Nocebo effects in systemic therapies for adult plaque psoriasis: A systematic review and meta-analysis

Introduction

The nocebo effect is defined as adverse outcomes secondary to negative patient expectations rather than the pharmacologic activity of an intervention. Nocebo effects can reduce treatment adherence and/or persistence. Therefore, nocebo effects in psoriasis need to be defined.

Methods

A Cochrane systematic review was updated with a search of MEDLINE, Embase, and the CENTRAL Register of Controlled Trials for phase II - IV RCTs comparing systemic therapy versus placebo for patients with moderate-to-severe plaque psoriasis. Estimates were pooled using a random effects model, and heterogeneity was evaluated using the I2 statistic. The primary outcome was the pooled proportion of any adverse event (AE) and corresponding risk difference (RD) in patients randomized to placebo versus systemic therapy.

Results

A total of 103 unique trials were identified enrolling 43,189 patients. The overall pooled AE rate in patients randomized to systemic therapy was 57.1% [95% CI: 54.7-59.5%] compared to 49.8% [95% CI: 47.1-52.4%] for placebo [RD 6.7% (95% CI: 4.6-8.9%), p < 0.00001, I2 = 75%]. Both biologic and non-biologic systemic therapy groups had a higher proportion of infectious AEs compared to placebo. No statistically significant RD in serious AEs or AEs leading to discontinuation was identified between systemic therapy and placebo groups.

Discussion

Half of patients exposed to inert placebo in clinical trials of systemic psoriasis therapies experienced AEs, which may be explained by nocebo effects. These findings have important implications when counseling patients and designing future studies.

Biosimilars: From Production to Patient

Biologic drugs are large, complex molecules produced through biotechnology. A biosimilar is a biologic product that is highly similar to an already approved biologic (reference product), with no clinically meaningful differences in purity, safety, or efficacy; as such, a biosimilar does not need to undergo the same level of study in a clinical trial program as the original reference product. Due to the potential impact of biosimilars on patient access and health care systems, the US Food and Drug Administration introduced an abbreviated pathway for approving biosimilars (351[k]) in 2009. There is strong evidence that switching from a reference product to a biosimilar does not reduce treatment effectiveness or increase the risk of adverse events. Biosimilars may reduce costs and increase patient access to biologic therapies. Biosimilar use in the United States has increased, as have the associated biosimilar cost savings, which are expected to reach $104 billion between 2020 and 2024. Yet, a need remains for increased knowledge among health care professionals and patients. Prescriber confidence is key to patient acceptance of biosimilars and minimizing the incidence of the nocebo effect. Infusion nurses are well positioned to help educate patients and to improve clinical outcomes across a range of diseases.

Health Scares: Tracing Their Nature, Growth and Spread

Background

Health scares are highly publicised threats to health that increase public concern and protective behaviours but are later shown to be unfounded. Although health scares have become more common in recent times, they have received very little research attention. This is despite the fact that health scares often have negative outcomes for individuals and community by affecting health behaviours and causing high levels of often unnecessary anxiety.

Method

In this paper we undertook a review and analysis of the major types of health scares as well as the background factors associated with health scares and their spread.

Results

We found most health scares fell into seven main categories; environmental contaminants, food, malicious incidents, medical treatments, public health interventions, radiation from technology and exotic diseases. For most health scares there are important background factors and incident characteristics that affect how they develop. Background factors include conspiracy theories, trust in governmental agencies, anxiety, modern health worries and wariness of chemicals. Incident characteristic include being newly developed, not understood or unseen, man-made rather than natural and whether the incident is out of personal control. We also identified the aspects of traditional and social media that exacerbate the rapid spread of health scares.

Conclusion

More research is needed to identify the characteristics of media stories that intensify the levels of public concern. Guidelines around the media's reporting of health incidents and potential health threats may be necessary in order to reduce levels of public anxiety and the negative public health impact of health scares.

Expectations Come True: The Placebo Effect of Exercise on Affective Responses

Objective: This study investigated the placebo and nocebo effects of habitual and induced expectations. Methods: In Study 1, 95 participants (Mage = 19.65 ± 2.21 years, MBMI = 21.94 ± 2.55) were grouped according to habitual expectations (positive, neutral, or negative) and completed a 30-min moderate-intensity aerobic exercise, and their affective response, rating of perceived exertion (RPE), and heart rate variability (HRV) were measured before, during, and after the exercise. In Study 2, the participants from Study 1 were grouped according to induced expectations (control, positive, or negative) and completed a 30-min moderate-intensity aerobic exercise. Affective response, RPE, and HRV were measured before, during, and after exercise. Results: In Study 1, positive habitual expectations increased affective response during and after exercise [F(2, 92) = 2.959, p = .057, ηp2 = .060], and negative habitual expectations increased RPE during exercise [F(2, 92) = 5.174, p = .007, ηp2 = .101]. In Study 2, positive induced expectation increased affective response during [F(2, 86) = 5.492, p = .006, ηp2 = .113] and after exercise [F(2, 86) = 6.096, p = .003, ηp2 = .124] and was not affected by habitual expectation. Conclusion: The affective response during and after exercise is influenced by habitual and induced expectations. Positive expectations enhance affective benefits, while negative expectations reduce affective benefits.

Nocebo effects in visceral pain: concept and design of the experimental randomized-controlled pain study 'NoVis'

The role of psychological factors in the pathophysiology and treatment of chronic visceral pain in disorders of gut-brain interactions (DGBI) is increasingly appreciated. Placebo research has underscored that expectations arising from the psychosocial treatment context and from prior experiences shape treatment responses. However, effects of negative expectations, i.e., nocebo effects, as they are likely crucial elements of DGBI patients' clinical reality, have thus far only rarely been investigated in the context of visceral pain, with untapped potential for improved prevention and treatment. The experimental randomized-controlled pain study "NoVis," carried out within the Collaborative Research Center (CRC) 289 ("Treatment Expectation"), aims to close gaps regarding the generation and persistence of nocebo effects in healthy volunteers. It is designed to elucidate effects of negative expectations in a multiple-threat paradigm with intensity-matched rectal distensions and cutaneous thermal stimuli, allowing to test nocebo effects in the visceral and somatic pain modalities. Negative expectations are experimentally induced by elements of doctor-patient communication (i.e., instruction) and/or by surreptitious amplification of symptom intensity (i.e., experience/learning) within a treatment context. Accordingly, the repeated measures between-subject design contains the between-group factors "treatment instruction" (negative vs. control) and "treatment experience" (negative vs. control), with volunteers randomized into four experimental groups undergoing several pain stimulation phases (repeated factor). This allows to compare the efficacy of instruction vs. experience, and more importantly, their combined effects on the magnitude of negative expectations and their impact on pain responses, which we expect will be greatest for the visceral modality. After a Baseline, short-term effects are assessed during a test phase accomplished on study day 1 (Test-1 Phase). To explore the persistence of effects, a second test phase is accomplished 1 week later (Test-2 Phase). Effects of negative expectations within and across pain modalities are assessed at the subjective and objective levels, with a focus on psychophysiological and neuroendocrine measures related to stress, fear, and anxiety. Since nocebo effects can play a considerable role in the generation, maintenance, or worsening of chronic visceral pain, and may even constitute risk factors for treatment failure, knowledge from experimental nocebo research has potential to improve treatment outcomes in DGBI and other clinical conditions associated with chronic visceral pain.

Practitioner warmth and empathy attenuates the nocebo effect and enhances the placebo effect

Augmented patient-practitioner interactions that enhance therapeutic alliance can increase the placebo effect to sham treatment. Little is known, however, about the effect of these interactions on maladaptive health outcomes (i.e., the nocebo effect). Healthy participants (N = 84) were randomised to a 3-day course of Oxytocin nasal drops (actually, sham treatment) in conjunction with a high-warmth interaction (Oxy-HW: N = 28), a low-warmth interaction (Oxy-LW: N = 28) or to a no treatment control group (NT: N = 28). All participants were informed that the Oxytocin treatment could increase psychological well-being but was associated with several potential side effects. Treatment-related side effects, unwarned symptoms, and psychological well-being were measured at baseline and all post-treatment days. Side effect reporting was increased in the Oxy-LW condition compared to the other groups across all days. Conversely, increased psychological well-being was observed in the Oxy-HW condition, relative to the other conditions, but only on Day 1. Among those receiving treatment, positive and negative expectations, and treatment-related worry, did not vary by interaction-style, while psychological well-being and side effect reporting were inversely associated at the level of the individual. Results have important implications for practice, suggesting poorer quality interactions may not only reduce beneficial health outcomes but also exacerbate those that are maladaptive.

