annoni M, Atlas LY, Benedetti F, Bingel U, Büchel C, Carvalho C, Colagiuri B, Crum AJ, Enck P, Gaab J, Geers AL, Howick J, Jensen KB, Kirsch I, Meissner K, Napadow V, Peerdeman KJ, Raz A, Rief W, Vase L, Wager TD, Wampold BE, Weimer K, Wiech K, Kaptchuk TJ, Klinger R, Kelley JM. Implications of Placebo and Nocebo Effects for Clinical Practice: Expert Consensus. Psychother Psychosom 2018; 87:204-210. [PMID: 29895014 PMCID: PMC6191882 DOI: 10.1159/000490354] [Citation(s) in RCA: 268] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 05/22/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Placebo and nocebo effects occur in clinical or laboratory medical contexts after administration of an inert treatment or as part of active treatments and are due to psychobiological mechanisms such as expectancies of the patient. Placebo and nocebo studies have evolved from predominantly methodological research into a far-reaching interdisciplinary field that is unravelling the neurobiological, behavioural and clinical underpinnings of these phenomena in a broad variety of medical conditions. As a consequence, there is an increasing demand from health professionals to develop expert recommendations about evidence-based and ethical use of placebo and nocebo effects for clinical practice. METHODS A survey and interdisciplinary expert meeting by invitation was organized as part of the 1st Society for Interdisciplinary Placebo Studies (SIPS) conference in 2017. Twenty-nine internationally recognized placebo researchers participated. RESULTS There was consensus that maximizing placebo effects and minimizing nocebo effects should lead to better treatment outcomes with fewer side effects. Experts particularly agreed on the importance of informing patients about placebo and nocebo effects and training health professionals in patient-clinician communication to maximize placebo and minimize nocebo effects. CONCLUSIONS The current paper forms a first step towards developing evidence-based and ethical recommendations about the implications of placebo and nocebo research for medical practice, based on the current state of evidence and the consensus of experts. Future research might focus on how to implement these recommendations, including how to optimize conditions for educating patients about placebo and nocebo effects and providing training for the implementation in clinical practice.
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Affiliation(s)
- Andrea W.M. Evers
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands,*Andrea W.M. Evers, Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, PO Box 9555, NL–2300 RB Leiden (The Netherlands), E-Mail
| | - Luana Colloca
- Department of Pain Translational Symptoms Science and Anaesthesiology, School of Nursing and Medicine, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Charlotte Blease
- Department of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Marco Annoni
- Department of Institute of Biomedical Technologies, National Research Council, Rome, Italy
| | - Lauren Y. Atlas
- Department of Section on Affective Neuroscience and Pain, NIH, Bethesda, Massachusetts, USA
| | - Fabrizio Benedetti
- Department of Physiology and Neuroscience, University of Turin Medical School, Turin, Italy
| | - Ulrike Bingel
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Christian Büchel
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Claudia Carvalho
- Department of Clinical and Health Psychology, Instituto Universitário de Ciências Psicológicas, Lisbon, Portugal
| | - Ben Colagiuri
- School of Psychology, University of Sydney, Sydney, New South Wales, Australia
| | - Alia J. Crum
- Department of Psychology, Stanford University, Stanford, California, USA
| | - Paul Enck
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
| | - Jens Gaab
- Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Andrew L. Geers
- Department of Psychology, University of Toledo, Toledo, Ohio, USA
| | - Jeremy Howick
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Karin B. Jensen
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Irving Kirsch
- Beth Israel Deaconess Medical Center, Program in Placebo Studies, Boston, Massachusetts, USA
| | - Karin Meissner
- Division of Health Promotion, University of Applied Sciences, Coburg, Germany
| | - Vitaly Napadow
- Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, Massachusetts, USA
| | - Kaya J. Peerdeman
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands
| | - Amir Raz
