Placebos in Clinical Practice: Comparing Attitudes, Beliefs, and Patterns of Use between Academic Psychiatrists and Nonpsychiatrists

Abstract

Controversial and ethically tenuous, the use of placebos is central to medicine but even more pivotal to psychosocial therapies. Scholars, researchers, and practitioners largely disagree about the conceptualization of placebos. While different professionals often confound the meanings of placebo effects with placebo responses, physicians continue to prescribe placebos as part of clinical practice. Our study aims to review attitudes and beliefs concerning placebos outside of clinical research. Herein we compare patterns of placebo use reported by academic psychiatrists with those reported by physicians from different specialties across Canadian medical schools. Using a web-based tool, we circulated an online survey to all 17 Canadian medical schools, with a special emphasis on psychiatry departments therein and in university-affi liated teaching hospitals. A variation on earlier efforts, our 5-minute, 21-question survey was anonymous. Among the 606 respondents who completed our online survey, 257 were psychiatrists. Our analysis revealed that psychiatrists prescribed signifi cantly more subtherapeutic doses of medication than physicians in other specialties, although about 20% of both psychiatrists and nonpsychiatrists prescribed placebos regularly as part of routine clinical practice. However, compared with 6% of nonpsychiatrists, only 2% of psychiatrists deemed placebos of no clinical benefi t. In addition, more than 60% of psychiatrists either agreed or strongly agreed that placebos had therapeutic effects relative to fewer than 45% of other practitioners. Findings from this pan-Canadian survey suggest that, compared with other physicians, psychiatrists seem to better value the infl uence placebos wield on the mind and body and maintain more favourable beliefs and attitudes toward placebo phenomena. Can J Psychiatry. 2011;56(4):198-208. Highlights• Most physicians acquiesce to the effects of placebos, yet they seem equivocal regarding a common placebo description.• Probably because they construe them as therapeutic, psychiatrists seem to administer signifi cantly more subtherapeutic doses of medication, compared with nonpsychiatrists.• Our fi ndings likely represent a valuable contribution to preliminary investigations of placebo use among physicians and their beliefs about placebo mechanisms and effectiveness.

What do we really know about the deliberate use of placebos in clinical practice?

“…They were undertaken between 1993 and 2011 in Sweden,8 Denmark,9 Israel,10 Switzerland,11 Canada,12 New Zealand,13 Germany (two studies)4 14 and the US (four studies) 3 15–17. A total of 11 studies were published as scientific articles in peer-reviewed journals, and 1 study13 was published as a letter.…”

“…It could be narrow and resemble the standard understanding of placebos in the research context: ‘… an inactive substance administered to a patient in place of a medication’ 15. Or it could be wide, as in one of the US studies16 and the Canadian study,12 which provided several alternatives for the definition of placebo. The respondents could give their own definition or choose between the following alternatives, the second of which was exactly the same as in the Danish study9: ‘(1) an intervention, that is, not expected to have an effect through a known physiologic mechanism, (2) an intervention not considered to have a ‘specific’ effect on the condition treated, but with a possible ‘unspecific’ effect, and (3) an intervention that is inert or innocuous’ 12 16…”

The Emperor’s New Drugs: Medication and Placebo in the Treatment of Depression

“…They are almost as effective as antidepressants, but elicit far fewer side effects. Surveys indicated that many physicians do in fact prescribe placebos (Tilburt et al 2008;Raz et al 2011). The conventional wisdom is that for a placebo to be effective, patients must believe they are receiving active medication, which entails deception.…”

The Mistreatment of Major Depressive Disorder

“…Unfortunately, placebo effects are not well understood by physicians. 26 Clinicians do not usually know whether the drugs they prescribe have worked, or whether their patients have been provided enough hope to move to a spontaneous recovery. One cannot assume that when patients feel better it proves that drugs have been effective.…”