Perceptions and Practices of Placebo Therapy Among Healthcare Practitioners

The provided content consists of research articles and studies exploring the perceptions, attitudes, and practices of healthcare professionals regarding placebo therapy. The studies, conducted in various countries including Saudi Arabia, Denmark, Germany, and the UK, investigate the use of placebo interventions by family physicians, infectious diseases specialists, physiotherapists, nurses, and paramedics. The findings suggest that many healthcare professionals believe the placebo effect is therapeutic, but often use real drugs as placebos or provide non-specific therapies. The studies highlight the importance of understanding the role of context, treatment efficacy, and deception in determining placebo acceptability.

Placebo Use in Medical Practice among
Physicians: Knowledge, Attitudes and
Practices

Table of Contents
Aims and Objectives.............................................................................................................................3
LITERATURE REVIEW.....................................................................................................................3
REFERENCES.....................................................................................................................................9

LITERATURE REVIEW
A literature review can be defined as text or information collected through scholarly paper,
journals or any articles that includes current knowledge and substantial findings as well as
methodological contributions associated with the studies (Linde & et al. 2014). . Placebo treatment
or an intervention can be defined as an ineffectual treatment for a particular disease with an
intention of deceiving the patient who is taking the medicine (Bradshaw, 2016). There are two cases
when a person is given placebo treatment. Either the patient or the person who is receiving the
treatment will have actual treatment or it will not produce any pharmacological effect on the body.
Placebo treatments are generally conducted for medical research which include pills like inert
tablets, vehicle infusion, sham surgery and sugar coated pills (Babel, 2012).
Concept of Placebo and its implications
The concept of Placebo has been widely used in medical treatment of psychiatric diseases
but beyond achieving the impressive results (Hull & et al.2013). In the field of medicine, the use of
placebo treatment has been widely criticized and biomedical tradition does not rely on the results
obtained through placebo treatment. Kong, Man, Shetty & Kamath, 2013 has stated that placebo is
usually helpful in treating patients who are suffering from psychiatric issues because it has been
noted that in a group of untreated patients with anxiety and depression, a notable percentage of
patient's condition will improve with time. Whereas, a higher percentage of change in condition will
be noted in patients who are given placebo treatment. In this article, the overall study was divided
into three hypothesis which explained the overall study in the research (Shere-Wolfe & et al. 2013).
At initial level, different factors such as non-specific factors, regression towards the mean, various
covert and overt factors etc. contributed for healing of the disease. In the second hypothesis, the
patients were given specific medical treatment so that characteristic results could be produced. And
in the last case, the patients were incorporated with placebo treatment or inert therapy as it did not
contain any type of pharmacological effect. The disease was only treated on the basis of
imaginations, beliefs and expectations of the patient (Kisaalita, Staud, Hurley & Robinson, 2014).
Similarly Živčić, Racz & Naletilić, 2014 has stated that placebo effect can be calculated by
estimating the difference between magnitude of the response received through placebo minus the
magnitude of time effect in patients who were untreated. This effect can only be calculated
theoretically because it is very difficult to calculate the true placebo response from perceived
placebo effect as they fail to provide precise results and data ((Linde & et al. 2014). Researchers
also state that as these results are very difficult to be obtained so this practice should be abandoned
in medical use. Nocebo is also a form of treatment that is likely to produce negative effects and

