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Comment by btilly | Hacker News Reader

Here is a simple rule.

Any condition that can be improved with a placebo, has a possible psychological component that can either be a cause or a contributing factor. This is not to say that it is all in your head, or that all people with it have it due to psychological reasons. But some of the people have at least some of their symptoms worsened by psychological factors.

Anyone who finds this controversial has psychological issues with reality. And this is true whether your condition is CFS or high blood pressure+heart disease.

Now people don't want to believe that acupuncture is a placebo, but there is ample evidence that it is. Therefore this applies to every condition that people find that acupuncture can help for. And that is a lot.

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It’s way more complicated than that. The diagnostic criteria changes over time, for many diseases with psychological components, in ways that make formerly pathological behaviors now healthy and vice versa.

Placebo doesn’t actually help you, obviously, despite what the outcome you’re measuring suggests. It represents a slack (something not quite an error, but not quite a useful measurement) in the outcomes based measurement regime. It’s a “cosmological constant” as a side effect of the limitations of enumerating causal and contributing factors.

People believe acupuncture is a placebo, and in an evidence based medicine regime it seems reasonable to prescribe it. But it depends what you’re calling pathological. Today, a population of video game players versus a control will score better on many psych outcomes. Tomorrow, they’ll change the tests, subtly, to account for “factors” better, and the results will reverse. The USMLE study book in 2018 pathologizes “video game fixation” (they can’t call it an addiction) before such a test change has occurred. The simple rule is that whatever society determines to be pathological will trickle down to the field of medicine, and placebo effects are the loudest signal of the limitations of an otherwise most superior way to administer therapies.

> Placebo doesn’t actually help you

What?

The first definition of the placebo effect I found was this:

"a beneficial effect produced by a placebo drug or treatment, which cannot be attributed to the properties of the placebo itself, and must therefore be due to the patient's belief in that treatment"

My highlight.

He means that most of the placebo is covered by a statistical effect, regression to the mean, etc.

https://sciencebasedmedicine.org/the-placebo-myth/

That may be most of the effect on the group taking the placebo. But it is not the placebo effect.

Were there no placebo effect, then we could test the effectiveness of drugs by simply observing one group and giving the other our proposed treatment.

There are drug candidates that make it all the way to phase 3 trials before they fail. One of the (surprisingly?) common reasons for failure at this stage is turning out to be less effective than placebo

https://www.nuventra.com/resources/blog/placebo-response-pha...

https://seekingalpha.com/article/256697-why-phase-3-trials-f...

Reading the articles left me with the impression not that they were less effective, but that they couldn't prove efficacy. So they could win, or lose, but it was close.

It is also worth noting that one of the reasons why this happens in stage 3 despite having passed through a test in stage 2 that was meant to whittle this out is that improved expectations increase the strength of the placebo effect. Which makes the real effect harder to detect.

> not that they were less effective, but that they couldn't prove efficacy

Could you explain the difference?

To prove efficacy, you have to have a statistically significant win.

If you're ahead by a small margin, it isn't evidence that you're less effective. But you did not prove efficacy.

> "Aint no such thing as a placebo effect, only a change in perception"

I find that statement disingenuous. Is the author really claiming that "a change in perception" isn't real?

You're right that changes in diagnostic criteria and statistical effects can cause a placebo group to look better or worse over time without the placebo having done anything. This is important, and thank you for the reminder.

However that is not to say that the placebo effect never helps you. As http://protomag.com/articles/the-placebo-problem shows, people who are receiving a placebo will experience medically significant effects, and which effects they experience depend on which placebo they got. Furthermore the reason why double blind studies became standard is that it turns out that the doctor's knowledge has an impact even when the doctor is trying to not communicate it. That is, if doctors are told that one group is receiving a placebo and another is not, the group that is not will do better EVEN THOUGH both groups are in fact receiving the same placebo! (I heard about this some time ago as a classic study, but I can't seem to track it down easily.)

Yes, I agree. I think my point really is that clinical outcomes care about how the patient feels, while scientific outcomes (like whether your medicine works the way you think it does) usually does not.

We got a lot of great medicine whose biomechanics we don’t really understand and whose trials don’t prove but definitely safely and significantly help people. A study just seeking to prove that your drug does the biomechanics it claims measures a placebo effect of zero if it is done correctly, because if you observe a placebo effect you’re not dealing with a biomechanically constrained outcome anymore.

There isn’t really a viable alternative to evidence based medicine, it’s the only game in town. We just have to carefully decide what outcomes we care about and whether or not those outcomes (1) discourage scientific understanding of the underlying biomechanics of our drugs, by virtue of making black-boxedness acceptable and (2) are co-opted, via enemy action, by either conspiracy theorists sowing doubt in things like vaccines or moneyed interests who make mediocre drugs look good.

>Anyone who finds this controversial has psychological issues with reality.

Isn't that something you can say about much of the population though? It seems to me that humans, in general, have psychological issues with reality.

But who’s to say which group’s reality is real and which group’s reality is false? In the end it boils down to politics and public perception - or in today’s world, whichever group is more effective in leveraging the large online platforms to their advantage.

Whatever side is more populated with people who think that is an important question, is likely to be the side that I'm against.

Reality is. I am willing to accept that the best well-conducted research available is a better guide to that than my own knowledge unless it is in one of the very limited areas where I have personal expertise. And those are very, very limited areas indeed.

I agree with you personally, but the cynic in me believes the vast majority of people fall under the category of my original post.

you know whats funny? CFS has one of the lowest placebo response rates.

Mandatory reference for those unable to google: https://www.ncbi.nlm.nih.gov/pubmed/15784798

I agree with possible psychological components is several health conditions. But saying that all acupuncture treatments are placebo is contradicting your first point, besides there are scientific studies that explains mechanisms behind acupunture.

What scientific studies would those be? And by what standards are they scientific?

Until a randomized controlled study can demonstrate real differences between acupuncture conducted with real needles and sham needles, I will happily call it a placebo. Ditto for acupuncture conducted per the way that acupuncturists think it should be conducted and acupuncture conducted per the way that they think it should not. Those studies have, in fact, been conducted. Acupuncture did not, in fact, do anything detectable. I am therefore on the side of calling it a placebo.

See http://www.dcscience.net/2013/05/30/acupuncture-is-a-theatri... for more.

Curious, if put in practice, what is the reference group for the placebo group?

I don't think it exists outside of scientific trials. I can't imagine getting a prescription from your doctor only to find out it was a sugar pill to be accepted by society in any way.

Two words. Essential oils.

Definitely happens:

https://www.cbc.ca/news/health/placebos-widely-prescribed-by...

Not parent, but don't we buy into our own placebos all the time? I was told I had RSI. I got a trackball and a ergodox. I don't have any issue when I use these two devices. When I use my planck my hand is a giant cramp within five minutes.

Sure, I think that the ergodox' layout helps and the trackball sure feels better. But based on the level of difference these two things have made and so quickly, I can't help but believe this is just a placebo.

Before the ergodox I used a planck and a vortex vibe and had zero problems with them. I initially purchased these two devices to combat my RSI and they too worked. Then I was recommended the ergodox and after using it the other keyboards are no longer effective. Swapped one placebo for another.

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