- Departments of Psychiatry, Neurology and Neurosurgery, McGill University, Montreal, Québec, Canada
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany
| | - Lene Vase
- Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
| | - Tor D. Wager
- Department of Psychology and Neuroscience, University of Colorado, Boulder, Colorado, USA
| | - Bruce E. Wampold
- Department of Counseling Psychology, University of Wisconsin-Madison, Madison, Wisconsin, USA,Modum Bad Psychiatric Center, Vikersund, Norway
| | - Katja Weimer
- Clinic for Psychosomatic Medicine and Psychotherapy, University Hospital Ulm, Ulm, Germany
| | - Katja Wiech
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands
| | - Ted J. Kaptchuk
- Beth Israel Deaconess Medical Center, Program in Placebo Studies, Boston, Massachusetts, USA
| | - Regine Klinger
- Department of Pain Translational Symptoms Science and Anaesthesiology, School of Nursing and Medicine, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - John M. Kelley
- Beth Israel Deaconess Medical Center, Program in Placebo Studies, Boston, Massachusetts, USA
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Gollub RL, Kirsch I, Maleki N, Wasan AD, Edwards RR, Tu Y, Kaptchuk TJ, Kong J. A Functional Neuroimaging Study of Expectancy Effects on Pain Response in Patients With Knee Osteoarthritis. J Pain 2018; 19:515-527. [PMID: 29325883 DOI: 10.1016/j.jpain.2017.12.260] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 12/01/2017] [Accepted: 12/13/2017] [Indexed: 12/18/2022]
Abstract
Placebo treatments and healing rituals share much in common, such as the effects of expectancy, and have been used since the beginning of human history to treat pain. Previous mechanistic neuroimaging studies investigating the effects of expectancy on placebo analgesia have used young, healthy volunteers. Using functional magnetic resonance imaging (fMRI), we aimed to investigate the neural mechanisms by which expectancy evokes analgesia in older adults living with a chronic pain disorder and determine whether there are interactions with active treatment. In this fMRI study, we investigated the brain networks underlying expectancy in participants with chronic pain due to knee osteoarthritis (OA) after verum (genuine) and sham electroacupuncture treatment before and after experiencing calibrated experimental heat pain using a well tested expectancy manipulation model. We found that expectancy significantly and similarly modulates the pain experience in knee OA patients in both verum (n = 21, 11 female; mean ± SD age 57 ± 7 years) and sham (n = 22, 15 female; mean ± SD age 59 ± 7 years) acupuncture treatment groups. However, there were different patterns of changes in fMRI indices of brain activity associated with verum and sham treatment modalities specifically in the lateral prefrontal cortex. We also found that continuous electroacupuncture in knee OA patients can evoke significant regional coherence decreases in pain associated brain regions. Our results suggest that expectancy modulates the experience of pain in knee OA patients but may work through different pathways depending on the treatment modality and, we speculate, on pathophysiological states of the participants. PERSPECTIVE To investigate the neural mechanisms underlying pain modulation, we used an expectancy manipulation model and fMRI to study response to heat pain stimuli before and after verum or sham acupuncture treatment in chronic pain patients. Both relieve pain and each is each associated with a distinct pattern of brain activation.
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Affiliation(s)
- Randy L Gollub
- Psychiatric Neuroimaging, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts.
| | - Irving Kirsch
- Program in Placebo Studies and Therapeutic Encounter, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Nasim Maleki
- Psychiatric Neuroimaging, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ajay D Wasan
- Departments of Anesthesiology and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert R Edwards
- Pain Management Center, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Yiheng Tu
- Psychiatric Neuroimaging, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ted J Kaptchuk
- Program in Placebo Studies and Therapeutic Encounter, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jian Kong
- Psychiatric Neuroimaging, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts
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Affiliation(s)
- Irving Kirsch
- Program in Placebo Studies, Harvard Medical School, USA.
