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

Article excerpt

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-affiliated 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 significantly 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 benefit. 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 influence 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 significantly more subtherapeutic doses of medication, compared with nonpsychiatrists.

* Our findings likely represent a valuable contribution to preliminary investigations of placebo use among physicians and their beliefs about placebo mechanisms and effectiveness.

Key Words: placebos, clinical practice, Canadian physicians, academic psychiatry, online surveys

Abbreviations

AD antidepressant

AMA American Medical Association

Congruent with the working definition assumed in the high-powered world of pharmacology, most physicians construe placebos as the nonspecific effects of medical treatment that, in clinical trials, must be controlled for to assess the specific effects of new (drug) interventions.1 Placebolike treatments, accordingly, refer to any short-term or illusory impression of improved health that some patients experience when they receive what appears to be effective treatment but actually is not for the condition being treated. As such, the placebo effect is a powerful mind-body phenomenon with a specific underlying biology that health professionals should investigate and exploit.2

Exemplifying the link between psychosocial factors and physiological processes, placebos are central to medicine3 but even more pivotal to psychiatry.4 Further, placebos bind behavioural science to the techniques of neuroscience.5-8 Several scholars grant placebos a prominent place in clinical psychiatry4,9,10 and mounting evidence suggests a large placebo component even in drugs forming the backbone of biological psychiatry.11-17 However, together with most physicians, most modern psychiatrists find the science of placebos difficult to swallow.18

Shrouded in a checkered history, placebo use in a therapeutic context remains controversial. Indeed, in 2006 the AMA cautioned that "[physicians may use [a] placebo for diagnosis or treatment only if the patient is informed of and agrees to its use. …