Nocebo: placebo's evil twin

We are likely all familiar with the idea of a placebo effect. This occurs when we experience a response to a perceived treatment when the treatment itself is biologically active.

I have written several times about the power of placebo, so common and beguiling that it is controlled against in the majority of clinical research for new medical treatments.

The term nocebo effect has been used for something described as the placebo’s evil twin.  

Although there isn’t a standardized definition for nocebo effect, it really is seen as the flip side of the placebo.

It is thought to occur when patients attribute negative reactions they experience to a treatment intervention — even when they are given an actual placebo (or inactive medicine).

Symptoms are often nondescript such as headache or fatigue and seem to occur most often among women, those with pessimistic temperaments, or those with negative attitudes about the treatment being offered.

A study published in 2015 in the Journal of Clinical Psychiatry by researchers at Deakin University in Australia suggests the nocebo effect is quite common and should be considered in the design of psychiatric clinical trials.

Prevalence rates for nocebo effect vary depending on the clinical setting and type of therapy examined.

In this study, researchers examined data from 2,400 subjects in clinical trials involving antidepressants and found the nocebo effect could be responsible for more than 60 percent of treatment-emergent adverse effects and almost five percent of those who stopped treatment.

These researchers say the nocebo effect can impact a study by causing distress and treatment non-compliance among subjects. It can also potentially lead to a study medication being prematurely withdrawn from the market.

This information raises questions about how to avoid the nocebo effect in both research and clinical settings.

While some say providing too much information to patients of possible side effects may contribute to increasing the nocebo effect, we must respect a patient’s right to informed consent and autonomy and avoid taking a paternalistic role.

Gone are the days when the healthcare professional is the only source of medical information.

Increasingly, I see the phenomenon of someone with negative pre-existing attitudes about taking medication who then goes home and searches online for information from others who have had negative experiences and then are intolerant to the medication prescribed.

This happens with each medication in turn and sometimes the side effects experienced are very atypical and very difficult to explain on a biological basis. Some such individuals become impossible to treat for this reason.

Like the placebo, it will likely be impossible to eliminate the nocebo response. Our best bet is to identify it and do our best to minimize it.


Mental health care problems

Inequality in mental health care

Around the world, there's a stark inequality in mental health care.

Perhaps not surprisingly, mental health care is very difficult to access in some of the world’s poorest countries.

Nearly half the people in the world live in countries where there is only one psychiatrist for every 100,000 people.

Comparatively, in wealthier nations it is more common to have one psychiatrist for every 2,000 people. In addition to limited available resources, there may be difficult travel conditions, extreme poverty, military conflict, or a natural disaster.

It is easy to see there are many who would have virtually no way of accessing a mental health care professional.

Although media reports tend to focus attention on physical needs in developing or war-torn countries, mental health needs are also great.

Worldwide, about one in 10 people experience a mental illness, but only one per cent of the global health workforce is treating these conditions, leaving vast numbers of people to suffer on their own.

In a 2015 report, the WHO said more investment in mental health care is needed to address this inequality. Interestingly, it also recommended increased investment in richer countries like Canada.

Although the ratio of psychiatrists to population is more appropriate in wealthier nations, this report suggests too many resources are being used on in-patient care while there is not enough for community care measures.

This is certainly true when I look at the care available in our province. I have written several times about the difficulty many people have in accessing community services and the lack of coordination between services. A well-resourced and coordinated approach could improve this a lot.

The WHO report also stressed a need to increase resources during times of economic crisis when rates of depression and suicide tend to increase. This is not surprising since stress is a key trigger for many mental health conditions.

When a person already living in an impoverished nation with very little in terms of a social safety net is in a mental health crisis, the results are often tragic for the individual, their family and community.

Similarly, in wealthier nations such as ours, untreated mental illness is devastating and places a huge burden on our society.

We have a long way to go before people around the world can safely access quality mental health care. We must continue to advocate for targeted and coordinated resources as well as reduced stigma surrounding these conditions.

Disorder leads to hard life

As its name implies, antisocial personality disorder is characterized by behaviour that is antisocial.

Socially irresponsible behaviour, failure to conform to the law, manipulation of others and lack of remorse are trademarks of this difficult condition.

Antisocial personality disorder affects roughly one per cent of the population, but it occurs two to four times more often in men than women and is extremely prevalent within correctional settings – affecting 80 per cent of that population.  

It is most commonly observed in people between the ages of 24 and 44.

People with antisocial personality disorder are also likely to experience addictive disorders, have a shortened life expectancy, and are more prone to traumatic injuries, accidents, suicide attempts and hepatitis C. They use a disproportionate amount of medical and mental health services.

Unfortunately, antisocial personality disorder is not easy to treat. People with this condition seldom seek help for their antisocial pattern of behaviour and tend to dislike the authority of a mental-health professional.

