The Most Powerful Placebo Is Not a Pill

The placebo effect--when a patient's symptoms improve with an inert pill--is widely recognized in medicine. Placebo has an especially important role in psychiatry, especially given the fact that a substantial proportion of patients with mood, anxiety, or psychotic disorders improve and experience some side effects with placebo in double-blind studies conducted by drug manufacturers as part of FDA registration trials. [ILLUSTRATION OMITTED] On the other hand, non-psychiatric medical disorders such as pneumonia and diabetes are unlikely to improve with placebo. Thus, psychiatric brain disorders appear to be particularly susceptible to the placebo effect, which implies it could be harnessed in psychiatric care. A component of every medication prescribed in psychiatry is a variable placebo effect in addition to the actual pharmacodynamic effects. Some physicians (including non-psychiatrists) openly admit to using placebo--which is sold as Obecalp capsules--to treat patients with vague aches, pains, insomnia, or low energy Some published studies have shown patients respond to inert pills even when the physician tells them in advance they will be receiving a placebo! 1 This reflects the power of the placebo effect programmed in the human brain, which may have an evolutionary advantage of instilling hope and sustaining faith things will get better despite serious physical or psychological adversity. What health care professionals often overlook is that the placebo effect transcends the pill itself. The most powerful placebo is the psychiatrist or nurse practitioner who prescribes the pill. In fact, the placebo effect of a clinician occurs even without prescribing any medication. The shape and color of a placebo pill may endow it with a greater effect (eg, a red and blue striped placebo caplet looks more impressive and may project an aura of being more effective than a plain white tablet). Similarly, a patient is influenced positively or negatively by a range of attributes that characterize his or her psychiatrist, and the totality of the impressions (positive or negative) the psychiatrist "projects" may enhance or detract from whatever treatment is administered, including medication or psychotherapy. This is why different pre-scribers may achieve disparate results when prescribing the same psychotropic. Many subtle and not-so-subtle verbal and nonverbal aspects of a clinician can project an "aura" of competence and trust for the patient, which will contribute to a better treatment outcome because of the patient's stronger unconscious expectation of improvement. These include the psychiatrist's grooming and clothing, his facial expression and demeanor, the neatness of his desk, the decor of his office, the cleanliness of the waiting room, even the appearance of the neighborhood where his clinic is located. Wearing a white coat instead of street clothes can evoke the image of a physician/healer, which is a strong positive placebo effect that can be exploited for many patients. Direct eye contact, an open body posture, a firm, reassuring voice, and a handshake or caring pat on the back at the end of the session when appropriate all contribute to patient improvement even before he or she ingests any pills. …