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Kendrick the placebo effect the most powerful treatment we've ever had?

Our clinical columnist, Dr Malcolm Kendrick, argues that taking placebos is far from 'taking nothing'

Our clinical columnist, Dr Malcolm Kendrick, argues that taking placebos is far from 'taking nothing'

Tired all the time, loss of libido, mild or moderate depression... The list of symptoms that cannot be measured by any objective test goes on and on.

GPs know better than anyone that such symptoms take up a huge amount of time and energy. Patients are investigated inside out and upside down, in a vain attempt to discover something – anything – that can be treated as a 'proper' disease. Usually, very little turns up, and if something is actually found it is often borderline or ambiguous.

In the end, people with such difficult, non-measurable symptoms often become the classic heartsink patients. Or, if they have some money to spare, they drift towards complementary medicine.

As we all know, complementary practitioners spend much more time listening to the patient. They take symptoms such as tiredness or aching very seriously. They are endlessly understanding and compassionate.

At the end of an in-depth interview they always seem to discover an underlying cause, usually something specific to that individual. A therapy is painstakingly devised.

The patient is usually delighted that they and their symptoms have been taken seriously – and the complementary practitioner is paid, so they too are delighted.

Quite often the symptoms will disappear and the patient will be convinced it was the acupuncture, homoeopathy or Chinese herbal medicine that did it.Most GPs look at this process and seethe with indignation.

It's just a placebo effect, they cry – and they are probably right. After all, study after study appears to prove that homoeopathy, for example, is merely a placebo.

A question of faith

A Reuters internet report on a study published in The Lancet1 last year said: 'The world may be beating a path to the doors of homoeopathic practitioners as an alternative to conventional medicines, but according to a new study they may just as well be taking nothing.' 2

Although most doctors would probably agree with this, there is a major problem with it: the statement '... they may just as well be taking nothing'.

But taking nothing would have no effect. In fact, the point of placebos is that they are far from being 'nothing'.

One of the most famous examples is an account from the late 1950s by Dr Bruno Klopfer of a patient with advanced cancer who was randomised to a new drug called Krebriozen as part of a clinical trial.

A study in BMC Health Services Research recounted the story. 'Klopfer describes how within 10 days "all signs of his disease had vanished". The patient relapsed within two months when he learned that trial results on Krebriozen were inconclusive.

His clinician somehow managed to convince the patient that he had: "a new super-refined, double-strength product", but instead administered saline injections. 'The patient's response was described as "even more dramatic than the first".

He remained symptom-free for over two months, until he read that "nationwide tests show Krebriozen to be a worthless drug in the treatment of cancer".

Within a few days, the patient was readmitted to the hospital in extremis. His faith was now gone, his last hope vanished, and he succumbed in less than two days.'3

Could 'nothing' have achieved such a powerful effect? Can 'nothing' reduce pain, as placebos can? And if a placebo were just 'nothing', there would be no need for placebo-controlled trials.

Placebos and the placebo effect are clearly far from being nothing. They are something very powerful. Indeed, recent work using PET scan and radioactive tracers has demonstrated that placebos can activate the brain to release more pain-relieving endorphins.

A real measurable effect, no less.So why don't doctors make an effort to harness the power of placebos, particularly in areas where they work best – for example, chronic pain and tiredness?

It has been argued that the deliberate use of placebos is resisted by doctors because they believe it is deceit. But is homoeopathy deceit? Is acupuncture deceit? Can it only work if the practitioner believes in it, or the patient, or both? In which case we should redefine the placebo effect as belief.

Then, after doing tests and listening carefully to the patient, the doctor can say. 'If you take this pill, I fully believe it will do you good.' In many cases it will. Where is the deceit in that?

Dr Malcolm Kendrick is a salaried GP in south Manchester

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