many physicians are not aware about the term. Bradshaw, 2016 has added that placebo is related to
effects that are produced in a positive manner but Nocebo depends on the negative emotions and
meanings which are perceived by patient during a medical treatment. Placebo also produces
negative effects such as increased headache and drowsiness (Bąbel, 2013). If a healthy patient or a
participant is given a placebo treatment then there are increased chances of person encountering
negative effects because they do not receive any type of medical benefit from those medicines (Hull
& et al.2013). When researchers deal with the concept of placebo they generally consider two
important questions which are whether placebo effect exits in reality or not. Second question is
about the ethical issues and considerations that should be taken into account while giving placebo
treatment. Based on the research, it is accepted that placebo is associated with producing powerful
non-specific effects on patient’s body without producing any pharmacological effect. Placebo has
been widely used for number of researches and clinical trials as compared to any other medicine
(Kong, Man, Shetty & Kamath, 2013).
Placebos provide a wide range of therapeutic value even if they do not cure illness in any
form (De Deyn & D'Hooge, 1996). According to a New England Journal of medicine it has been
clearly stated that placebos should be considered as one of the major components of medical care
which helps in relieving patients to a certain degree (Linde, 2013). It should not be considered as
insignificant baseline in accordance to different medicines that are used in medical studies.
Significant primary research has determined that placebos are responsible for encompassing
numerous aspects in the healthcare field which helps in increasing the knowledge, practice and
attitude of all the physicians who use them to provide relief to the patients (Goldberg, Leigh &
Quinlan, 1979).
Although it is reported to produce better outcomes as compared to the anticipation estimated
but still there are increased number of susceptible conditions which are not only subjective but they
are also objectives. The subjective susceptible conditions include pain and anxiety whereas
objectives include blood pressure, EEG, serum hormone concentration and heart rate (Shere-Wolfe
& et al. 2013). In a double blind randomised controlled trial research, it was recorded that better
healing results are obtained in various conditions of angina pectoris, epilepsy, parkinson's disease
and cancer. Based on the placebo treatment, more than 19 possible reasons for changes have been
estimated and it has been reported that there is a spectrum of care and treatment present in placebo
effect (Kermen, Hickner, Brody & Hasham, 2010). Further, it was also included that reports which
were produced are misleading the actual results and placebo treatment can provide both
spontaneous as well as natural recovery from different types of diseases (Kisaalita, Staud, Hurley &
Robinson, 2014). The reports also confirmed that true placebo effects exist in medical practice.
Positive and negative effects of placebo use in medical practice

The use of placebos can have both negative and positive impacts in medical practice. For
example if placebos are used for research without the consent of patient then there are chances that
it will lead to breaching of patient's rights related to medical practice (Kong, Man, Shetty &
Kamath, 2013). They should be informed that they have been given the treatment which is not
pharmacologically active. On other in many cases it has been observed that placebos can produce
adverse drug reactions on patients such as feeling of nausea, headache and vomiting. Hence it is
very necessary to inform the patients before giving them placebo effects in medical practice. A
detailed study conducted by director at Harvard university stated that placebos have the capacity of
relieving symptoms of any diseases even if the patient is aware about the taking placebos. But there
have been cases of side effects that have been produced after patients were administered of placebo.
Major side effects can be nausea, severe headache and anxiety (Hassan, Fauzi & Hasan, 2011).
On other hand there are many positive impacts of placebos in medical practice. It can help in
conducting various medical researches which are based on determining the therapeutic values of
different types of drugs (Kisaalita, Staud, Hurley & Robinson, 2014). Although it is not ethical to
prescribe placebos to patients because it does not produce any therapeutic response in the body but
it is generally given due to many reasons. 17% of physicians administer placebo to patient so that
they are able to relieve various symptoms associated with the disease. They also provide placebo
treatments so that they can stop patients from complaining (Hróbjartsson & Norup, 2003).
Knowledge and relationships with Background Information and Predictors
According to the research, the placebo is not only limited to clinical trials and medical
research but it has now also extended to routine clinical treatment where this is used to improve the
mental and physical pain of patients who are suffering from various diseases and ailments (Živčić,
Racz & Naletilić, 2014). In a study conducted by a hospital, various specialists and residents
doctors were included. The overall study was based on questionnaire survey which consisted of 2
groups of prescribers. In each group, there were 30 individuals. For interviewing them, they were
personally approached and overall 2 visits were made in the interval of 1 week so that they could be
able to collect answers for the by using survey questionnaires. In the research, statistical analysis
with the help of SPSS was performed and the results obtained from it were considered statistically
significant (Linde & et al. 2014). Out of 90 participants, 83 were males and 7 were females whose
mean age was reported to be 35.2 years (24 to 59 years). No significant difference was recorded in
the three groups. The results obtained from the study stated that non-specific symptoms were
recorded to be 61.1% as a supplement to main therapy, 40% as a diagnostic tool, 32.2% to calm a
patient, 33.3% to satisfy/ mollify a patient and 23.3% to control pain. In the placebo the medicines
which are used are generally vitamin tablets 74%, oral analgesics 39%, antacids 15% and injections
with distilled water and normal saline 12% (Bradshaw, 2016). There has been a positive link