Impact of Verbal Suggestions on Finger Flexor Activation and Strength in Healthy Individuals

BACKGROUND Words uttered by other people can have an enormous influence on how we perceive our surroundings, what we expect, what we experience, and how we behave. This study aimed to evaluate the effect of verbal reinforcement on the placebo effect in the context of finger flexor muscle activation measured with surface electromyography (sEMG) and hand grip strength measured with a hand dynamometer in healthy subjects. MATERIAL AND METHODS Eighty-eight individuals aged 22.64±5.2 years took part in the study. For each person, paper tape was applied (placebo). The participants were randomly assigned to 1 of the 3 groups: positive information group (P) - "the tape increases hand muscle strength", negative information group (N) - "the tape decreases hand muscle strength", and control group (C) - "the effect of the tape on hand muscle strength is unknown." The activation of muscles was assessed using surface electromyography (sEMG) while measuring the strength of wrist and finger flexors with a hand dynamometer. Each participant was examined twice - prior to and immediately after taping and providing verbal reinforcement. RESULTS Only group N manifested a decrease in muscle strength, from 39.7N to 37.6N (P=0.003). Group C displayed an increase in muscle strength from 34.3N to 36.4N (P=0.035). None of the groups demonstrated statistically significant changes in bioelectrical activity of the muscles. At no stage of examination were the differences between the groups significant. CONCLUSIONS Negative verbal information combined with the placebo intervention resulted in a significant decrease in the strength of finger flexors.

Conditioning induced placebo-like and nocebo-like effects of thermal discomfort in adults but not in youth

Introduction

Conditioning can be used to modulate the perception of pain, in the form of placebo and nocebo effects. Previous studies show inconsistent results as to whether adolescents show similar, weaker, or non-significant conditioned placebo and nocebo effects compared to effects found in adults. There are suggestions that such differences (if any) may dependent on the cues used in the thermal conditioning paradigms. Therefore, in this current study, we utilized novel, neutral 3D-shaped visual cues to implicitly induce conditioned placebo-like and nocebo-like effects in adolescents and adults.

Methods

During the conditioning paradigm, distinct cues (Fribbles) were paired with low and high temperatures in 24 adults and 20 adolescents (mean age = 25.5 years). In the testing phase, these conditioned cues as well as a neutral (unconditioned) cue were presented with moderate temperatures.

Results

Thermal discomfort of moderate temperatures was lower when presented with the conditioned low heat cue (placebo-like effect) and higher when thermal stimuli were presented with the high heat cue (nocebo-like effect) compared to the neutral cue. The effects were driven by adults, as neither the placebo-like nor the nocebo-like effect was significant in adolescents. The difference between adolescents and adults was not explained by differences in temperature or discomfort levels, as adults and adolescents had comparable calibrated temperatures and levels of discomfort during heat stimuli.

Conclusion

Our findings suggest that thermal perception in adolescents is less influenced by conditioning to an engaging novel visual cue, compared to adults. Our work may have implications for better understanding the scope and limitations of conditioning as a key mechanism of placebo and nocebo effects in youth.

Nocebo response intensity and influencing factors in the randomized clinical trials of functional dyspepsia: A systematic review and meta-analysis

OBJECTIVES

In this study we aimed to evaluate the nocebo response rate in patients with functional dyspepsia (FD) and to explore its influencing factors.

METHODS

A literature search of the EMBASE, PubMed, and Cochrane Library databases was conducted for all articles published up to March 2021. Randomized, parallel-designed, placebo-controlled trials on pharmacological interventions for patients with FD were included. A meta-analysis that utilized random effects to analyze the incidence of adverse events (AEs) among participants who were given placebo was conducted, and the correlation between trial characteristics and the magnitude of the nocebo response rate was analyzed.

RESULTS

Altogether, 27 studies including 1866 paitents were deemed eligible and included in the analysis. The total nocebo response rate was 26% (95% confidence interval [CI] 18%-33%). The most frequently reported AEs included nasopharyngitis (9%), constipation (6%), headache (5%), and diarrhea (3%). There were significant differences in nocebo response rates among studies conducted in different country or region, treatment duration, types of medication, sponsorship and different versions of the Rome criteria used for FD diagnosis. While number of centers engaged in the study, types of FD diagnosis and dosing frequency were not significantly associated with the nocebo response rate.

CONCLUSIONS

Patients with FD exhibit notable nocebo response strength in clinical trials. The researchers should adopt a more careful approach when analyzing the relationships between AEs and interventions in such trials.

Placebo hypoalgesic and nocebo hyperalgesic effects in post-extraction patients-A cross sectional study

Background and objectives

Pain is an unpleasant sensory and emotional experience that affects people's physical, mental, and social health. Patients at times present with postoperative pain with no clinical signs after the surgical dental procedures and adequate pharmacological management. This can be due to the amplified emotional component of the individual in their postoperative period. Hence, this study aimed to estimate the association between placebo, nocebo effects, and postoperative pain associated with tooth extraction procedures.

Methods

A cross-sectional study was conducted among 301 patients attending the Department of Oral and Maxillofacial Surgery for tooth extraction. Preoperatively, the expected postoperative pain score was recorded using the "Numerical Rating Scale" (NRS), Anxiety and Depression were assessed using the "Hospital Anxiety and Depression Scale" (HADS), and Patients' expectancy regarding the treatment outcome was assessed using the "Credibility Expectancy Questionnaire" (CEQ). Observed postoperative pain scores at the 6th hour, 24th hour, and peak pain score of the day were recorded using the NRS.

Results

There were statistically significant associations (p < 0.05) found between expected and observed postoperative pain, preoperative anxiety and observed postoperative pain, preoperative depression and observed postoperative pain, placebo, nocebo effects, and observed postoperative pain.

Interpretation and conclusion

Our study showed a strong association between these variables suggesting that post-extraction pain is a multifaceted condition wherein pain expectation, preoperative anxiety, depression, and expectancy regarding the treatment outcome should be scrutinized before the extraction procedure.

Psychological distress, perceived stress and nocebo effect (multifood adverse reaction) in irritable bowel syndrome patients

BACKGROUND

Psychological distress and perceived stress may complicate the clinical presentation, course, and treatment of patients with functional gastrointestinal disorders. The correlation between psychological distress, perceived stress, and the nocebo effect (multifood adverse reaction) in patients with irritable bowel syndrome (IBS) was the main aim of the present study.

MATERIALS AND METHODS

In this cross-sectional correlation study, data on 4,763 Iranian adults, 748 of whom by purposive sampling were patients with IBS (65.1% female), working in 50 different health centers affiliated to the Isfahan University of Medical Sciences across Isfahan province were examined. For assessing dietary intake, a 106-item self-administered Dish-based Semi-Quantitative Food Frequency Questionnaire that was specifically designed and validated for Iranian adults was used. General Heath Questionnaire 12 and Stressful Life event Questionnaire were used to assess psychological distress and perceived stress. By using a modified Persian version of the Rome III questionnaire, IBS was assessed. Based on researcher-made definition of nocebo effect (multiitem food intolerance), 164 people had the nocebo phenomenon in IBS group.

RESULTS

Age, sex, education, marital status, antidepressant use, and specifically chronic underlying disease (odds ratio [OR]: 3.54, 95% confidence interval [CI]: 1.73-7.23) of general characteristics had a significant correlation (P <.05) with presenting nocebo responses in IBS patients. Psychological distress (OR: 1.415; 95% CI: 0.992-2.020; P = 0.056) had a significant correlation with nocebo effect and did not find significant correlation with perceived stress (OR: 0.999; 95% CI: 0.990-1.008; P = 0.865). Data were analyzed by Chi-square test, analysis of variance, and OR.

