Dorothy Rowe

Positive Health Magazine
July 2004

Our Best Drug

Dorothy Rowe

Research in psychiatry over the last 50 years has been largely concerned with comparing one drug with another. Pharmaceutical companies have always been well aware that drugs used in psychiatry could produce vast profits, and so there has always been much competition between drug companies to produce the most effective drugs in the treatment of mental disorder. Many different drugs appear in the research literature, but one drug keeps appearing, a simple drug called placebo. It does remarkably well compared with drugs that contain active ingredients but the authors such of research reports have always preferred not to draw too much attention to these findings. How can a drug company make money out of a sugar pill whose effectiveness resides solely in the how the person taking the drug sees it? If the person thinks it will make him well, it will; if he doesn't, it won't.

However, recent research in physical medicine is putting placebo centre stage because researchers are using methods very different from those used in psychiatry. Psychiatric research simply counted the number of people taking a drug and, of these, how many got better. Recent research in physical medicine has looked at aspects of the situations in which a placebo was used, such as the status of the person doing the prescribing, the way in which the drug was given, even the colour of the pill.

Thus a high status prescriber such as a consultant was more likely to be believed than a low status prescriber such as a nurse. A placebo tablet wasn't as an effective as an intramuscular placebo injection. An injection is a more serious matter than swallowing a pill, and doesn't an injection go straight into the blood stream while a pill has to negotiate the complexities of the digestive system? Pinky red placebos were found to be more effective than blue ones, possibly because pinky red suggests health and vitality while blue suggests illness and failure. Machines, as we all know, can do extraordinary things, so if a person we trust tells us that a machine can reduce our pain we believe this and find that our pain is diminished, even though, unbeknownst to us, the machine wasn't switched on. This is what happened when researchers investigated the use of an ultrasound machine in the treatment of post-operative dental pain. Such a result is hardly surprising, given what is now known about pain.

It used to be thought that there was a direct correlation between the severity of an injury and the degree of pain felt. Yet it was well known that in the height of battle a soldier can be unaware that he has received a massive wound, while in a situation where the person is keenly aware of what is actually happening a tiny injury can be extremely painful. In trying to explain why this was so researchers discovered that the pathways which carry pain messages from the site of the injury to the brain have a series of 'gates' which are open or closed according to the mental state of the person. When we're concentrating on something other than our injury or when we're relaxed and happy many of the pain gates are closed, thus blocking or slowing down the message, but when we're stressed and anxious the gates are open and the pain message goes unimpeded to our brain.

Discoveries like this take our understanding of the relationship between mind and body out of the realm of mystery and into the realm of science. Another research area where this is happening is in those studies of brain activity made possible by the invention of techniques for scanning the brain to determine which part of the brain is being used when the person is engaged in different kinds of activities. One of these techniques is quantitative electroencephalography imaging, a measure associated with blood flow in the brain. Psychiatrists at UCLA compared depressed patients treated with placebo and depressed patients treated an antidepressant drug. It was found that the patients who responded well to placebo showed increased activity in the prefrontal cortex, while patients who responded well to medication showed decreased activity in the prefrontal cortex. It had already been established that the prefrontal cortex is involved in the business of making sense of what's going on, for which we need to be able to think, process information, remember recent events, pay attention, and organise what we're doing.

Amongst people who've been prescribed anti-depressants it's common knowledge that these drugs make thinking and feeling very difficult. Such people will say, 'My head's full of cotton wool,' or, 'I watch things happen but I don't feel anything.' It's perhaps not surprising that many of the depressed people treated only with anti-depressants fail to get better or, if they do, they get depressed again.

By contrast, if we're able to think clearly when we've been prescribed a drug which we believe is going to make us better, we're able to feel hopeful and happy and able to plan for a better future. But only if we value and care for ourselves.

Neither active drugs nor placebos work well for people who are convinced beyond doubt that they are incorrigibly bad, unworthy of health and happiness. People who see themselves like this live constantly in a state of stress. Always expecting rejection, they're constantly frightened of other people. Expecting to be punished for their wickedness, they live in constant fear of what is about to happen. Heartache and self-disgust create pain as real as that which follows physical injury. It's not surprising that researchers are now finding that many major and minor illnesses follow stress and depression.

There's nothing magic about a placebo, no matter what form it takes. Placebos work only when we've already got inside us the key to make a placebo work. That key is the best drug of all, and it's simply the belief that we're valuable and acceptable and that life is worth living.