The occurrence of placebo effects has been known for a very long time. A first “trick trial” concerning it took place in the late 1500s when instead of holy water, ordinary water was placed in a religious flask and given to a girl who was said to be possessed by the devil – which caused her to contort in pain. Likewise, when priests read a Latin text to the women, misinforming her that it was the Holy Scripture (while in actuality, it was Virgil’s Aeneid) she nonetheless squirmed in agony1.

The placebo effect can be viewed as controversial: on one hand, when doing placebo-controlled pharmacological trials, a strong placebo effect is dreaded as it might lead to a smaller effect size of the active agent and consecutively to failed trials and limits in drug development. In recent years, several psychopharmacological trials have failed to establish new therapy options due to “placebo response rates ruining drug development” ².

There have been multiple interesting outcomes from trials focusing especially on the placebo effect.

When informing a patient that he would be receiving analgesics, the intravenous application of isotonic saline had the same response as a hidden application of 6-8mg morphine³. A trial focusing on migraine patients and treating them with either placebo or rizatriptan found that the efficacies of the active agent labeled as placebo and placebo labeled as rizatriptan were similar. Furthermore, even open-label placebo was superior to no treatment. Authors concluded that increasing “positive” information incrementally boosted the efficacy of both placebo and medication during migraine attacks4. Furthermore, depending on the efficiency of a medication, 20-85% of its “treatment impact” have been found the be caused by placebo effect5.

When talking about placebo, one shouldn’t forget its “evil brother” nocebo, as – like Hansen et al. (2017) expressed in their journal article – you cannot have a placebo without a nocebo effect.

After a lumbar puncture, half of the patients who were told they might experience a headache afterward did have one, whereas of the control group (patients not warned about this side effect), all but one of thirteen remained headache-free6. A meta-analysis of patient expectancy and post-chemotherapy nausea reported a robust positive association between both, suggesting that patients with stronger expectancies experience more chemotherapy-induced nausea7.

In conclusion, the way clinicians introduce a new treatment and explain desired effects and possible side effects shapes the therapeutic outcome more than we believe. Even though physicians, of course, cannot hide possible side effects when informing about treatment options, it is very important to stress positive effects and avoid using words painting negative pictures. Instead of telling a patient “this medication can lead to bleedings”, one might rephrase and say “due to this, blood clotting might be impaired”.

Don’t forget though: as mentioned above, even when knowing they were receiving placebo, pain reduced in patients suffering from migraines compared to pain increasing in the no-treatment group. Therefore, believing that a drug or diet or any other kind of treatment can and will work is one of the most important steps you can take towards it actually helping you.

REFERENCES:
1   Kaptchuk, T.J., C.E. Kerr, and A. Zanger, Placebo controls, exorcisms, and the devil. Lancet, 2009. 374(9697): p. 1234-5.
2  Stahl, S.M. and G.D. Greenberg, Placebo response rate is ruining drug development in psychiatry: why is this happening and what can we do about it? Acta Psychiatr Scand, 2019. 139(2): p. 105-107.
3  Levine, J.D., et al., Analgesic responses to morphine and placebo in individuals with postoperative pain. Pain, 1981. 10(3): p. 379-89.
4  Kam-Hansen, S., et al., Altered placebo and drug labeling changes the outcome of episodic migraine attacks. Sci Transl Med, 2014. 6(218): p. 218ra5.
5   Hansen, E., N. Zech, and K. Meissner, [Placebo and nocebo : How can they be used or avoided?]. Internist (Berl), 2017. 58(10): p. 1102-1110.
6   Daniels, A.M. and R. Sallie, Headache, lumbar puncture, and expectation. Lancet, 1981. 1(8227): p. 1003.
7   Colagiuri, B. and R. Zachariae, Patient expectancy and post-chemotherapy nausea: a meta-analysis. Ann Behav Med, 2010. 40(1): p. 3-14.

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Mens sana in corpore sano – healthy mind and healthy body

Food insecurity – defined as an individual or household lacking access to sufficient, safe, and nutritious food that meets individuals’ dietary needs – has been linked to children’s behavioral, academic, and emotional problems and an increased risk of the development of mental health disorders [1, 2].

In a Canadian study on food insecurity in young children, researchers found that children from food-insecure families were disproportionately likely to experience persistent symptoms of hyperactivity and inattention. These results were still true after controlling for immigrant status, family structure, maternal age at child’s birth, family income, maternal and paternal education, prenatal tobacco exposure, maternal and paternal depression and negative parenting [3].

Accordingly, a systematic review on food insecurity and attention-deficit hyperactivity disorder (ADHD) symptoms in children reported a predictive and inverse relationship between the two, with possible lasting impacts into adulthood. Authors concluded that evidence exists to hypothesize that childhood food insecurity is associated with predisposing or exacerbating ADHD symptoms in children [4].