Although not diagnosed in children, the pattern of behaviour often begins before the age of eight. In childhood it is referred to as conduct disorder. A quarter of girls and 40 per cent of boys with conduct disorder will have antisocial personality disorder as adults and the variety and severity of childhood behaviour problems are the best predictors of adult antisocial behaviour.

If a child makes it to age 15 without exhibiting conduct disorder, he or she will not likely have antisocial personality disorder as an adult.

For parents of children with these maladaptive behaviours, it is a difficult diagnosis to accept and deal with. Typically, parents are advised to maintain close supervision and enforce strict consequences that are firm, but fair for inappropriate behaviours.

It is not a good idea to shield children from the consequences of their behaviour with police or school authorities.

Many such young people become involved in drugs and related criminal activity and end up leaving home at a young age. They are not above taking advantage of their parents, family and friends if given the opportunity. Firm limits are required if those close to them are to avoid becoming victims of their behaviour.

Marriage is said to be a moderating influence on those with antisocial personality disorder. Over half of those with antisocial personality disorder who are married improve while few who are unmarried do.

Job stability is another predictor of improvement. These factors may, however, simply reflect a less severe personality disorder to begin with.

Although the antisocial and criminal behaviour tends to lessen with age this does not mean that older people with this personality disorder are necessarily happy and well adjusted. They may continue to have many behavioural, psychiatric and social problems that continue to be difficult to treat.

Unfortunately, there is no easy solution to this problem and a realistic and long-term view of the likely outcome is important. There is always hope, but the improvement tends to be slow and gradual when it occurs.


Psychiatry: the couch is out

Psychiatry 101 – Battling myths and stereotypes

It seems that practically every person who comes in for treatment has a different idea of what constitutes psychiatry and what they should expect when seeing a psychiatrist.

Many stereotypical impressions of psychiatry arise out of television shows or books.

In these stories, patients are portrayed lying on a couch, delving into the deep recesses of their childhood memories to discover why they have a problem with anxiety or binge eating in their present life.

While childhood experiences are sometimes important in psychiatric treatment, this method is definitely not the mainstay of the profession and the couch is out.

A lot of people are unsure what the difference is between a psychiatrist and a psychologist. Often, the two terms are used interchangeably, but they imply two very different professions.

A psychiatrist is a medical doctor. Every psychiatrist has gone through the same medical school training as a family doctor or heart surgeon, but has chosen to specialize in mental illness rather than surgery or general practice.

This medical background helps the psychiatrist to understand the biological underpinnings of psychological disorders. Unlike psychologists, psychiatrists can prescribe medication to treat mental disorders.

This is an important distinction because while psychologists can be very beneficial, and counselling is often an important part of treatment, some severe psychiatric illnesses such as schizophrenia or bipolar disorder cannot be effectively managed with talk therapy alone.

Also, psychiatric treatment is covered by Canada’s health care system and visits are paid for through an individual’s basic provincial medical services plan. This means that even without extended medical coverage, a person can see a psychiatrist and receive treatment for a mental illness.

There are no limits to the number of sessions per year or the number of years of therapy, as some of these illnesses are life-long.

A referral to a psychiatrist by your family doctor is necessary in order to qualify for MSP coverage.

Even when medications are used, there are other facets to treatment in almost every case.

First and foremost is education. Giving information about the disorder and why it has occurred is a crucial first step. There may be genetic predispositions, environmental contributions or both, as is usually the case.

Providing education about the treatment is also important — why it is recommended and how it will work to alleviate the problem.

In some cases, no medication is necessary and instead it will be important to identify real-life problems and how to work to solve them.

Contrary to popular characterization, a visit to a psychiatrist should involve more than passive listening on the part of the doctor. Following a diagnosis and education about your disorder, your doctor should discuss your treatment goals with you, explain the technique behind your treatment and give you specific activities to work on between sessions.

The psychiatrist should be supportive, giving real advice and guidelines while encouraging you to be independent in your actions and opinions.

Each session should have a specific focus and centre on themes such as ideas or belief systems.

An effective therapist will be confident and self-assured and will structure the session – introducing new topics and seeking more information or elaboration from you as well as presenting things in a new or different light. 

As medical knowledge improves, it becomes easier to treat mental illnesses. This is a quickly advancing field and many effective treatments are now available.

The information outlined in this column may help to minimize some of the misconceptions about seeking psychiatric help.

More States of Mind articles

About the Author

Paul Latimer has over 25 years experience in clinical practice, research, and administration.

After obtaining his medical degree from Queen's University in Kingston, Ontario, he did psychiatric training at Queen's, Oxford and Temple Universities. After his residency he did a doctorate in medical science at McMaster University where he was also a Medical Research Council of Canada Scholar.

Since 1983 he has been practicing psychiatry in Kelowna, BC, where he has held many administrative positions and conducted numerous clinical trials.

He has published many scientific papers and one book on the psychophysiology of the functional bowel disorders.

He is an avid photographer, skier and outdoorsman.

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The views expressed are strictly those of the author and not necessarily those of Castanet. Castanet does not warrant the contents.

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