CONCLUSION

The present study showed that psychological distress with chronic underlying disease and antidepressant use are important elements in presenting multifood adverse reactions that we named here as the nocebo effect in IBS patients. Reducing psychological distress and managing chronic underlying diseases appear to be an effective factor in reducing the nocebo phenomenon in IBS patients. For managing the nocebo responses in IBS patients, these findings may help clinicians to improve their interventions. Further studies are required to confirm these findings.

The Biology of Placebo and Nocebo Effects on Experimental and Chronic Pain: State of the Art

(1) Background: In recent years, placebo and nocebo effects have been extensively documented in different medical conditions, including pain. The scientific literature has provided strong evidence of how the psychosocial context accompanying the treatment administration can influence the therapeutic outcome positively (placebo effects) or negatively (nocebo effects). (2) Methods: This state-of-the-art paper aims to provide an updated overview of placebo and nocebo effects on pain. (3) Results: The most common study designs, the psychological mechanisms, and neurobiological/genetic determinants of these phenomena are discussed, focusing on the differences between positive and negative context effects on pain in experimental settings on healthy volunteers and in clinical settings on chronic pain patients. Finally, the last section describes the implications for clinical and research practice to maximize the medical and scientific routine and correctly interpret the results of research studies on placebo and nocebo effects. (4) Conclusions: While studies on healthy participants seem consistent and provide a clear picture of how the brain reacts to the context, there are no unique results of the occurrence and magnitude of placebo and nocebo effects in chronic pain patients, mainly due to the heterogeneity of pain. This opens up the need for future studies on the topic.

Susceptibility to Nocebo Hyperalgesia, Dispositional Optimism, and Trait Anxiety as Predictors of Nocebo Hyperalgesia Reduction

OBJECTIVES

The current paper explores the psychological predictors of nocebo hyperalgesia and whether the reduction of nocebo hyperalgesia can be predicted by susceptibility to nocebo hyperalgesia and psychological characteristics.

METHODS

Nocebo effects on pressure pain were first experimentally induced in 83 healthy female participants through conditioning with open-label instructions about the pain-worsening function of a sham TENS device to assess susceptibility to nocebo hyperalgesia. Participants were then randomized to 1 out of 2 nocebo-reduction conditions (counterconditioning/extinction) or to continued nocebo-conditioning (control), each combined with open-label instructions about the new sham device function. Dispositional optimism, trait and state anxiety, pain catastrophizing, fear of pain, and body vigilance were assessed at baseline.

RESULTS

The results showed that lower optimism and higher trait anxiety were related to a stronger induction of nocebo hyperalgesia. Moreover, a stronger induction of nocebo hyperalgesia and higher trait anxiety predicted a larger nocebo reduction across interventions. Also, nocebo hyperalgesia and optimism moderated the effects of the nocebo-reduction interventions, whereby larger nocebo hyperalgesia and lower optimism were associated with a larger nocebo reduction after counterconditioning, compared with control, and also extinction for larger nocebo hyperalgesia.

DISCUSSION

Our findings suggest that open-label conditioning leads to stronger nocebo hyperalgesia when trait anxiety is high and dispositional optimism is low, while these psychological characteristics, along with larger nocebo hyperalgesia, also predict open-label counterconditioning to be an effective nocebo-reduction strategy. Susceptibility to nocebo hyperalgesia, trait anxiety, and dispositional optimism might be indicators of a flexible pain regulatory system.

Nocebo response in dentistry: A systematic review and meta-analysis of adverse events in analgesic trials of third molar removal

BACKGROUND

The nocebo response refers to the phenomenon where non-specific factors, including negative verbal suggestion and treatment expectations, cause adverse events (AE) following a placebo treatment. Non-specific factors are also likely to influence AE occurrence following administration of active pharmacological treatments.

OBJECTIVE

This meta-analysis aimed to estimate the nocebo response in dentistry by assessing the AEs prevalence in placebo- and active arms of randomised controlled trials (RCTs) assessing analgesic treatment following third molar (M3) surgery.

METHODS

A systematic search was performed in PubMed, Embase, Scopus, Web of Science and the Cochrane Central Register of Controlled Trials. Eligible studies had to report the number of patients experiencing at least one drug-related AE (patients with AE ≥ 1) separately for the active and placebo arms. The proportion of patients with AE ≥ 1 and drug-related dropouts were pooled, and risk differences (RDs) between patients in the placebo- and active arm were calculated.

RESULTS

In 50 independent RCTs of 47 identified articles, the pooled rates of patients with AE ≥ 1 were 22.8% in the placebo arm and 20.6% in the active arm. The pooled rates of drug-related dropout were 0.24% in the placebo arm and 0.08% in the active arm. There were no significant RDs in patients with AE ≥ 1 and drug-related dropouts.

CONCLUSION

These results show that patients in the placebo arm reported AEs to the same extent as patients receiving active treatment, suggesting that most AEs in analgesic medication following M3 surgery may be attributed to the nocebo phenomenon.

Can placebo and nocebo affect post-exercise executive function?

This study examined the placebo and nocebo effects of conditioning and induced expectations on executive function after acute aerobic exercise. The results showed that the benefits of exercise on executive function were influenced by both conditioning and induced expectations. Further, positive conditioning or expectations enhanced cognitive benefits, negative conditioning or expectations reduced cognitive benefits, but induced expectations on executive function were not moderated by conditioning. This study revealed and quantitively estimated the placebo and nocebo effects in improving executive function after acute aerobic exercise, providing evidence to advance the understanding of the cognitive benefits of exercise.

Complexity theory in the management of patients with musculoskeletal pain

Nonlinear systems are not susceptible to research with a reductionist approach. In this sense, the complexity theory provides an alternative approach to quantify the importance of contextual factors in patients with musculoskeletal pain. The use of positive (placebo) or negative (nocebo) contextual factors in the therapeutic setting could largely account for the non-specific component of treatment efficacy, directly affecting the quality of patients’ health-related outcomes (e.g., pain, disability, or satisfaction). In recent years, there has been a better understanding of the effects of contextual factors. However, the knowledge and awareness of them is limited and heterogeneous among physical therapists, reducing their translational value in the field of physiotherapy. The purpose of this essay is to describe the management of patients with musculoskeletal pain from the complexity theory perspective.

Why context matters when changing the diet: A narrative review of placebo, nocebo, and psychosocial context effects and implications for outcome research and nutrition counselling

Placebo (PE) and nocebo effects (NE) have been subjects of systematic research in medicine and psychotherapy for many decades to distinguish between the (specific) pharmacological effect of medication and the (unspecific) effect of the context. Despite this significant research, the awareness, operationalisation, and reflection of the multiplicity of PE, NE, and psychosocial context effects (PSCE) is currently limited when researching outcomes of diet changes in studies without randomisation and placebo control. This neglection is critical as it could systematically influence outcomes by moderating and mediating them and thus reducing the validity and evidence base of these studies. Therefore, we performed a (non-systematic) narrative review (NR) on the following objectives: (1) present a concise overview about the relevance of PE, NE, and PSCE in medicine and nutrition research; (2) review the current state of research on reflecting context effects when studying diet changes; (3) provide useful theoretical foundations via consideration and integration of micro- and macro context effects; (4) operationalise as hypotheses the potential PE, NE, and PSCE which are specific for researching diet changes; and (5) derive their impact for future research as well as for nutrition counselling. The electronic search in this NR for objective (2) identified N = 5 publications and for objective (4) we found N = 61 articles retrieved in the first round of search, additional references were identified by a manual and snowball search among the cited references resulting finally in N = 37. This NR offers a synoptical basis to foster awareness and operationalisation of a variety of PE, NE, and PSCE. Interdisciplinary research teams should monitor these factors using, e.g., qualitative, mixed-method studies, process evaluation, item bank approaches, moderator and mediator analysis that might reveal substantially new insights, and outcomes of relevance to science and nutrition counselling. Nevertheless, the present NR has several limitations, especially as it is non-systematic, because it is a very heterogeneous field of research, in which the topic we are investigating is usually regarded as marginal and subordinate. Therefore, future research should conduct systematic reviews and particularly theory-based primary studies (experimental research) on hypotheses of PE, NE, and PSCE in outcome research in diet changes.

