Mind over matter

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Some doctors still administer inert tablets or injections to people who do not respond to treatment.

A final possibility is harder to measure, but no less intriguing. It's the placebo effect itself. The mind is as powerful as any organ in the body. People who took their placebo faithfully in the belief it would help may actually have gotten real help.

In fact, the modern treatment of HF includes medications that counter the effects of the stress hormone adrenaline along with additional measures to lower the blood pressure and slow the heart rate.

It's not much of a stretch to suppose that confidence and belief in a pill can exert similar effects, even if the pill itself is inert. Placebos can be powerful assets - but there can sometimes be a dark side to the placebo effect.

Pricey placebos

In our consumer society, many people believe "you get what you pay for." For example, when a single bottle of wine is split into two portions, tasters typically prefer the sample labeled as expensive over the identical one labeled as "bargain brand."

Wine has a certain snob appeal - but could the same bias apply to medication, or even placebos?

In a 2008 study, researchers at the Massachusetts Institute of Technology tested the ability of placebos to reduce the pain of electric shocks in 82 healthy volunteers.

The scientists administered identical placebos that were touted as painkillers; one was "priced" at $2.50 a pill, the other at $0.10. Both placebos were reported to reduce pain, but the "expensive" one was consistently more effective.

It's only one small study, but it may help explain why some patients prefer brand-name drugs to generic equivalents. Since the volunteers were each paid $30 to participate in this shocking experiment, they may have been particularly price-conscious folks.

The notorious nocebo

Faith in a medication can boost its effectiveness - but fear of a medication can magnify its toxicities. In today's world, everyone knows that medications can produce side effects.

And placebos can, too. In every placebo-controlled trial, some volunteers report ill effects from their placebo, sometimes even unpleasant enough to force discontinuation of the pills. Doctors have a name for this, too: the nocebo effect.

A recent trial is a case in point. The volunteers were 225 men with moderate to severe symptoms of benign prostatic hyperplasia (BPH).

The men were randomly assigned to take saw palmetto or a placebo for one year. At the end of the trial, there was no difference in the men's symptoms or in their urine flow rates, bladder emptying, prostate size, or PSA (prostate-specific antigen) levels.

The results conflict with earlier, briefer trials that found benefit from saw palmetto. Like all "dietary supplements," saw palmetto is not regulated by the FDA, so preparations may vary in potency.

More research is needed to find out if saw palmetto can reduce symptoms of BPH, which preparations are best, and which men are candidates for the herb. If nothing else, though, the current study showed that saw palmetto was safe.

Only 8 of 112 men who took it experienced a serious adverse event during the one-year study. That compares favorably to the placebo: 18 of the 113 men who took the inert pill experienced a serious adverse event. And less important side effects were equally common in the two groups.

The mind matters

The placebo effect is an old story, the nocebo response a newer one. Both reflect the power of belief. At one time, doctors attempted to harness that power by administering inert tablets or injections to people with distressing symptoms that defied diagnosis and treatment with conventional methods.

Although the practice is no longer recommended, a 2008 study found that 45% of clinicians surveyed reported prescribing placebos. And even without resorting to a placebo, a trusting, positive therapeutic relationship between doctor and patient is as important as ever.

It's sadly threatened by the fast pace of today's technologically oriented, evidence-based style of medical practice, but it can never be allowed to vanish. Medicine is a science, and healing is an art.

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