associated with knowledge and relationship in case of placebos. In a primary research conducted on
placebos it was stated that placebos were introduced to the genetic level and patient who were
diagnosed with certain level of gene variation were not likely to respond in a positive manner in the
cases of fake acupuncture (Czerniak & Davidson, 2012). As a result of this scientist can develop
more knowledge about designing various drugs that can produce more positive effect on the body.
Attitude and relationships with Background Information and Predictors
Out of 90 placebo prescribers, only 80 were selected for the studies. Out of these 80
participants 48 (60%) labelled placebo treatment as medicine. Resident doctors were more prompt
and frequent in delivering answers. Out of the rest, no body revealed anything to the patient while
one GP revealed that it was placebo. Out of 80 participants 72 were convinced that placebo is
usually effective sometimes. The answers recorded from the three groups did not differed
significantly. Based on appropriateness of prescribing placebo to patients it was revealed that 58%
believed it should be use by only those practitioners who are experienced (Hull & et al.2013). 15%
favoured the use of placebo for the purpose of research whereas 21% stated that it should only be
used when there is no previous experience associated with it. A higher percentage of 895 prevalence
was recorded for placebo prescribing for more than 10 times a year (Meissner, Höfner, Fässler &
Linde, 2012). The study also stated that an increased number of placebo based on vitamins and
analgesics were used whereas only 9% were used for saline and distilled water injections (Shere-
Wolfe & et al. 2013). Although much data can be collected from this research but due to less sample
size there has been possible under reporting which is one of the limitation of studies. Like most of
the studies a majority of doctors and practitioners also believed that placebo tends to change the
psychological mechanism of the body (Goodwin, Goodwin & Vogel, 1979).
In another research paper, studies were conducted to examine the attitude of practitioners
and patients about the use of placebo treatments in medical care (Kisaalita, Staud, Hurley &
Robinson, 2014). The study was based on one time telephone survey in northern California. 853
participants of Kaiser Permanente Northern California were included in the studies which were
between the age group of 18-75 years. They all had been seen by primary care provider because of
the occurrence of chronic health issues at least twice in every sex months. From all the members
who were eligible to participate, there was 53.4% (853/1598) response and 73.2% (853/1165) who
can be interviewed through telephone. Majority of the respondents accepted the recommendation of
placebo treatment under various conditions so that maximum benefits can be produced (Živčić,
Racz & Naletilić, 2014). Only 21.9% of the total participants argued that it was not favourable to
provide placebo treatment to the patient. Respondents also valued honesty which was provided by
physicians and the use of placebo revealed that non transparent use of placebo treatment can
undermine the relationship which exits between patients and doctors. In this research different case

scenarios were considered which were related to placebo treatments. In the first case of this study a
person visits a doctor as he has consistent stomach ache. After the diagnosis and test, the doctors
reveal that issue is not serious even though the cause of pain is not known (Linde & et al. 2014)
(Bradshaw, 2016). Based on this case (430 participants randomized) and doctors recommended a
sage herbal treatment which did not have any therapeutic effect on the body. The patients are not
aware about the treatment which is given to them. They are only given these type of treatment so
that doctors are able to assess the level of pain that is caused to patients. Patients are also advised to
call the physicians again if they are not relieved of their symptoms in three days (Hull & et al.2013).
Practice and relationships with Background Information and Predictors
In another case scenario the patient is aware that the doctor has prescribed them placebo
treatment so that it might help in promoting placebo effect in patients (Fässler, Gnädinger
Rosemann & Biller-Andorno, 2011). Those patients are also advised to call doctors if they are not
able to get relief from the pain and symptoms. In yet another study, a 28-year old female complains
about cold and cough symptoms from past one week and insists the doctor to recommend
antibiotics so that her physical health is restored. The physician aware about the symptoms and
knows that she has developed viral infection (Shere-Wolfe & et al. 2013). Antibiotics do not show
any effect on viral infections, hence she was advised with placebo treatment. Based on this study a
group of 78 patients were included in the study which were reported to suffer from chronic
abdominal pain. After prescribing them placebo treatment it was diagnosed that none of the patient
were suffering from serious health issues. All the patients who received the treatment were aware
that they have been given placebo treatment Kisaalita, Staud, Hurley & Robinson, 2014). The pills
contained sugar coated pills which were reported to produce relief through mind-body self healing
processes. The result of research stated that a majority of participants in the study were women
(n=524, 61.4%) with an average age group of 45 years. All the participants were once seen by
physicians for their chronic condition and most reported being in excellent (n=170, 19.9%) or very
good (n=359, 42.1%) health (Živčić, Racz & Naletilić, 2014). Placebo can be used in medical
practice because it helps in relieving the symptoms of pain and other diseases. Studies conduct in
recent times provided evidence on the use of clinical use of placebos in medical practice. A survey
was conducted within a hospital and 44% of the total respondents reported that placebos improved
the mental and physical conditions of patients who were suffering from various symptoms and
medical emergencies (Foddy, 2009). But there are many ethical dilemmas that are faced by
physicians and the patients that take placebo treatments. It is very necessary to take the ethical
considerations into account because it helps in increasing the satisfaction level of all the patient in
healthcare organisations (Lione, 2003).
There are advantages as well as disadvantages of placebo treatment in