In 2017 Dr. Raju, President of the Indian Psychiatric Society concluded in a speech on medical nutrition in mental health and disorders that there is growing evidence for a relationship between quality of diet and mental health. According to Raju, the importance of nutrients as important agents for prevention, treatment, or augmentation of treatment for mental disorders has been established. “Empathic interactions and rational nutrition along with specific pharmacological and physical interventions could form an ideal and humane patient-friendly package in psychiatric practice” [5].

Therefore, identifying families in risk of food insecurity and getting children and adolescents the best possible food supply could result in fewer children with ADHD symptoms.

REFERENCES:

  1. Althoff, R.R., M. Ametti, and F. Bertmann, The role of food insecurity in developmental psychopathology. Prev Med, 2016. 92: p. 106-109.
  2. Shankar, P., R. Chung, and D.A. Frank, Association of Food Insecurity with Children’s Behavioral, Emotional, and Academic Outcomes: A Systematic Review. J Dev Behav Pediatr, 2017. 38(2): p. 135-150.
  3. Melchior, M., et al., Food insecurity and children’s mental health: a prospective birth cohort study. PLoS One, 2012. 7(12): p. e52615.
  4. Lu, S., et al., The Relationship between Food Insecurity and Symptoms of Attention-Deficit Hyperactivity Disorder in Children: A Summary of the Literature. Nutrients, 2019. 11(3).
  5. Raju, M., Medical nutrition in mental health and disorders. Indian J Psychiatry, 2017. 59(2): p. 143-148.
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When going to a doctor, you mostly aim for two things to happen: one, you want the doctor to tell you what kind of disorder you are currently suffering from and two, you hope for him or her to give you adequate treatment. While most people are able to follow their physician’s instructions well enough when they have to take medication like antibiotics for a few days, the longer the therapy needs to be, the less likely they are to “adhere”.

Adherence is a term to describe to what extent a person’s behavior in taking medication corresponds with agreed recommendations from a healthcare provider1. This means that after a physician has informed you about possible treatment options, you decide together what kind of treatment you are going to receive². Afterwards, if you stop taking the medication or choose not to take some of it, your behavior might be classified as non-adherent. Said non-adherence has significant impact on treatment effectiveness, individual suffering and health care costs³. If prescribed medication is secretly not taken, doctors might increase doses or switch to different substances as they suspect the current drug is not working properly.

A recent study explored adolescents’ health beliefs and subjective opinions relating to psychotropic medication, and statistically linked them to reported medication adherence. Adolescents age 12-17 answered a series of interview questions regarding their personal perceptions of their own course of disease, experienced symptoms and physician–patient relationship. Additionally they reported on their individual appraisal of positive effects from psychotherapy and/or medication, thoughts on adverse events, and thoughts on disease-related interactions with their friends and families.

Authors found that patients classified as non-adherent could be characterized as more likely to report feeling worse after taking medication, to describe a lower sense of self-efficacy concerning the improvement of their symptoms, and/or to perceive a less trustful physician–patient relationship. Furthermore, non-adherent patients were more likely to state that their attitude toward medication worsened after experiencing “side effects”, that they subjectively felt less support from their relatives, and/or they had fewer individuals in their family who were fully informed about their condition4.

In summary, if the medication you are taking is making you feel worse than you did before, if you feel like you have little or no control over your own symptoms, if you distrust your physician or if you feel your family isn’t supporting you (enough), this might lead you to stop your medication – possibly without telling your physician about it.

What can we learn from these results?

Health care providers can learn how important it is to repeatedly talk to their patients about their feelings towards the medication and encourage them to speak openly about medication-related doubts or worries. They can also learn how important their interaction with patients is, as even the best drug can’t work properly if it isn’t taken.

As a patient, one might realize that not wanting to take prescribed medication is a common occurrence, and one shouldn’t feel embarrassed or guilty about it. What is important, though, is to openly talk to the treating physician about it and find a solution together.

REFERENCES:

1  World Health Organization: Adherence to Long-Term Therapies. WHO Library Cataloguing-in-Publication Data, 1–211. 2003. www.who.int/chp/knowledge/publications/adherence_full_report.pdf

2  Ahmed, R., & Aslani, P. (2014). What is patient adherence? A terminology overview. Int J Clin Pharm, 36(1), 4-7, 2014.

3  Julius RJ, Novitsky MA, Jr., Dubin WR: Medication adherence: A review of the literature and implications for clinical practice. J Psychiatr Pract 15:34–44, 2009.

4  Niemeyer, L., et al., “When I Stop My Medication, Everything Goes Wrong”: Content Analysis of Interviews with Adolescent Patients Treated with Psychotropic Medication. J Child Adolesc Psychopharmacol, 2018. 28(9): p. 655-662.

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