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Locher C, Koechlin H, Zion SR, Werner C, Pine DS, Kirsch I, Kessler RC, Kossowsky J. Efficacy and Safety of Selective Serotonin Reuptake Inhibitors, Serotonin-Norepinephrine Reuptake Inhibitors, and Placebo for Common Psychiatric Disorders Among Children and Adolescents: A Systematic Review and Meta-analysis. JAMA Psychiatry 2017; 74:1011-1020. [PMID: 28854296 PMCID: PMC5667359 DOI: 10.1001/jamapsychiatry.2017.2432] [Citation(s) in RCA: 195] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 06/24/2017] [Indexed: 01/23/2023]
Abstract
Importance Depressive disorders (DDs), anxiety disorders (ADs), obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD) are common mental disorders in children and adolescents. Objective To examine the relative efficacy and safety of selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and placebo for the treatment of DD, AD, OCD, and PTSD in children and adolescents. Data Sources PubMed, EMBASE, PsycINFO, Web of Science, and Cochrane Database from inception through August 7, 2016. Study Selection Published and unpublished randomized clinical trials of SSRIs or SNRIs in youths with DD, AD, OCD, or PTSD were included. Trials using other antidepressants (eg, tricyclic antidepressants, monoamine oxidase inhibitors) were excluded. Data Extraction and Synthesis Effect sizes, calculated as standardized mean differences (Hedges g) and risk ratios (RRs) for adverse events, were assessed in a random-effects model. Main Outcomes and Measures Primary outcomes, as defined by authors on preintervention and postintervention data, mean change data, and adverse event data, were extracted independently by multiple observers following PRISMA guidelines. Results Thirty-six trials were eligible, including 6778 participants (3484 [51.4%] female; mean [SD] age, 12.9 [5.1] years); 17 studies for DD, 10 for AD, 8 for OCD, and 1 for PTSD. Analysis showed that SSRIs and SNRIs were significantly more beneficial compared with placebo, yielding a small effect size (g = 0.32; 95% CI, 0.25-0.40; P < .001). Anxiety disorder (g = 0.56; 95% CI, 0.40-0.72; P < .001) showed significantly larger between-group effect sizes than DD (g = 0.20; 95% CI, 0.13-0.27; P < .001). This difference was driven primarily by the placebo response: patients with DD exhibited significantly larger placebo responses (g = 1.57; 95% CI, 1.36-1.78; P < .001) compared with those with AD (g = 1.03; 95% CI, 0.84-1.21; P < .001). The SSRIs produced a relatively large effect size for ADs (g = 0.71; 95% CI, 0.45-0.97; P < .001). Compared with participants receiving placebo, patients receiving an antidepressant reported significantly more treatment-emergent adverse events (RR, 1.07; 95% CI, 1.01-1.12; P = .01 or RR, 1.49; 95% CI, 1.22-1.82; P < .001, depending on the reporting method), severe adverse events (RR, 1.76; 95% CI, 1.34-2.32; P < .001), and study discontinuation due to adverse events (RR, 1.79; 95% CI, 1.38-2.32; P < .001). Conclusions and Relevance Compared with placebo, SSRIs and SNRIs are more beneficial than placebo in children and adolescents; however, the benefit is small and disorder specific, yielding a larger drug-placebo difference for AD than for other conditions. Response to placebo is large, especially in DD. Severe adverse events are significantly more common with SSRIs and SNRIs than placebo.
