• EPA 2011: 19th European Congress of Psychiatry

This coverage is not sanctioned by, nor a part of, the European Congress of Psychiatry.

March 16, 2011 (Vienna, Austria) — Nearly three-quarters of healthy individuals report that they would consent to being prescribed a placebo medication if they experienced depression, according new research presented here at EPA 2011: 19th European Congress of Psychiatry.

Most study participants also reported that they do not believe receiving a placebo pill would interfere with their sense of autonomy or their relationship with their treating physician.

"We believe that our data should provoke a discussion with our colleagues about their longstanding opposition to the use of placebo to treat depression in their clinical practices," study investigator Uri Nitzan, MD, a psychiatry resident at Shalvata Mental Health Center in Hod Hasharon, Israel, told Medscape Medical News.

"While discussion about the ethics of prescribing a placebo has largely been the domain of academicians who have focused on its use as a research tool, our study shows for the first time that laypeople — our potential patients — are receptive to the use of placebo treatment for depression," he said.

Led by Shmuel Fennig, MD, head of the outpatient clinic at Shalvata Medical Center, the research team analyzed responses to questionnaires completed by 344 healthy students 18 years or older. The questionnaires were aimed at assessing respondents’ attitudes toward placebo treatments and the physicians who prescribe them.

The investigators decided to focus on depression because the lifetime prevalence of the disorder is reportedly as high as 20% and antidepressants are among the most widely prescribed medications.

At the same time, placebo pills in depressed patients have produced response rates of 30% to 50% with sustained efficacy, minimal side effects, and nominal cost.

Antidepressant Efficacy Questioned

In addition, research is increasingly challenging the magnitude of the reported efficacy of antidepressants over placebo for the treatment of mild to moderate depression. Concern has also been voiced about publication bias in favor of studies with positive results.

Even so, prescribing a placebo for depression, or other conditions, is viewed as unethical and unsound.

Commonly cited reasons are that effective treatment options are available and that the use of a placebo violates the principle of informed consent because physicians are required to hide from their patients the placebo’s mechanism of action to optimize its efficacy.

Also, some physicians believe that the use of a placebo can undermine a patient’s trust in his/her physician and thereby negatively affect the patient-physician relationship and diminish the patient’s autonomy.

Participants in the present survey were provided with a detailed written explanation about the placebo effect and its efficacy and limitations in the treatment of depression. The investigators also confirmed that patients understood the ethical complexity associated with placebo use.

Overall, 243 survey participants (70%) said they would agree to the use of a placebo as a first-line treatment if they developed depression. Also, 248 (73%) said they would consent to receive placebo treatment for other medical conditions.

Also, 275 (88%) said that they did not consider a physician who administered a placebo deceitful, and 256 (75%) did not feel that taking a placebo medication would negatively affect their sense of autonomy or the patient-physician relationship.

"We urge physicians to revise their notion about the use of placebo in clinical practice," Dr. Nitzan said. "In fact, while administering a placebo medication deprives the patient of his/her right to a full informed consent, it seems that in certain settings our patients would opt to waive their rights for complete information."

Placebo-Effect Strategy Used Routinely

In a second study, Kfir Feffer, MD, also a psychiatry resident at Shalvata Mental Health Center, presented data on a study that compared attitudes toward placebo in 81 patients who were currently or formerly depressed and undergoing drug therapy and in 108 healthy controls.

"Contrary to what most physicians assume, our data showed that most patients are willing to use placebo as first-line therapy, even when their depression is severe," Dr. Feffer said.

Ironically, despite controversy about the use of placebo, practitioners routinely aim for a placebo effect using nonpharmacologic and nonsurgical methods, Dr. Nitzan and Dr. Feffer pointed out. For example, the use of verbal suggestions or a confident demeanor can have a placebo effect.

Ethical Issues

"The ethical problems associated with placebo use for conditions without highly effective treatments are related to the inherent deception involved," Paul S. Appelbaum, MD, Elizabeth K. Dollard Professor of Psychiatry, Medicine and Law and director of the Division of Law, Ethics & Psychiatry at Columbia University College of Physicians and Surgeons in New York City, told Medscape Medical News. "Those problems go away if patients consent to use of placebo — as in this study — since they are no longer being deceived."

However, there's an important caveat to this study, he added. "And that is that just because many people are willing to consent to placebo use when healthy, that does not necessary imply that they would feel the same way when they are ill and in need of treatment. Nor does it justify treating them with placebo without their consent."

EPA 2011: 19th European Congress of Psychiatry: Abstracts P02-160 and FC31-02. Presented March 14 and 15, 2011.