Nothing can cure you

http://www.timesonline.co.uk/article/0,,8125-2278807,00.html

The placebo effect is powerful, so why aren’t we testing and using it? Toby Murcott finds the catch
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Imagine a future in which NHS doctors and nurses have been given free rein to use dummy tablets and therapies on patients. It would be a future in which the power of placebos — inactive treatments that make patients feel better through expectation — was officially recognised.
A placebo-development race begins among the leading drug companies, which spend millions finding the exact shade of blue, white or pink sugar pill that inspires most confidence in the patient. The pharmacist oozes optimism about your future health as he hands you the package of pills. “Trust me. This will help you,” he says. And it probably will, because placebos do help people get better.
The scenario is, of course, ridiculous. It would mean pharmaceutical companies being given, in effect, a licence to produce snake oil. And doctors, nurses and pharmacists would effectively con patients to try to make them feel better.
But the fact is that the placebo is powerful. Four years ago, a big study examined two popular treatments for depression: the herbal remedy St John’s Wort, the antidepressant tablet Zoloft, and a placebo. It revealed, amazingly, that the placebo was more effective than both of them.
Though they may be unwilling to admit it, doctors and their treatments often owe at least some of their success to the placebo. Just the reassurance of a consultation with your doctor can be enough. Complementary therapists, however, are often explicit about the placebo effect as one of their main tools. Spending time listening to patients and offering support and sympathy is one of the reasons given for the success of complementary therapies, rather than the efficacy of the actual treatments.
As a science writer and scientist, the full implications of this began to hit me as I researched my book The Whole Story, investigating the power of complementary therapy. I realised that the placebo, while being at the heart of why many complementary therapies work, is also the root cause of why they should never be made freely available on the NHS unless they can be shown to be more than a placebo.
My voyage of discovery began in Bristol, in summer 2004. I was interviewing Professor Paul Dieppe, a consultant rheumatologist and Professor of Health Services Research at Bristol University. He was adamant that complementary medicine should be wary of seeking orthodox approval, a position I found striking from an established and respected doctor. He argued that if complementary therapists sought recognition and approval by the medical establishment then this would compromise the benefits of the treatments they practised.
His comments puzzled me at the time, but I came to appreciate their wisdom. First, he was saying that as soon as you seek orthodox approval for unorthodox approaches, you have to be open about the operation of the placebo effect. And once everyone knows that a treatment works through a sophisticated form of deception, the power of the placebo dissipates.
Secondly, he was saying that in a head-to-head with conventional medicines, complementary medicines are bound to come off worse, so it’s not worth even trying to compete on the same ground. It’s all about the techniques used to test treatments before doctors can prescribe them.
The gold standard of clinical research is the double-blind randomised controlled trial. It’s the best way we have of testing whether a treatment works, but it’s not good at testing treatments that aren’t pharmaceuticals. One reason for this is that during the trials, half of the patients receive the new treatment, and half receive a dummy pill (placebo). It is vital that neither group knows which they are getting, and that the practitioner doesn’t know which treatment he is giving (ie, double-blind). But with psychiatry, shiatsu, reiki, laying on of hands, physiotherapy and many others, it is impossible for the therapist to give a dummy treatment and for the patient or the therapists not to know it, as they can see or feel that it’s different (unlike with pills).
Another reason that complementary therapies are difficult to tackle with double-blind randomised controlled trials is that the treatment is invariably accompanied by elements of lifestyle change and emotional support from the therapist. Clinical trials try to cancel out all these “external” differences to measure the effect of the treatment alone, so all other benefits go unrecorded.
This last point was brought home to me at a conference on complementary therapy that I attended at Southampton University in 2004. At lunch I met a PhD student, John Hughes, who was conducting social scientific research into why some arthritis patients went to see an acupuncturist. What he found was that some people said that while the needles did nothing for the pain, the treatment made them feel more able to live their lives.
In other words, complementary treatments can work in a complex, multifaceted way, in which inspiring the confidence of the patient (the placebo) is an intrinsic part. Clinical trials do not reflect this. To assess complementary therapies properly, we need to find new ways of assessing them that measure this complexity; double-blind randomised controlled trials will never do it. This is not to say that there should not be rigorous testing, and this is particularly true of herbal medicines — such as black cohosh, which this week was the subject of a warning from the medicines regulatory agency because of a link to liver disorders.
But it does leave us with a dilemma. By testing complementary therapies using the best means we have — double-blind randomised controlled trials — we diminish them. In fact, treatments that aren’t pharmaceuticals tend either not to get this high quality trialling, or to come out of it rather badly — in which case they inevitably receive a public battering.
But unless we test them thoroughly, and find them to be effective, there can be no justification for introducing them into the NHS. If we allowed state-sponsored administration of treatments that have little more backing them than the power of placebo, it would be open season, with every elixir-pusher provided with a new legitimacy. The power of placebo lands complementary therapy in a Catch-22 situation.
Complementary medicines help many people, and we need to recognise that the power of the placebo is their strength, rather than their weakness. But until we agree a better way of testing treatments, it is best that the complementary remains exactly that — available separately and privately, and not even trying to compete with the medical big boys.
The Whole Story, by Toby Murcott (published by Macmillan in paperback, July 20, £8.99), is available from Books First for £8.54, free p&p. Call 0870 1608080, or visit www.timesonline.co.uk/booksfirstbuy