Management of patients with statin intolerance

Atherosclerotic cardiovascular disease is a leading cause of morbidity and mortality, and statins have become a cornerstone in its treatment and prevention. Despite the well-documented benefits of statins, many patients stop taking them, with adverse muscle symptoms being a commonly cited reason. Although some statin-associated adverse muscle effects are real, some can be attributed to the nocebo effect, which is the patient's perception of harm. The purpose of this article is to review the literature on statin safety, particularly that related to muscle, to analyze adverse effects, and to propose various treatment strategies for the statin intolerant patient.

Optimized Informed Consent for Psychotherapy: Protocol for a Randomized Controlled Trial

Background

Informed consent is a legal and ethical prerequisite for psychotherapy. However, in clinical practice, consistent strategies to obtain informed consent are scarce. Inconsistencies exist regarding the overall validity of informed consent for psychotherapy as well as the disclosure of potential mechanisms and negative effects, the latter posing a moral dilemma between patient autonomy and nonmaleficence.

Objective

This protocol describes a randomized controlled web-based trial aiming to investigate the efficacy of a one-session optimized informed consent consultation.

Methods

The optimized informed consent consultation was developed to provide information on the setting, efficacy, mechanisms, and negative effects via expectation management and shared decision-making techniques. A total of 122 participants with an indication for psychotherapy will be recruited. Participants will take part in a baseline assessment, including a structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders-fifth edition (DSM-5) disorders. Eligible participants will be randomly assigned either to a control group receiving an information brochure about psychotherapy as treatment as usual (n=61) or to an intervention group receiving treatment as usual and the optimized informed consent consultation (n=61). Potential treatment effects will be measured after the treatment via interview and patient self-report and at 2 weeks and 3 months follow-up via web-based questionnaires. Treatment expectation is the primary outcome. Secondary outcomes include the capacity to consent, decisional conflict, autonomous treatment motivation, adherence intention, and side-effect expectations.

Results

This trial received a positive ethics vote by the local ethics committee of the Center for Psychosocial Medicine, University-Medical Center Hamburg-Eppendorf, Hamburg, Germany on April 1, 2021, and was prospectively registered on June 17, 2021. The first participant was enrolled in the study on August 5, 2021. We expect to complete data collection in December 2022. After data analysis within the first quarter of 2023, the results will be submitted for publication in peer-reviewed journals in summer 2023.

Conclusions

If effective, the optimized informed consent consultation might not only constitute an innovative clinical tool to meet the ethical and legal obligations of informed consent but also strengthen the contributing factors of psychotherapy outcome, while minimizing nocebo effects and fostering shared decision-making.

Trial Registration

PsychArchives; http://dx.doi.org/10.23668/psycharchives.4929

International Registered Report Identifier (IRRID)

DERR1-10.2196/39843

Informed Consent for Placebo-Controlled Trials: Do Ethics and Science Conflict?

The use of a placebo has been considered the best method for controlling bias in a prospective randomized clinical trial and provides the most rigorous test of treatment efficacy for evaluating a medical therapy. Placebos commonly produce clinically important effects particularly in studies where the primary outcomes are subjective. Yet the potential beneficial or harmful effects of placebos are often not addressed in designing a clinical trial, calculating the sample size, seeking consent, or interpreting clinical trial results. In this manuscript, we use an actual study to indicate three approaches that might be considered in seeking informed consent for placebo-controlled trials, and we explore the fundamental ethical and scientific complexities involved with each.

The Perception of Lactose-Related Symptoms of Patients with Lactose Malabsorption

Background: Dairy products are frequently considered responsible for post-prandial symptoms and are withdrawn from the diet, even against medical advice. We analysed the symptoms patients consider as lactose related; we also evaluated if psychological profile may affect the interpretation of the relationship between lactose and symptoms. Methods: In 268 patients undergoing lactose breath test, symptoms considered evoked by lactose intake were recorded and their severity measured. In the second part, symptom onset of 40 randomly selected patients was detected after both lactose and glucose breath test were blindly performed. Questionnaires evaluating anxiety, suggestibility and personality trait were administered. Key Results: Symptoms depending on functional gastrointestinal disorders or reflux disease were frequent in self-reported lactose-intolerant patients. In comparison with lactose malabsorption, these symptoms proved to be more frequent in patients with negative lactose breath test. The blinded administration of lactose and glucose demonstrated that a correct link between lactose intake and symptom onset was possible, only in 47.5% of the subjects, making this test inaccurate. None of the investigated psychological characteristics were different between patients with a nocebo response and patients not experiencing nocebo. Conclusions: Patients with self-reported lactose intolerance are frequently unaware about clinical presentation of this condition, and correct information is needed. The detection of symptom onset after lactose is an inaccurate test for lactose intolerance. Furthermore, the analysis of psychological characteristics of patients undergoing hydrogen breath test is not useful to select the subgroup at risk for a nocebo response. New strategies to diagnose lactose intolerance are mandatory.

Enhanced Instructed Fear Learning in Delusion-Proneness

Psychosis is associated with distorted perceptions and deficient bottom-up learning such as classical fear conditioning. This has been interpreted as reflecting imprecise priors in low-level predictive coding systems. Paradoxically, overly strong beliefs, such as overvalued beliefs and delusions, are also present in psychosis-associated states. In line with this, research has suggested that patients with psychosis and associated phenotypes rely more on high-order priors to interpret perceptual input. In this behavioural and fMRI study we studied two types of fear learning, i.e., instructed fear learning mediated by verbal suggestions about fear contingencies and classical fear conditioning mediated by low level associative learning, in delusion proneness—a trait in healthy individuals linked to psychotic disorders. Subjects were shown four faces out of which two were coupled with an aversive stimulation (CS+) while two were not (CS-) in a fear conditioning procedure. Before the conditioning, subjects were informed about the contingencies for two of the faces of each type, while no information was given for the two other faces. We could thereby study the effect of both classical fear conditioning and instructed fear learning. Our main outcome variable was evaluative rating of the faces. Simultaneously, fMRI-measurements were performed to study underlying mechanisms. We postulated that instructed fear learning, measured with evaluative ratings, is stronger in psychosis-related phenotypes, in contrast to classical fear conditioning that has repeatedly been shown to be weaker in these groups. In line with our hypothesis, we observed significantly larger instructed fear learning on a behavioural level in delusion-prone individuals (n = 20) compared to non-delusion-prone subjects (n = 23; n = 20 in fMRI study). Instructed fear learning was associated with a bilateral activation of lateral orbitofrontal cortex that did not differ significantly between groups. However, delusion-prone subjects showed a stronger functional connectivity between right lateral orbitofrontal cortex and regions processing fear and pain. Our results suggest that psychosis-related states are associated with a strong instructed fear learning in addition to previously reported weak classical fear conditioning. Given the similarity between nocebo paradigms and instructed fear learning, our results also have an impact on understanding why nocebo effects differ between individuals.

Shedding Light on SARS-CoV-2, COVID-19, COVID-19 Vaccination, and Auditory Symptoms: Causality or Spurious Conjunction?

There are reports of associations between SARS-CoV2, COVID-19, COVID-19 vaccines, and auditory symptoms (hearing difficulty, tinnitus). However, most studies have relied on self-report and lack baseline and/or non-COVID control groups. This makes it problematic to differentiate if symptoms are associated with SARS-CoV2, COVID-19, the vaccine, psychosocial factors or recall bias. In this study, we differentiate these by comparing hearing and tinnitus survey data collected pre- and during the pandemic. The survey conducted during the pandemic asked about the onset and change in three types of symptom. Type One—known association (loss of smell, memory/concentration issues, persistent fatigue), Type Two—indeterminate association (auditory symptoms), and Type Three—no established association with COVID-19 (toothache). We hypothesized that if auditory symptoms are directly associated with COVID-19, their onset and change would be similar to Type One symptoms, but if indirectly associated (reflecting psychosocial factors and/or recall bias) would be more similar to Type Three symptoms. Of the 6,881 individuals who responded, 6% reported confirmed COVID-19 (positive test), 11% probably had COVID-19, and 83% reported no COVID-19. Those with confirmed or probable COVID-19 more commonly reported new and/or worsened auditory symptoms than those not reporting COVID-19. However, this does not imply causality because: (1) new auditory symptoms coincided with COVID-19 illness among just 1/3 of those with confirmed or probable COVID-19, and another 1/3 said their symptoms started before the pandemic—despite reporting no symptoms in the pre-pandemic survey. (2) >60% of individuals who had COVID-19 said it had affected their Type 3 symptoms, despite a lack of evidence linking the two. (3) Those with confirmed COVID-19 reported more Type 1 symptoms, but reporting of Type 2 and Type 3 symptoms did not differ between those with confirmed COVID-19 and those without COVID-19, while those who probably had COVID-19 most commonly reported these symptom types. Despite more reports of auditory symptoms in confirmed or probable COVID-19, there is inconsistent reporting, recall bias, and possible nocebo effects. Studies that include appropriate control groups and use audiometric measures in addition to self-report to investigate change in auditory symptoms relative to pre-COVID-19 are urgently needed.

