Useful links about placebos


Short analysis of the paper:

Basically: their definition of placebo is quite amazingly different from what is used elsewhere. Placebos are commonly thought of as a sugar pill or chalk tablet – a biologically inert substance which cannot directly treat the disorder it is offered for.

This paper decided that these were ‘pure placebos’ and that lots of other things were ‘impure placebos’, such as

“Positive suggestions

  • Nutritional supplements for conditions unlikely to benefit from this therapy (such as vitamin C for cancer)
  • Probiotics for diarrhea
  • Peppermint pills for pharyngitis
  • Antibiotics for suspected viral infections [5]
  • Sub-clinical doses of otherwise effective therapies [32]
  • Off-label uses of potentially effective therapies
  • Complementary and Alternative medicine (CAM) whose effectiveness is not evidence-based [33][34]
  • Conventional medicine whose effectiveness is not evidence-based [35][36][37][38]
  • Diagnostic practices based on the patient’s request or to calm the patient such as
    • Non-essential physical examinations
    • Non-essential technical examinations of the patient (blood tests, X-rays)”

They are wrong; homeopathy or vitamin C for cancer ( their ‘non evidence based’ complementary medicine) is pure placebo, and it involves deception as well.

Whereas, clinical examination when someone has say mild symptoms of a cold does not involve deception. It may also not be very necessary either, but if it is done with discretion in order to reassure a patient that they were correct about the origin of their illness, and that they do not have, say,  a chest infection, and is not promised to do anything else, is not a ‘placebo’. It may be unnecessary; many things in medicine may be.  Whereas, someone who sets up a private health screening clinic and offers ‘whole body check ups’ which will somehow promise better health, this is deception, because the promise is not  based in evidence.

Similarly, positive suggestion is evidence based in some circumstances, for example, if a group of patients are given exercise to do for health, only the group told that it will help with self esteem will report this benefit.

The literature on antibiotics for viral infections, is in a post from Inside Health below – this is a whole other ball park. The question is not about antibiotics in viral infections, it is about the role of antibiotics in upper respiratory infections full stop – they don’t really work, basically. This isn’t about GPs prescribing antibiotics, but about an antibiotic prescribing culture.

This paper does not show that placebos are being given out in quantity by GPs. It may show that GPs who prescribe homoeopathy accept that it is a placebo. Other than that, I can ‘t quite understand how it’s attracted so much attention.


Chapter 16  The unseen benefits of professional healthcare

1.    De Craen AJM, Roos PJ. Effect of colour of drugs: systematic review of perceived effect of drugs and of their effectiveness. BMJ 1996;

2.    Blackwell B, Bloomfield S. Demonstration to medical students of placebo responses and non-drug factors. Lancet 1972; 229(7763)

3.    Moseley JB, O’Malley K. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002;

4.    Dimond EG, Kittle CF. Comparison of internal mammary artery ligation and sham operation for angina pectoris. Original Research Article Am J Cardiol 1960; 5(4)

5.    Branthwaite A, Cooper P. Analgesic effects of branding in treatment of headaches. BMJ1981; 282:1576-1578

6.    Desharnais R, Jobin J. Aerobic exercise and the placebo effect: a controlled study.Psychosomatic Medicine 1993; 55(2):

7.    Stovner LJ, Oftedal G. Nocebo as headache trigger: evidence from a sham-controlled provocation study with RF fields. Acta Neurologica 2008; 117(s118):

8.    Ivan Pavlov – Biography. 28 Oct 2011

9.    Phillips DP, Ruth TE. Psychology and survival. Lancet 1993; 342(8880):

10. Philips DP, Liu GC. The hound of the baskervilles effect: natural experiment on the influence of psychological stress on timing of death. BMJ 2001; 323(7327):

11. Ladwig KH, Roll G. Post-infarction depression and incomplete recovery 6 months after acute myocardial infarction. Lancet 1994; 343(8888)

12.  Blumenthal J, Lett HS. Depression as a risk factor for mortality after coronary artery bypass surgery. Lancet 2003; 362(9384):

13. Lindstone SC, Schulzer M. Effects of expectation on placebo-induced dopamine release in Parkinson Disease. Arch Gen Psychiatry 2010; 67(8):857-865

14. Pollo A, Amanzio M. Response expectancies in placebo analgesia and their clinical relevance. Pain 2001; 93(1):77-84

15. Grevert P, Albert LH. Partial antagonism of placebo analgesia by naloxone. Pain 1983; 16(2):129-143

16. Hróbjartsson A, Gøtzsche PC. Placebo interventions for all clinical conditions. Cochrane Db of Syst Rev 2010, Issue 1. Art. No.:

17. Finniss DG, Kaptchuk TJ. Placebo effects: biological, clinical and ethical advances.Lancet 2010; 375(9715): 686-695

18. Kaptchuk TJ. Powerful placebo: the dark side of the randomised controlled trial. Lancet1998; 351: 1722-1725

19. The Humble Humbug. Lancet 1954; 264(6833)

20. Kaptchuk T, Kelley JM. Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome. BMJ 2008; 336:999

21. Thomas KB. General practice consultations: is there any point in being positive? BMJ1987; 294: 1200-1202

22. Little P, Everitt H. Observational study of effect of patient centeredness and positive approach on outcomes of general practice consultations. BMJ 2001;

23. Hughes D. Consultation length and outcome in two group general practices. J R Coll Gen Pract. 1983 33(248): 143-144,

24. Campbell SM, Hann M. Identifying predictors of high quality care in English general practice: observational study. BMJ 2001

25. Wilson A, Childs S. The relationship between consultation length, process and outcomes in general practice: a systematic review Br Gen Pract. 2002; 52(485)

26. Stirling AM, Wilson P. Deprivation, psychological distress, and consultation length in general practice. Br J Gen Pract. 2001; 51(467)

27. Mercer SW, Fitzpatrick B. More time for complex consultations in a high-deprivation practice is associated with increased patient enablement. Br J Gen Pract. 2007; 57(545): 960-966

28. Linde K, Ramirex G. St John’s Wort for depression – an overview and meta-analysis of randomised clinical trials. BMJ 1996; 313:253

29. Gratus C, Damery S. The use of herbal medicines by people with cancer in the UK: a systematic review of the literature.  QJM. 2009; 102(12):

30. Astin JA. Why patients use alternative medicine. JAMA 1998; 279(19):

31. Turner D, Tarrant C. Do patients value continuity of care in general practice? An investigation using stated preference discrete choice experiments. J Health Serv Res Policy 2007; 12(3):132-137

32. Kearley KE, Freeman GK. An exploration of the value of the personal doctor-patient relationship in general practice. Br Gen Pract. 2001; 51(470):

33.  Gill JM, Mainous AG. The role of provider continuity in preventing hospitalizations.Arch Fam Med 1998; 7:352-357

34.  Cree M, Bell NR. Increased continuity of care associated with decreased hospital care and emergency department visits for patients with asthma. Dis Manag 2006; 9(1)

35.  Knight JC, Dowden JJ. Does higher continuity of family physician care reduce hospitalizations in elderly people with diabetes. Popul Health Manag 2009; 12(2)

36.  Burge F, Lawson B. Family physician continuity of care and emergency department use in end-of-life cancer care. Med Care 2003; 41(8)

37.  Raddish M, Horn SD. Continuity of care: is it cost effective? Am J Manag C 1995; 5(6):727-734

38.  Bamji AN. Southeast London – the unspoken problem. BMJ 2011;

39.  Mitchell AJ, Vaze A. Clinical diagnosis of depression in primary care: a meta-analysis.Lancet 2009; 374(9690):609-619

40.  Kai J, Crossland A. People with enduring mental health problems described the importance of communication, continuity of care, and stigma. Evid Based Nurs 2002;

41.  McQueen D, St John Smith P. Psychiatric professionalism, multidisciplinary teams and clinical practice. European Psychiatric Review, 2009;2(2)

42.  Craddock N, Antebi D. Wake-up call for British psychiatry. Brit J Psychiat 2008; 193:6-9

43.  Simmons P, Hawley CJ. Service user, patient, client, user or survivor: describing recipients of mental health services. The Psychiatrist Online 2010;

44.  Propper C, Burgess S. Competition and quality: evidence from the NHS internal market.

45.  Samuel M. NHS Market reforms pose risk to service, warn, 24th January

46.  Health and social care bill 2011. Royal College of Psychiatrists, Second reading Briefing House of


2 Responses to “Useful links about placebos”

  1. Keith Walker March 21, 2013 at 1:30 pm #

    Thanks Margaret. I don’t know why it got such attention, but the way it was reported suggested that some GPs had ‘admitted’ (ie guilty of) using placebos, which to non-medics like me means giving out sugar and chalk pills when they ought not to. Some of my colleagues interpreted that as outrageous, since they paid prescription charges for nothing, and presumed it was done to get them out of the surgery more quickly. Perhaps this is the angle that the media hoped would attract public attention. Using ‘admitted’ is powerful in that regard.

  2. David Colquhoun March 22, 2013 at 12:01 pm #

    This post is, as usual, a superb analysis.

    The only thing that I’d like to add is to draw attention to Hróbjartsson & Gøtzsche

    This, and other evidence, seems to be showing that the placebo effect, though certainly real, is often too small and too transient to have much clinical significance. In other words, when people who get better after an ineffective treatment, it’s quite likely that they’d have got better anyway. Insofar as that’s true, in removes the last plank for alternative scamsters. It’s interesting that some of them seem now to admit that their treatments are only placebos, but still seek to justify them because of the great power of placebo effects. That seems to be untrue.

    Of course if all you mean by placebo is giving the patient a physical examination that isn’t (as far as you can guess) strictly necessary, in order to reassure them, that’s totally justified in my opinion.

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