Tuesday, November 10, 2009

101 Interesting Things, part thirty-three: The Placebo Response

The placebo effect was the reason that randomized double-blind trials became so necessary in medicine. You see, people sometimes get better all on their own, and us being the pareidoliac (did I just make up a word?) pattern-matching machines that we are, we tend to give the credit to whatever we were doing at the time. But as we all know, correlation does not entail causation, and so we must be a bit more thorough to make sure we're not hastily generalizing when we tell our friends, "Hey, I sang I Am the Very Model of a Modern Major General while eating a fudgesicle in the shower, and the next day my cold went away! You should try it!"

And sometimes, having something cold in your mouth while your body's warmed up and you're exercising your vocal cords is just what you need to get rid of a sore throat. The world, it turns out, is a complex and confusing place. And so we come next to the idea of experimental control. When you suspect that this cause might have that effect, how can you coax reality into giving up the goods? You control for all other possible variables that you can identify, so that the only difference between trial A and trial B is your suspected cause. And if you can't? Randomize the other stuff and get as many trials as you can, a large enough sample for the random noise to cancel out so that a coherent picture of the situation can emerge.

In medicine, not only do patients vary in their bodies and minds, they also vary in the matter of precisely how disease X affects them, and there is also variance among and between doctors in terms of how they treat their patients. So to see if drug Y can really cure disease X, we need to "cancel out" those unhelpful stalwarts who convalesce on their own, or due to Doctor Z's magical bedside manner. Heroes in labcoats do this by blinding themselves to the matter of whether or not they are giving the "real" drug Y to their patients, and because informed consent is important, the patients know that they may be getting drug Y or a "placebo," but they don't know which is actually going down their gullet.

And there you have it! We've just walked through the last several decades or so of medical research (in principle, anyway). But now there's a new problem. What was once called the placebo effect, because some hastily generalizing folk perhaps thought that the inert sugar pill actually did something, is now being called the placebo response by Fabrizio Benedetti, because it seems to have more to do with the patient than the pill.

Oh, and it's getting bigger, too. Or "worse," if you're the kind of person who thinks that the command, "Body, heal thyself," ought to be medically inert. For my part, I think it would be awesome if that really worked!

Benedetti was mentioned in one of the latest issues of Wired magazine, in their article, The Placebo Problem. I'll bottom-line it for you folks: "Big Pharma" is trying desperately to find drugs that can be meaningfully distinguished from sugar pills, and they're having problems because people seem to be getting the benefits all on their own, in greater numbers. Drugs aren't stopping working, mind you - those methodologically problematic stalwarts I mentioned above are just getting more numerous. The drugs still do whatever it is that they do, but now Big Pharma is running out of places to intelligently throw money to prove things, because a whole host of confounding variables are now rearing their ugly heads.

That's right, folks: drug companies are fretting because their ability to scientifically prove that they're helping people is slipping through their fingers, and they don't know what to do about it. The principle they're operating on is a simple and obvious one: drugs that work are more profitable than drugs that don't. Bill Maher, you can just eat a big ol' bowl of dicks. (Special thanks to PZ and Orac for teaching me of the still-insightfully-funny man's peculiar and disturbing lunacy.)

Anyway, enough pimping for the system; what do we do? You can read the article to find out just how tangled this Gordian knot really is: the color of the pill can affect things, the culture of the place can affect things, the frequency of dosage can affect things, and a million other screwy things that can all interact with each other and we have no idea why. Yet.

My pet speculation on this matter is that people are a whiny and suggestible lot, and when you live in places that are developed enough to do things like make happy pills, people think that they ought to be happy all the time. We deserve it, right? Oh, man... I feel a rant brewing.

I'll just say that I've done my share of wrestling with depression, and I've been on pills before. Everyone's different, and a multiplicity of treatments is best, because then we can treat more people more effectively (but we have to pay attention to them, and not treat it like a magic spell!). Merck can't dominate the central nervous system with drugs alone; they ought to branch out to psychotherapy techniques or something if they want to keep on top of the game. Some people's problems just can't be solved with a pill, they need some damned TLC and to think that someone important cares about them; other people's problems can be solved with any pill, it seems, so long as they think that their problems are being acknowledged. And a million fuckin' things in between.

So think about it, Merck: when your only tool is a hammer, every problem starts to look like a nail.


Cathy S said...

It's just too tempting to treat a pill like magic...and that's rather unfortunate, because this can prevent people from being simply curious about how their own bodies work.

The human mind is very self-referential: inputs affect outputs, which affect inputs and so on. It's almost a miracle (!?) that it doesn't break down all the time. But that's explainable by natural selection: brains that mess up often don't get through to the next generation.

As for the shortcut to mental health: the companies are somewhat responsible for making fear a weapon of choice.

D said...

Scott Peck calls this "the miracle of health." It makes me want to stab him, for exactly the evolutionary reason you point out. Except replace "stab" with "teach." ... OK, "and then stab."

I'm not sure I catch your meaning on making fear a weapon of choice. Care to elaborate?

metamorphhh said...

If the universe is a miracle, it's a miracle of it's own un-designed design. I'm all for calling things miracles, as long as I don't have to pick and choose.:)

*love your blog!*

D said...

That's a good point, metamorphhh! Emphasis and perspective, my friend - so much comes down to emphasis and perspective.

The other side of the coin is that, in a very real sense, things could not have been otherwise. The miracle is mundane, the mundane itself an everyday miracle. Thanks for the kind words!

metamorphhh said...

Yep, things are exactly the way they are, and possibilities only exist in retrospect. That's why when I hear people asking the existential 'why', I always point out that the fundamental characteristics of existence, requiring no antecedents, could be absolutely anything at all, and now is just the logical extrapolation of then.

Or so, that's the way I see it from this evolutionarily driven vantage point, the perceptual box that I'm stuck in.

Keep writin'!

See ya!