medical practice. In a randomised control trial 450 participants were randomly
selected and interviewed on the basis of treatment they were receiving for
different medical condition (Linde & et al. 2014). They were selected randomly
through random sampling techniques and were purposely provided with
placebo and effectual treatment. A group of 80 members did not participated
and 20 could not satisfactorily answer the questions of the interviews. Out of
350 members 175 were given placebo treatment and the another group was
given effectual treatment so that various medical issues can be solved. Out of
175 patients who were given placebo treatment 40% of them were informed
about the placebo treatment which was given to them. Rest of the patients
were not informed (Bradshaw, 2016). Results of the study stated that placebo
controlled trials helped in providing more clear evidence about the clinical
benefits associated with placebo treatment. The medicines for the placebo
treatment helps in improving the efficiency of therapeutic information to a
higher extent. Due to smaller size of sample there are less chances of bias
study hence all the individuals are given equal treatment (Fässler, Gnädinger,
Rosemann & Biller-Andorno, 2009). But one of the greatest disadvantages of placebo
treatment is that one group who is participating in the study or research
remains untreated (Hull & et al.2013). There are many types of placebos that can
be given to patient depending upon the pharmacological therapies that are
present. Based on the survey it is reported that pain killing and anti-anxiety
reducing drugs are more effective when patient do not know about the
treatment which they are receiving. Some common placebos are sugar pills and
saline injections. Fake surgeries are also used in many medical treatment. One
of the best example of sham meniscal surgery was published in The New
England Journal of Medicine (Shere-Wolfe & et al. 2013). The response produced in
placebo treatment is physiological effect but according to a recent research it
has been stated placebo treatment seems to be illogical as it contains inert
substance that do not cause any effect on the body. Further the term “meaning
response was introduced which could relate the association of brain with the
placebo effect.” Another author Kisaalita, Staud, Hurley & Robinson, 2014 also tried to
create a difference between true and perceived effect produced due to
placebo. They also concluded that some placebo are likely to produce more
physiological effect on the body as compared to other placebos. For example
large pills are more effective than small pills (Comaroff, 1976). Coloured pills

seems to be attractive hence they are likely to produce more effectiveness as
compared to other placebo pills. Injections are also reported to be more
powerful than pills and surgeries are more effective as compared to pills and
injections (Živčić, Racz & Naletilić, 2014).
Based on the clinical significance of the studies it was revealed that there
was no statistically significant data recovered which can create a difference
between improved and not improved group (Linde & et al. 2014). Likewise there
was no placebo effect noticed which could improve the subjective and objective
outcomes of the treatment. Apart from positive effects there are many
negative effects that are produced due to placebo treatment. Similar to
placebo treatment, the inert substances are also likely to produce negative
effects via Nocebo effect. In this type of treatment, a negative consequences of
inert substance is produced on a person hence the treatment is not very
effective (Bradshaw, 2016). Another side effects that can be produced due to
placebos can be symptoms and negative outcomes related to real treatment
(Geers, Rose & Brown, 2014). One of the best example of Nocebo treatment is that
if a person has already taken opiate then the chances of respiratory depression
are likely to be produced if is again given in the form of placebo. In yet another
study it was revealed that withdrawal symptoms are also likely to be produced
after a female has discontinued hormone replacement therapy for menopause
(Hull & et al.2013). Women was on a placebo treatment for more than 6 years.
According to the results it was stated that 4.8% of women who were on placebo
treatment were reported to have withdrawal symptoms whereas 21.3% of
those on hormone replacement. It has also been stated that placebo
treatments are not effective for everyone. It depends on the physiological as
well as other bodily factors which are responsible for producing placebo effect.
Responding to symptoms also plays a very important role in producing placebo
effect on a person (Shere-Wolfe & et al. 2013). The response produced by analgesic
placebos has been linked to regional neurochemical differences in the
individuals who are experiencing pain. For example, patients who have
Alzheimer's disease do not tent to respond to placebos and it destroys the
capacity of pre-frontal cortex to have expectations (Kisaalita, Staud, Hurley &
Robinson, 2014).