What is the role of placebo in neurotherapeutics?

INTRODUCTION

The widespread use of the word 'placebo' in the medical literature emphasizes the importance of this phenomenon in modern biomedical sciences. Neuroscientific research over the past thirty years shows that placebo effects are genuine psychobiological events attributable to the overall therapeutic context, and can be robust in both laboratory and clinical settings.

AREAS COVERED

Here the authors describe the biological mechanisms and the clinical implications of placebo effects with particular emphasis on neurology and psychiatry, for example in pain, movement disorders, depression. In these conditions, a number of endogenous systems have been identified, such as endogenous opioids, endocannabinoids, and dopamine, which contribute to the placebo-induced benefit.

EXPERT OPINION

Every effort should be made to maximize the placebo effect and reduce its evil twin, the nocebo effect, in medical practice. This does not require the administration of a placebo, but rather the enhancement of the effects of pharmacological and nonpharmacological treatments through a good doctor-patient interaction.

The Role of Expectation and Beliefs on the Effects of Non-Invasive Brain Stimulation

Non-invasive brain stimulation (NIBS) techniques are used in clinical and cognitive neuroscience to induce a mild magnetic or electric field in the brain to modulate behavior and cortical activation. Despite the great body of literature demonstrating promising results, unexpected or even paradoxical outcomes are sometimes observed. This might be due either to technical and methodological issues (e.g., stimulation parameters, stimulated brain area), or to participants’ expectations and beliefs before and during the stimulation sessions. In this narrative review, we present some studies showing that placebo and nocebo effects, associated with positive and negative expectations, respectively, could be present in NIBS trials, both in experimental and in clinical settings. The lack of systematic evaluation of subjective expectations and beliefs before and after stimulation could represent a caveat that overshadows the potential contribution of placebo and nocebo effects in the outcome of NIBS trials.

Adverse events of active and placebo groups in SARS-CoV-2 vaccine randomized trials: A systematic review

Background

For safety assessment in clinical trials, adverse events (AEs) are reported for the drug under evaluation and compared with AEs in the placebo group. Little is known about the nature of the AEs associated with clinical trials of SARS-CoV-2 vaccines and the extent to which these can be traced to nocebo effects, where negative treatment-related expectations favor their occurrence.

Methods

In our systematic review, we compared the rates of solicited AEs in the active and placebo groups of SARS-CoV-2 vaccines approved by the Western pharmaceutical regulatory agencies.We implemented a search strategy to identify trial-III studies of SARS-CoV-2 vaccines through the PubMed database. We adopted the PRISMA Statement to perform the study selection and the data collection and identified three trial: two mRNA-based (37590 participants) and one adenovirus type (6736 participants).

Findings

Relative risks showed that the occurrence of AEs reported in the vaccine groups was higher compared with the placebo groups. The most frequently AEs in both groups were fatigue, headache, local pain, as injection site reactions, and myalgia. In particular, for first doses in placebo recipients, fatigue was reported in 29% and 27% in BNT162b2 and mRNA-1273 groups, respectively, and in 21% of Ad26.COV2.S participants. Headache was reported in 27% in both mRNA groups and in 24% of Ad26.COV2.S recipients. Myalgia was reported in 10% and 14% in mRNA groups (BNT162b2 and mRNA-1273, respectively) and in 13% of Ad26.COV2.S participants. Local pain was reported in 12% and 17% in mRNA groups (BNT162b2 and mRNA-1273, respectively), and in 17% of Ad26.COV2.S recipients. These AEs are more common in the younger population and in the first dose of placebo recipients of the mRNA vaccines.

Interpretation

Our results are in agreement with the expectancy theory of nocebo effects and suggest that the AEs associated with COVID-19 vaccines may be related to the nocebo effect.

Funding

Fondazione CRT - Cassa di Risparmio di Torino, IT (grant number 66346, "GAIA-MENTE" 2019).

The Nocebo Effect and Informed Consent-Taking Autonomy Seriously

The nocebo effect, a phenomenon whereby learning about the possible side effects of a medical treatment increases the likelihood that one will suffer these side effects, continues to challenge physicians and ethicists. If a physician fully informs her patient as to the potential side effects of a medicine that may produce nocebogenic effects, which is usually conceived of as being a requirement associated with the duty to respect autonomy, she risks increasing the likelihood that her patient will experience these side effects and therefore suffer (unnecessary) harm, a violation of the duty of nonmaleficence. If, on the other hand, she intentionally withholds side effect information in an effort to protect her patient from suffering unnecessary harm from side effects, which is consistent with the duty of nonmaleficence, she violates the duty to respect patient autonomy. In this paper, the author discusses several previous attempts to deal with the nocebo effect and explains their weaknesses. He then proposes a means of managing the nocebo effect and argues that it does not share the weaknesses found in previous approaches. He concludes with a discussion of a simple, yet practical tool that might help clinicians manage the tension resulting from the nocebo effect.

The Great Debate With IBD Biosimilars: Con: Biosimilars Should Not Be Routinely Used as a First Line Biologic and Not Switched From Reference Biologics

The costs associated with biologic therapy in immune-mediated diseases, including inflammatory bowel disease has steadily increased since their introduction over 2 decades ago. The introduction of biosimilars has the promise of cost savings and putting reimbursement pressure on future market entries. However, the interpretation of evidence to support the use of biosimilars either as first line or as part of a nonmedical switch strategy is not straight forward due to low to very low-quality evidence. In particular, switching to a biosimilar is associated with both clinical, ethical, and possibly medicolegal issues. Due to these factors, solutions to address cost efficiency should involve an open, transparent, and collaborative dialogue among the various stakeholders and if at all possible involve strategies that allow patients to remain on originator biologics.

Experiencing COVID-19 symptoms without the disease: The role of nocebo in reporting of symptoms

Background:

A nocebo effect occurs when inactive factors lead to worsening of symptoms or reduce treatment outcomes. Believing that one is or has been infected with COVID-19 may act as a nocebo. However, not much is known about potential nocebo effects associated with the reporting of COVID-19 symptoms.

Aim:

An online survey investigated whether certainty of being infected with COVID-19, age, sex, cognitive, emotional and personality factors were associated with perceived severity of COVID-19 symptoms.

Methods:

Participants (N=375) filled out an online survey containing 57 questions asking about symptoms resembling COVID-19, certainty of being infected with COVID-19, anxiety, stress and personality dimensions.

Results:

Certainty of being infected with COVID-19 and anxiety predicted 27% of the variance in reporting of COVID-like symptoms. The mediation analysis showed that both higher certainty of being infected and anxiety independently predicted increased reports of COVID-like symptom. Females had higher anxiety and stress levels, and reported more COVID-like symptoms than males did. Older age was not associated with reporting COVID-like symptoms.

Conclusions:

Believing to be infected with COVID-19, along with anxiety, can enhance the severity of COVID-like symptoms. Thus, the nocebo effect was due to both cognitive and emotional factors and was higher in females.

Safety and Effectiveness of an In-Hospital Screening Station for Coronavirus Disease 2019 in Response to the Massive Community Outbreak

Purpose

To evaluate the results of operating an in-hospital coronavirus disease 2019 screening station on an outpatient basis and to identify the effectiveness and necessity of such a screening station.