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Affiliation(s)
- Cosima Locher
- Department of Clinical Psychology & Psychotherapy, University of Basel, Basel, Switzerland
| | - Helen Koechlin
- Department of Clinical Psychology & Psychotherapy, University of Basel, Basel, Switzerland
- Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sean R. Zion
- Department of Psychology, Stanford University, Stanford, California
| | - Christoph Werner
- Department of Clinical Psychology & Psychotherapy, University of Basel, Basel, Switzerland
| | - Daniel S. Pine
- Intramural Research Program, National Institute of Mental Health, Bethesda, Maryland
| | - Irving Kirsch
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Joe Kossowsky
- Department of Clinical Psychology & Psychotherapy, University of Basel, Basel, Switzerland
- Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
- Computational Health Informatics Program, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Sugarman MA, Kirsch I, Huppert JD. Obsessive-compulsive disorder has a reduced placebo (and antidepressant) response compared to other anxiety disorders: A meta-analysis. J Affect Disord 2017; 218:217-226. [PMID: 28477500 DOI: 10.1016/j.jad.2017.04.068] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/19/2017] [Accepted: 04/28/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Previous studies have indicated that obsessive-compulsive disorder (OCD) might have a reduced placebo response compared to other anxiety-related disorders including generalized anxiety disorder, panic disorder, post-traumatic stress disorder, and social anxiety disorder. No previous analysis has directly compared antidepressant and placebo responses between OCD and these conditions. METHOD We analyzed pre-post change scores within drug and placebo groups as well as between-groups change scores (i.e., drug compared to placebo) for all FDA-approved antidepressants for the treatment of these five anxiety-related disorders. Antidepressants included duloxetine, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, and venlafaxine. Random effects meta-analysis was used to examine all trials submitted to the FDA, plus additional post-approval trials available from manufacturer-sponsored clinical trial registers. Clinician-rated symptom inventories were the outcome measures for all conditions to facilitate comparisons across diagnoses. RESULTS Fifty-six trials met inclusion criteria. OCD had significantly lower pre-post effect sizes (ps<0.003) for both placebo (Hedges' g=0.49) and antidepressants (g=0.84) compared to the other four conditions (gs between 0.70 and 1.10 for placebo and 1.11 and 1.40 for antidepressants). However, the drug-placebo effect sizes did not significantly differ across diagnoses (Q(4)=6.09, p=0.193, I2 =34.3% [95% CI: -7.0,59.7]), with gs between=0.26 and 0.39. CONCLUSIONS Overall pre-post change scores were smaller for OCD compared to other anxiety disorders for both antidepressants and placebo, although drug-placebo effects sizes did not significantly differ across disorders. Theoretical and clinical implications for the understanding and treatment of OCD are discussed.
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Affiliation(s)
- Michael A Sugarman
- Department of Psychology, Bedford Veterans Affairs Medical Center, United States.
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Ballou S, Kaptchuk TJ, Hirsch W, Nee J, Iturrino J, Hall KT, Kelley JM, Cheng V, Kirsch I, Jacobson E, Conboy L, Lembo A, Davis RB. Open-label versus double-blind placebo treatment in irritable bowel syndrome: study protocol for a randomized controlled trial. Trials 2017; 18:234. [PMID: 28545508 PMCID: PMC5445390 DOI: 10.1186/s13063-017-1964-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 04/29/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Placebo medications, by definition, are composed of inactive ingredients that have no physiological effect on symptoms. Nonetheless, administration of placebo in randomized controlled trials (RCTs) and in clinical settings has been demonstrated to have significant impact on many physical and psychological complaints. Until recently, conventional wisdom has suggested that patients must believe that placebo pills actually contain (or, at least, might possibly contain) active medication in order to elicit a response to placebo. However, several recent RCTs, including patients with irritable bowel syndrome (IBS), chronic low back pain, and episodic migraine, have demonstrated that individuals receiving open-label placebo (OLP) can still experience symptomatic improvement and benefit from honestly described placebo treatment. METHODS AND DESIGN This paper describes an innovative multidisciplinary trial design (n = 280) that attempts to replicate and expand upon an earlier IBS OLP study. The current study will compare OLP to double-blind placebo (DBP) administration which is made possible by including a nested, double-blind RCT comparing DBP and peppermint oil. The study also examines possible genetic and psychological predictors of OLP and seeks to better understand participants' experiences with OLP and DBP through a series of extensive interviews with a randomly selected subgroup. DISCUSSION OLP treatment is a novel strategy for ethically harnessing placebo effects. It has potential to re-frame theories of placebo and to influence how physicians can optimize watch-and-wait strategies for common, subjective symptoms. The current study aims to dramatically expand what we know about OLP by comparing, for the first time, OLP and DBP administration. Adopting a unique, multidisciplinary approach, the study also explores genetic, psychological and experiential dimensions of OLP. The paper ends with an extensive discussion of the "culture" of the trial as well as potential mechanisms of OLP and ethical implications. TRIAL REGISTRATION ClinicalTrials.gov, identifier: NCT02802241 . Registered on 14 June 2016.
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Affiliation(s)
- Sarah Ballou
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Ted J. Kaptchuk
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
- Department of Global Health and Social Medicine Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115 USA
| | - William Hirsch
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Judy Nee
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Johanna Iturrino
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Kathryn T. Hall
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
- Division of Preventive Medicine, Brigham and Women’s Hospital/Harvard Medical School, 900 Commonwealth Avenue, Boston, MA 02215 USA
| | - John M. Kelley
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
- Department of Psychology, Endicott College, 376 Hale Street, Beverly, MA 01915 USA
| | - Vivian Cheng
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Irving Kirsch
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Eric Jacobson
- Department of Global Health and Social Medicine Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115 USA
| | - Lisa Conboy
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
- Department of Medicine, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Anthony Lembo
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 USA
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Roger B. Davis
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
- Department of Medicine, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 USA
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Jensen KB, Kirsch I, Pontén M, Rosén A, Yang K, Gollub RL, des Portes V, Kaptchuk TJ, Curie A. Certainty of genuine treatment increases drug responses among intellectually disabled patients. Neurology 2017; 88:1912-1918. [PMID: 28424273 PMCID: PMC5444309 DOI: 10.1212/wnl.0000000000003934] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 02/28/2017] [Indexed: 02/06/2023] Open
Abstract
Objective: To determine the placebo component of treatment responses in patients with intellectual disability (ID). Methods: A statistical meta-analysis comparing bias-corrected effect sizes (Hedges g) of drug responses in open-label vs placebo-controlled clinical trials was performed, as these trial types represent different certainty of receiving genuine treatment (100% vs 50%). Studies in fragile X, Down, Prader-Willi, and Williams syndrome published before June 2015 were considered. Results: Seventeen open-label trials (n = 261, 65% male; mean age 23.6 years; mean trial duration 38 weeks) and 22 placebo-controlled trials (n = 721, 62% male; mean age 17.1 years; mean trial duration 35 weeks) were included. The overall effect size from pre to post treatment in open-label studies was g = 0.602 (p = 0.001). The effect of trial type was statistically significant (p = 0.001), and revealed higher effect sizes in studies with 100% likelihood of getting active drug, compared to both the drug and placebo arm of placebo-controlled trials. We thus provide evidence for genuine placebo effects, not explainable by natural history or regression toward the mean, among patients with ID. Conclusions: Our data suggest that clinical trials in patients with severe cognitive deficits are influenced by the certainty of receiving genuine medication, and open-label design should thus not be used to evaluate the effect of pharmacologic treatments in ID, as the results will be biased by an enhanced placebo component.
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Affiliation(s)
- Karin B Jensen
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France.
| | - Irving Kirsch
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Moa Pontén
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Annelie Rosén
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Kathy Yang
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Randy L Gollub
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Vincent des Portes
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Ted J Kaptchuk
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Aurore Curie
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
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Rutherford BR, Wall MM, Brown PJ, Choo TH, Wager TD, Peterson BS, Chung S, Kirsch I, Roose SP. Patient Expectancy as a Mediator of Placebo Effects in Antidepressant Clinical Trials. Am J Psychiatry 2017; 174:135-142. [PMID: 27609242 PMCID: PMC5288269 DOI: 10.1176/appi.ajp.2016.16020225] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Causes of placebo effects in antidepressant trials have been inferred from observational studies and meta-analyses, but their mechanisms have not been directly established. The goal of this study was to examine in a prospective, randomized controlled trial whether patient expectancy mediates placebo effects in antidepressant studies. METHOD Adult outpatients with major depressive disorder were randomly assigned to open or placebo-controlled citalopram treatment. Following measurement of pre- and postrandomization expectancy, participants were treated with citalopram or placebo for 8 weeks. Independent samples t tests determined whether patient expectancy differed between the open and placebo-controlled groups, and mixed-effects models assessed group effects on Hamilton Depression Rating Scale (HAM-D) scores over time while controlling for treatment assignment. Finally, mediation analyses tested whether between-group differences in patient expectancy mediated the group effect on HAM-D scores. RESULTS Postrandomization expectancy scores were significantly higher in the open group (mean=12.1 [SD=2.1]) compared with the placebo-controlled group (mean=11.0 [SD=2.0]). Mixed-effects modeling revealed a significant week-by-group interaction, indicating that HAM-D scores for citalopram-treated participants declined at a faster rate in the open group compared with the placebo-controlled group. Patient expectations postrandomization partially mediated group effects on week 8 HAM-D. CONCLUSIONS Patient expectancy is a significant mediator of placebo effects in antidepressant trials. Expectancy-related interventions should be investigated as a means of controlling placebo responses in antidepressant clinical trials and improving patient outcome in clinical treatment.