REFERENCES
Books and Journals
Babel, P. (2012). The Effect of Question Wording in Questionnaire Surveys on Placebo Use in
Clinical Practice. Evaluation and the Health Professions, 35(4), 447-461.
Bąbel, P. (2013). Use of Placebo Interventions in Primary Care in Poland. Medical Principles and
Practice, 22(5), 484-488.
Bradshaw, M. L. (2016). Knowledge, Attitudes, and Personal Use of Complementary and
Alternative Medicine among Occupational Therapy Educators in the United States.
Occupational therapy in health care, 30(1), 80-94.
Comaroff, J. (1976). A Bitter Pill to Swallow: Placebo Therapy in General Practice. Sociological
Review, 24(1), 79.
Czerniak, E., & Davidson, M. (2012). Placebo, a Historical Perspective. European
Neuropsychopharmacology, 22(11), 770-774.
De Deyn, P. P., & D'Hooge, R. (1996). Placebos in Clinical Practice and Research. Journal of
Medical Ethics, 22(3), 140-146.
Fässler, M., Gnädinger, M., Rosemann, T., & Biller-Andorno, N. (2011). Placebo Interventions in
Practice: A Questionnaire Survey on the Attitudes of Patients and Physicians. British Journal of
General Practice, 61(583), 101-107. doi: 10.3399/bjgp11X556209
Fässler, M., Gnädinger, M., Rosemann, T., & Biller-Andorno, N. (2009). Use of Placebo
Interventions among Swiss Primary Care Providers. BMC Health Services Research, 9(1), 144.
Foddy, B. (2009). A Duty to Deceive: Placebos in Clinical Practice. American Journal of Bioethics,
9(12), 4-12
Geers, A. L., Rose, J. P., & Brown, J. A. (2014). Aligning Research and Practice: Implications of
Patient-Centered Care for Placebo Effects. The Patient, 7(1), 1-3
Goldberg, R. J., Leigh, H., & Quinlan, D. (1979). The Current Status of Placebo in Hospital
Practice. General Hospital Psychiatry, 1-3,
Goodwin, J. S., Goodwin, J. M., & Vogel, A. V. (1979). Knowledge and Use of Placebos by House
Officers and Nurses. Annals of Internal Medicine, 91(1), 106.
Hassan, T., Fauzi, M., & Hasan, D. (2011). Perceptions of Placebo Therapy Among Health
Practitioners in Jazan Region of Saudi Arabia. International Journal of Health Sciences, 5(1),
45-49.
Howick, J., Bishop, F. L., Heneghan, C., Wolstenholme, J., Stevens, S., Hobbs, F. R., & Lewith, G.
(2013). Placebo use in the United Kingdom: results from a national survey of primary care
practitioners. PLoS One, 8(3), e58247.
Hróbjartsson, A., & Norup, M. (2003). The Use of Placebo Interventions in Medical Practice-a
National Questionnaire Survey of Danish Clinicians. Evaluation and the Health Professions,
26(2), 153-165.
Hull, S. C. & et al. (2013). Patients’ attitudes about the use of placebo treatments: telephone survey.
Kermen, R., Hickner, J., Brody, H., & Hasham, I. (2010). Family Physicians Believe the Placebo
Effect Is Therapeutic but Often Use Real Drugs as Placebos. Family Medicine, 42(9), 636.
Kisaalita, N., Staud, R., Hurley, R., & Robinson, M. (2014). Placebo use in pain management: The
role of medical context, treatment efficacy, and deception in determining placebo
acceptability. PAIN®, 155(12), 2638-2645.
Kong, F. H., Man, L. K., Shetty, R. S., & Kamath, V. G. (2013). Knowledge, attitude and practice of
complementary and alternative medicine (CAM) among medical practitioners. IJRRMS,
April-Jan, 3, 5-8.
Linde, K. & et al. (2014). The use of placebo and non-specific therapies and their relation to basic
professional attitudes and the use of complementary therapies among German physicians–A
cross-sectional survey. PloS one, 9(4), e92938.
Linde, K. (2013). The Use of Placebo Interventions in Clinical Practice. Complementary Therapies

in Medicine, 21(2), 109-111. doi: http://dx.doi.org/10.1016/j.ctim.2012.11.010
Lione, A. (2003). