Placebo-psychotherapy combinations: Inappropriate representations of psychotherapy in drug-psychotherapy comparative trials.

Abstract

In studies comparing drugs with psychotherapy, the practice of using placeboplus-psychotherapy combinations to represent psychotherapy has been extensive, totaling 78% of all comparisons. Such a procedure is seen in this article as being unjustifiable. These combinations involve potential additive or interactive effects derived from the patient's or the therapist's perception that the patient is receiving an active medication. This perception renders this condition nonrepresentative of psychotherapy as it is typically practiced, Further, these combinations (in the absence of a psychotherapy-alone cell) are logically incapable of providing the controls that are necessary to rule out the existence of drug taking by psychotherapy interactions, precisely the hypothesis that their inclusion is intended to test. Finally, a review of the existing drug-psychotherapy literature points to bidirectionality in the noncomparability of placebo plus psychotherapy relative to psychotherapy alone. That is, the combination may sometimes overestimate, but appears more typically to underestimate, the efficacy of psychotherapy alone. Suggestions are provided for the appropriate selection of control conditions in drug-psychotherapy comparisons,

Cognitive-behavioral issues in the treatment and management of chronic daily headache

“…It is unclear why poorer results were obtained with the combined treatment than the biofeedback training alone. However, some investigators have cautioned that patients who receive combined pharmacologic and nonpharmacologic treatment attribute their improvement to pharmacotherapy and may discontinue or limit their use of self-regulation skills, thereby limiting the efficacy of the combined treatment [24].…”

Dynamics of Changes in Self-Efficacy and Locus of Control Expectancies in the Behavioral and Drug Treatment of Severe Migraine

“…On the other hand, drug therapy, at least when successful, might be expected to decrease chance headache locus of control and increase medical professionals headache locus of control. However, drug therapy also has been postulated to undermine internal headache locus of control [28]. Unfortunately, empirical data bearing on these hypotheses for migraine treatment is lacking.…”

Defining empirically supported therapies.

“…In such a case, exposure instructions would be beneficial, but only in the context of the morale boost from the placebo. Thus, in the absence of a fifth cell in which patients receive only psychological treatment, confident conclusions about the efficacy of the psychological intervention are precluded (for a further discussion of these issues, see Hollon & DeRubeis, 1981 ).…”