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Affiliation(s)
- Bret R Rutherford
- From Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York; the Department of Psychology and Neuroscience and the Institute of Cognitive Science, University of Colorado at Boulder, Boulder, Colo.; the Institute for the Developing Mind, Children's Hospital Los Angeles; the Keck School of Medicine at the University of Southern California, Los Angeles; Harvard Medical School, Boston; and Beth Israel Deaconess Medical Center, Boston
| | - Melanie M Wall
- From Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York; the Department of Psychology and Neuroscience and the Institute of Cognitive Science, University of Colorado at Boulder, Boulder, Colo.; the Institute for the Developing Mind, Children's Hospital Los Angeles; the Keck School of Medicine at the University of Southern California, Los Angeles; Harvard Medical School, Boston; and Beth Israel Deaconess Medical Center, Boston
| | - Patrick J Brown
- From Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York; the Department of Psychology and Neuroscience and the Institute of Cognitive Science, University of Colorado at Boulder, Boulder, Colo.; the Institute for the Developing Mind, Children's Hospital Los Angeles; the Keck School of Medicine at the University of Southern California, Los Angeles; Harvard Medical School, Boston; and Beth Israel Deaconess Medical Center, Boston
| | - Tse-Hwei Choo
- From Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York; the Department of Psychology and Neuroscience and the Institute of Cognitive Science, University of Colorado at Boulder, Boulder, Colo.; the Institute for the Developing Mind, Children's Hospital Los Angeles; the Keck School of Medicine at the University of Southern California, Los Angeles; Harvard Medical School, Boston; and Beth Israel Deaconess Medical Center, Boston
| | - Tor D Wager
- From Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York; the Department of Psychology and Neuroscience and the Institute of Cognitive Science, University of Colorado at Boulder, Boulder, Colo.; the Institute for the Developing Mind, Children's Hospital Los Angeles; the Keck School of Medicine at the University of Southern California, Los Angeles; Harvard Medical School, Boston; and Beth Israel Deaconess Medical Center, Boston
| | - Bradley S Peterson
- From Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York; the Department of Psychology and Neuroscience and the Institute of Cognitive Science, University of Colorado at Boulder, Boulder, Colo.; the Institute for the Developing Mind, Children's Hospital Los Angeles; the Keck School of Medicine at the University of Southern California, Los Angeles; Harvard Medical School, Boston; and Beth Israel Deaconess Medical Center, Boston
| | - Sarah Chung
- From Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York; the Department of Psychology and Neuroscience and the Institute of Cognitive Science, University of Colorado at Boulder, Boulder, Colo.; the Institute for the Developing Mind, Children's Hospital Los Angeles; the Keck School of Medicine at the University of Southern California, Los Angeles; Harvard Medical School, Boston; and Beth Israel Deaconess Medical Center, Boston
| | - Irving Kirsch
- From Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York; the Department of Psychology and Neuroscience and the Institute of Cognitive Science, University of Colorado at Boulder, Boulder, Colo.; the Institute for the Developing Mind, Children's Hospital Los Angeles; the Keck School of Medicine at the University of Southern California, Los Angeles; Harvard Medical School, Boston; and Beth Israel Deaconess Medical Center, Boston
| | - Steven P Roose
- From Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York; the Department of Psychology and Neuroscience and the Institute of Cognitive Science, University of Colorado at Boulder, Boulder, Colo.; the Institute for the Developing Mind, Children's Hospital Los Angeles; the Keck School of Medicine at the University of Southern California, Los Angeles; Harvard Medical School, Boston; and Beth Israel Deaconess Medical Center, Boston
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