Patients and Methods

This cross-sectional study included 1345 individuals who were tested for COVID-19 using real-time reverse transcription polymerase chain reaction (RT-PCR) at an in-hospital screening station on an outpatient basis. The subjects were healthcare workers (HCWs) with suspected COVID-19 symptoms or exposure to patients with confirmed COVID-19, caregivers at the hospital for complete enumeration, and patients who were scheduled to be admitted to a nonrestricted area in the hospital or to visit for outpatient treatment, but had suspected COVID-19 symptoms. The subjects were divided and compared as follows: HCW versus non-HCW groups and RT-PCR positive versus negative groups.

Results

A total of 140 had symptoms, 291 wanted to be tested, and 664 were asymptomatic but were screened. Seven subjects had positive results for COVID-19. Compared with the non-HCWs, the HCWs were younger and had a lower rate of underlying medical conditions. In addition, there were more women, individuals with exposure to confirmed cases, and individuals with symptoms or those who just wanted to be tested. The frequency of all symptoms was high among the HCWs. The results of the logistic regression analysis showed that the HCWs were significantly associated with the presence of symptoms, having an odds ratio of 23.317 (confidence interval, 15.142-35.907L; P < 0.001). The positive group had a high rate of exposure to patients with confirmed COVID-19 and had more subjects with symptoms or those who wanted to be tested.

Conclusion

In-hospital screening stations are a relatively safe way to protect and support HCWs and to reduce and manage the spread of infection within the hospital effectively during an outbreak in the community.

How do nocebo effects in placebo groups of randomized controlled trials provide a possible explicative framework for the COVID-19 pandemic?

Introduction: Randomized clinical trials (RCTs) are useful to study the role of individual and contextual factors in which therapies vs placebos are administered and to provide an important perspective for understanding the phenomenon of nocebo-related risks.Areas covered: The results of nocebo effects in RCT placebo groups, measured in terms of adverse events (AEs) and dropouts, will be presented as an explicative framework for the COVID-19 pandemic. Currently, SARS-CoV-2 vaccines are the only RCTs routinely conducted during the pandemic. Information about efficacy and safety of different vaccines represents a fertile ground for nocebo phenomena. Individual and contextual factors will be emphasized in order to understand the presence of a refusal of immunization associated with a specific vaccine considered less effective and safe. Critical aspects and some guidelines will be presented in order to counteract the nocebo effects and to improve adherence to drug treatments and the vaccination campaign.Expert opinion: The nocebo effect could explain the presence of strong resistance in European countries to immunization with a vaccine perceived as less effective, compared to others. Increased awareness of the nocebo effect would be relevant as it could lead to a greater participation in the vaccination campaign and in protecting individuals against SARS-CoV-2 infection.

Nocebo-Hypothesis Cognitive Behavioral Therapy (NH-CBT) for Persons With Functional Neurological Symptoms (Motor Type): Design and Implementation of a Randomized Active-Controlled Trial

Introduction: Functional Neurological Symptom Disorders (FNSD) are associated with high levels of disability and immense direct and indirect health costs. An innovative interdisciplinary rehabilitation approach for individuals with functional neurological symptoms of motor type–Nocebo-Hypothesis Cognitive Behavioral Therapy (NH-CBT)—combines CBT and movement retraining with video feedback embedded in a comprehensive explanatory model of the etiology of FNSD.

Methods: This protocol describes the development and implementation of a phase II, parallel group, randomized controlled trial with blinded outcome assessors to compare the efficacy of NH-CBT with an active control condition (supportive counseling and movement retraining). Individuals meeting diagnostic criteria of an FNSD or psychogenic movement disorder will be randomly assigned to one of the 8-week interventions. Self-report scales of motor and other physical symptoms, symptom-related psychological variables, and assessor ratings of participants' mobility will be administered at baseline, and at 8- and 16-week follow-up. Adverse events will be monitored across all sessions and therapeutic alliance will be measured at the end of therapy. The primary statistical analysis will test the hypothesis that NH-CBT is more effective than the control intervention at the 8-week follow-up.

Discussion: The therapeutic strategies of NH-CBT are theory-driven by assumptions of the predictive coding model of the etiology of FNSD. Strengths and limitations of this trial will be discussed.

Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR; identifier: ACTRN12620000550909).

Examining the Nocebo Effect of Statins Through Statin Adverse Events Reported in the Food and Drug Administration Adverse Event Reporting System

BACKGROUND

This study aimed to evaluate whether the high frequency of reported statin adverse effects (AEs) may be associated with the nocebo effect. We compared nocebo-related subjective AEs with objective AEs and investigated factors potentially associated with the nocebo effect.

METHODS

A retrospective cohort study was conducted using the Food and Drug Administration Adverse Event Reporting System between January 2010 and December 2019 for statins, including, atorvastatin, lovastatin, pravastatin, rosuvastatin, and simvastatin. Subjective AEs included fatigue, subjective muscular, and nervous system AEs. Objective AEs were defined as hepatic and objective muscular AEs. We compared the number of subjective and objective AEs using the Mann-Whitney U test and examined trends in the frequency of subjective versus objective reports over time using linear regression with interaction terms. We evaluated the association between AEs and gender and country using linear regression. Quantitative detection of signals was estimated using proportional reporting ratio and reporting odds ratio for simvastatin.

RESULTS

Of 2 994 487 overall AE reports, more subjective than objective AEs were reported per quarter (mean±SD: 4777±1375.45 versus 999±276.95; P<0.0001), and over time during the study period (P<0.001). Women reported more subjective AEs than men per quarter (fatigue: 86.98 more per quarter, P=0.035; subjective muscular AE: 417.95, P<0.0001; nervous system AE: 273.60, P<0.0001), but fewer objective muscular AEs (-125.23 per quarter, P<0.0001). More subjective AEs and fewer objective AEs were reported per quarter in the United States relative to other countries. Simvastatin-associated reports showed signals for higher objective muscular AEs relative to all other statins (reporting odds ratio, 1.53 [95% CI, 1.49-1.58]).

CONCLUSIONS

This study found that significantly more subjective than objective AEs are reported for statins. Subjective statin AEs, potentially related to the nocebo effect are reported more often by women than by men, and in the United States than in other countries.

What Physiotherapists Specialized in Orthopedic Manual Therapy Know About Nocebo-Related Effects and Contextual Factors: Findings From a National Survey

Objective

The aim of this study was to investigate the knowledge of orthopedic manual therapists (OMTs) regarding context factors (CFs) capable of triggering nocebo effects during the treatment and how this knowledge is related to their socio-demographic features.

Design

A cross-sectional online survey.

Setting

National.

Main Outcome Measures

A 20 items questionnaire composed by open-ended and closed single-choice questions was administered to explore: (a) socio-demographic variables (10 questions); (b) the relation between different CFs and nocebo-related effects (2 questions); and (c) the knowledge of participants about nocebo-related effects and how they managed them in the clinical practice (8 questions).

Participants

1288 OMTs were recruited from the database of the Master in Rehabilitation of Musculoskeletal Disorders (MRDM) of the University of Genova from March to May 2019. Inclusion criteria were: (a) to possess a valid email account; (b) to understand and use as a native language the Italian; (c) to be graduated as OMTs; and (d) to be employed as physiotherapists specialized-OMTs during the survey.

Results

791 responses were received (61.4%); 473 of them were male (59.8%), with an average age of 31.0 ± 7.1 years. OMTs defined nocebo-related effects as the psychosocial context effects around therapy and patient with specific biological bases (72.2%). OMTs know that their clinical practice is pervaded by nocebo-related effects (42.5%), triggered by CFs. Participants communicated nocebo-related effects balancing the positive features of the therapy with the negative ones (50.9%), during the decision of the therapeutic plan (42.7%). They reported associative learning as the main mechanism involved in nocebo-related effects (28.8%). OMTs taught and trained patient’s strategies to manage nocebo-related effects (39.6%) through an evaluation and correction of patient’s anxieties, doubts and expectations (37.7%). OMTs most frequently considered themselves to have a “medium” education about nocebo-related effects (48.2%) and that their management should be taught during bachelor (78.6%).

Conclusion

OMTs believed that nocebo-related effects were present in their clinical practice and that they can be triggered by CFs.

Biosimilar switching in inflammatory bowel disease: from evidence to clinical practice

INTRODUCTION

After patents' expiration of biological originators, several biosimilars of infliximab and adalimumab have been authorized. The approval is based on data extrapolated from other indications for which the originator has been previously tested. Despite rigorous approval processes by regulatory entities, physicians' and patients' knowledge about biosimilars is limited and some concerns about their use persist.

AREAS COVERED

This article summarizes the evidence on efficacy, safety, and immunogenicity of biosimilars currently approved in Europe for IBD treatment, by reviewing the literature on PubMed, EMBASE, and Web of Science databases up to mid-July 2020. Particular emphasis was placed on the need to further improve communication with patients and physicians' knowledge on biosimilars.

EXPERT OPINION

Adoption of biosimilars in clinical practice represents a great opportunity from an economic point of view, reducing healthcare costs and increasing patients' access to effective biologic treatments. Clinicians should be aware and confident of the latest evidence on available biosimilars and be very careful in communicating information to patients. Nocebo effect should not be overlooked since it can negatively influence outcomes of biosimilar-treated subjects, limiting the wide use of biosimilars. Evaluating the outcomes of reverse, multiple, and cross-switch will be a challenge for the next years.

Nocebo effect and biosimilars in inflammatory bowel diseases: what's new and what's next?

INTRODUCTION

The use of biosimilars for the treatment of patients with chronic inflammatory bowel diseases (IBD) showed to be a valid strategy to reduce the economic burden of biologics on health-care costs and to increase patient access to treatment. However, the nocebo effect constitutes an important limitation to the wide use of biosimilars.

AREAS COVERED

We conducted a literature overview to summarize information on nocebo effect in IBD population and to provide physicians with practical key strategies to prevent the nocebo effect in daily clinical practice and to improve patients' outcomes.

EXPERT OPINION

Despite the proven efficacy and safety of biosimilars, further clinical studies are needed to define the effects of reverse and multiple switches in the management of patients with IBD. The development of new subcutaneous formulations, better accepted by patients, could contribute to reduce patients' negative expectations, and limit the nocebo effect.

A systematic review of factors associated with side-effect expectations from medical interventions

BACKGROUND

Fear of side-effects can result in non-adherence to medical interventions, such as medication and chemotherapy. Side-effect expectations have been identified as strong predictors of later perception of side-effects. However, research investigating predictors of side-effect expectations is disparate.

OBJECTIVE

To identify factors associated with side-effect expectations.

SEARCH STRATEGY

We systematically searched Embase, Ovid MEDLINE, Global Health, PsycARTICLES, PsycINFO, Web of Science and Scopus.

INCLUSION CRITERIA

Studies were included if they investigated associations between any predictive factor and expectations of side-effects from any medical intervention.

DATA EXTRACTION AND SYNTHESIS

We extracted information about participant characteristics, medication, rates of side-effects expected and predictors of side-effect expectations. Data were narratively synthesized.

MAIN RESULTS

We identified sixty-four citations, reporting on seventy-two studies. Predictors fell into five categories: personal characteristics, clinical characteristics, psychological traits and state, presentation format of information, and information sources used. Using verbal risk descriptors (eg 'common') compared to numerical descriptors (eg percentages), having lower quality of life or well-being, and currently experiencing symptoms were associated with increased side-effect expectations.

DISCUSSION AND CONCLUSIONS

Decreasing unrealistic side-effect expectations may lead to decreased experience of side-effects and increased adherence to medical interventions. Widespread communications about medical interventions should describe the incidence of side-effects numerically. Evidence suggests that clinicians should take particular care with patients with lower quality of life, who are currently experiencing symptoms and who have previously experienced symptoms from treatment. Further research should investigate different clinical populations and aim to quantify the impact of the media and social media on side-effect expectations.

Can insights from placebo and nocebo mechanisms studies improve the randomized controlled trial?

Background and aims The randomized controlled trial (RCT) is currently facing several challenges, one of these being that the placebo response appears to be increasing in RCTs, thereby making it difficult to demonstrate an effect of potentially new treatments over placebo. This problem has primarily been approached by predicting the magnitude of the placebo response via stable factors, such as demographic variables, and/or by developing complex designs aimed at reducing the placebo response in the hope that it will improve the test of the active treatment. Yet, the success of this approach has so far been limited. Methods A new approach toward improving the RCT is put forward based on placebo and nocebo mechanism studies, i.e. studies that investigate the mechanisms underlying placebo analgesia and nocebo hyperalgesia. In a series of meta-analyses the magnitude of placebo and nocebo effects were determined. Experimental studies across nociplastic and neuropathic pain conditions and across pharmacological and acupuncture treatments investigated psychological and neurobiological mechanisms underlying these effects. The obtained results were used to make approximations of expectations to see if that could predict the placebo response in RCTs and function as a new way of tapping into the placebo component of treatment effects. Results The magnitude of placebo and nocebo effects is large and highly variable. Placebo effects exist across chronic pain conditions with varying degrees of known etiology as well as across pharmacological and non-pharmacological treatments. Patients' perception of the treatment, the verbal suggestions given for pain relief, and the patients' expectations toward pain relief contribute to the magnitude of the placebo effect and to pain relief following placebo interventions. Also, unintentional unblinding and patients' perception of a treatment markedly influence the treatment outcome. By making approximations of expectations toward treatment effects it was possible to predict the magnitude of the placebo response in RCTs. Conclusions and implications The new approach of tapping into or directly asking patients about their perception and expectations toward a treatment, along with the account of the natural history of pain, has the potential to improve the information that can be obtained from RCTs. Thus, by interfacing insights from placebo and nocebo mechanism studies, it may be possible to enhance the information that can be obtained from RCTs and to account for a large part of the variability in the placebo component of the overall treatment effect. This approach has the potential to improve the scientific evaluation of treatments, as well as to illustrate how the effect of treatments can be optimized in clinical practice, which is the crux of evidence-based medicine.

Understanding and Preventing Health Concerns About Emerging Mobile Health Technologies

New technologies and innovations have often improved population well-being and societal function; however, these are also often initially accompanied by worry and fear. In some cases, such worries can impede, or even prevent entirely, the adoption of the technology. Mobile health (mHealth), a discipline broadly focused on employing ambulatory technologies to improve the affordability, reach, and effectiveness of health promotion and clinical intervention approaches, offers new innovations and opportunities. Despite emerging evidence supporting mHealth efficacy (eg, for improving health outcomes), some individuals have concerns about mHealth technology that may impede scalability, efficacy, and, ultimately, the public health benefits of mHealth. We present a review and conceptual framework to examine these issues, focusing on three overarching themes: biophysiological, psychological, and societal concerns. There are features of mHealth that lead to worries about the potential negative effects on an individual’s health (eg, due to exposure to electromagnetic or radio waves), despite evidence supporting the safety of these technologies. When present, such beliefs can lead to worry that gives rise to the experience of unpleasant and concerning physical symptoms—the nocebo effect. This may represent an important implementational barrier because of apprehension toward beneficial mHealth products (or features thereof, such as wireless charging, wearable or implantable sensors, etc) and may also have broader ramifications (eg, leading to economic, governmental, and legislative actions). In addition to reviewing evidence on these points, we provide a broad three-step model of implementation research in mHealth that focuses on understanding and preventing health concerns to facilitate the safe and effective scalability of mHealth (and that may be generalizable and applied to similar technologies): (1) evaluating and better discerning public perceptions and misperceptions (and how these may differ between populations), (2) developing theory-based public health communication strategies regarding the safety of mHealth, and (3) disseminating this messaging using evidence-based methods. Collectively, these steps converge on reviewing evidence regarding the potential role of worry and nocebo in mHealth and providing a model for understanding and changing attitudes and preventing unfounded negative perceptions related to mHealth technology.

Just Say No…to the Nocebo Effect

Biosimilars are highly similar products of an innovator biologic used to decrease costs. The nocebo effect is an increase in symptoms resulting from a patient’s negative perceptions about a biosimilar. Multistep notification, organized transition, and opt-out ability constitute a framework for switching patients from a reference product to a biosimilar.

Effects of Oxytocin on Placebo and Nocebo Effects in a Pain Conditioning Paradigm: A Randomized Controlled Trial

Oxytocin has been shown to increase trust, decrease anxiety, and affect learning as has been observed in conditioning paradigms. Trust, anxiety, and learning are important factors that influence placebo effects. In this study, we investigated whether oxytocin can increase placebo analgesia, decrease nocebo hyperalgesia, and influence extinction processes of both. Eighty male volunteers were assigned to a 40 IU of oxytocin nasal spray group, or to a placebo control group. Placebo analgesia and nocebo hyperalgesia were induced by a conditioning procedure in combination with verbal suggestions. The results demonstrate that the conditioning procedure successfully elicited significant placebo analgesia and nocebo hyperalgesia responses (P < .001). Furthermore, extinction was observed (P < .001), although placebo and nocebo responses did not return to baseline and remained significant. Oxytocin did not influence placebo analgesia or nocebo hyperalgesia and had no effect on extinction. This study provides support against the placebo-boosting effects of oxytocin and was the first one to demonstrate that it also did not influence nocebo effects or extinction processes, however, these results pertain to only a male sample. As managing placebo and nocebo effects has widespread clinical implications, further research should investigate other neurobiological or behavioral pathways to boost placebo and decrease nocebo effects. PERSPECTIVE: The present study demonstrated that placebo analgesia and nocebo hyperalgesia can be successfully induced by conditioning and verbal suggestions. We could not confirm the hypothesis that oxytocin affects either of these phenomena. Other pharmacological agents and behavioral manipulations for increasing placebo and decreasing nocebo effects should be investigated.

Conditioned Placebo- and Nocebo-Like Effects in Adolescents: The Role of Conscious Awareness, Sensory Discrimination, and Executive Function

Background: Conditioning is a key mechanism of placebo and nocebo effects in adults. Little is known about the underlying mechanisms of placebo and nocebo effects in youth and how they might be influenced by conscious awareness and cognitive abilities. In this study, the role of conditioning on thermal perception in youth was investigated. Methods: Differences in thermal ratings were assessed in response to consciously and non-consciously perceived cues that were conditioned to either low or high heat. Furthermore, we tested whether executive function mediates the effect of conditioning on thermal perception. Thirty-five high-school students (14-17 years) completed an executive function task and underwent a sensory perception paradigm. In a conditioning phase, two distinct neutral faces (conditioned cues) were coupled to either a low or a high temperature stimulus delivered to participants' forearms. In a testing phase, the conditioned cues, and novel faces (non-conditioned control cues), were paired with identical moderate thermal stimuli. In this testing phase, for half of the participants cues were presented consciously (supraliminally) and for the other half non-consciously (subliminally). Results: We found a significant main effect of cue type on thermal ratings (p = 0.003) in spite of identical heat being administered following all cues. Post-hoc analyses indicated that the nocebo-like effect (conditioned high cue compared to control) was significant (p = 0.027); the placebo-like effect (conditioned low cue compared to control) was non-significant. No difference between cues presented supra- vs. subliminally and no significant interaction effects were found. The association between sensory discrimination and the magnitude of the nocebo-like effect was mediated by executive function. Conclusions: To our best knowledge, this is the first study establishing a relationship between thermal perception, nocebo effects, and executive function in youth. Our results may have important implications for understanding cognitive/ learning processes involved in nocebo effects.

"Placebo by Proxy" and "Nocebo by Proxy" in Children: A Review of Parents' Role in Treatment Outcomes

The "placebo (effect) by proxy" (PbP) concept, introduced by Grelotti and Kaptchuk (1), describes a positive effect of a patient's treatment on persons in their surrounding such as family members or healthcare providers, who feel better because the patient is being treated. The PbP effect is a complex dynamic phenomenon which attempts to explain a change in treatment outcome arising from an interaction between a patient and an effect from proxies such as parents, caregivers, physicians or even the media. By extension the effect of the proxy can also have a negative or adverse effect whereby a proxy feels worse when a patient is treated, giving rise to the possibility of a "nocebo (effect) by proxy" (NbP), and by extension can influence a patient's treatment response. While this has yet to be systematically investigated, such an effect could occur when a proxy observes that a treatment is ineffective or is perceived as causing adverse effects leading the patient to experience side effects. In this narrative review, we take these definitions one step further to include the impact of PbP/NbP as they transform to affect the treatment outcome for the patient or child being treated, not just the people surrounding the individual being treated. Following a systematic search of literature on the subject using the Journal of Interdisciplinary Placebo Studies (JIPS) database (https://jips.online) and PubMed (NCBI) resulted in very few relevant studies, especially in children. The effect of PbP per se has been studied in parents and their children for temper tantrums, acupuncture for postoperative symptoms, as well as for neuroprotection in very preterm-born infants. This paper will review the PbP/NbP concepts, show evidence for its presence in children's treatment outcome and introduce clinical implications. We will also offer suggestions for future research to further our understanding of the role of the proxy in promoting or distracting from treatment benefit in children. Increasing an appreciation of the PbP and NbP phenomena and the role of the proxy in children's treatment should improve research study design and ultimately harness them to improve clinical child healthcare.

The Clinical Implications of Nocebo Effects for Biosimilar Therapy

Nocebo effects encompass negative responses to inert interventions in the research setting and negative outcomes with active treatments in the clinical research or practice settings, including new or worsening symptoms and adverse events, stemming from patients' negative expectations and not the pharmacologic action of the treatment itself. Numerous personality, psychosocial, neurobiological, and contextual/environmental factors contribute to the development of nocebo effects, which can impair quality of life and reduce adherence to treatment. Biologics are effective agents widely used in autoimmune disease, but their high cost may limit access for patients. Biosimilar products have gained regulatory approval based on quality, safety, and efficacy comparable to that of originator biologics in rigorous study programs. In this review, we identified gaps in patients' and healthcare professionals' awareness, understanding, and perceptions of biosimilars that may result in negative expectations and nocebo effects, and may diminish their acceptance and clinical benefits. We also examined features of nocebo effects with biosimilar treatment that inform research and clinical practices. Namely, when biosimilars are introduced to patients as possible treatment options, we recommend adoption of nocebo-reducing strategies to avoid negative expectations, including delivery of balanced information on risk-benefit profiles, framing information to focus on positive attributes, and promoting shared decision-making processes along with patient empowerment. Healthcare professionals confident in their knowledge of biosimilars and aware of bias-inducing factors may help reduce the risk of nocebo effects and improve patients' adherence in proposing biosimilars as treatment for autoimmune diseases such as rheumatoid arthritis and inflammatory bowel disease.

Nocebo in Biosimilars and Generics in Neurology: A Systematic Review

Background: Nocebo refers to adverse events related to patients’ negative expectations and previous experiences, mediated by several neurobiological pathways within the brain. It is common among neurological patients and affects adherence and treatment outcomes, representing a real clinical challenge.

Methods: We conducted a systematic search based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines in MEDLINE database, using several keywords for studies that can be processed to investigate the magnitude of nocebo in generics and biosimilars used in the most common neurological diseases. The aim was to estimate its size and suggest strategies to minimize its prevalence in clinical trials and practice.

Results: Of a total of 2,606 identified articles, after criteria-based selection, 35 studies were included for analysis. Overall, there was vast heterogeneity across the studies concerning population, study design, and outcomes. Nocebo response could be estimated only in one double-blind randomized trial of generic glatiramer acetate in relapsing remitting multiple sclerosis that included a placebo arm. In this trial, no significant differences observed between the three arms (innovator, bioequivalent, and placebo) in favorable and unfavorable outcomes. In the open-label phase of the trial, an increased withdrawal rate was recorded in patients switched from placebo to bioequivalent (8.4%) that may be related to nocebo. In other open-label and real-world studies evaluating biosimilars or generics for brain disorders, a similar indirect nocebo effect is assuming by several investigators. Also, knowledge gaps between health-care providers and patients exist towards generics and biosimilars.

Conclusions: Despite its presence, the true burden of the nocebo response and effect cannot be accurately estimated in existing studies with generics and biosimilars in neurological diseases. Targeted strategies for clinical trials’ design are needed in order to measure the exact nocebo’s size.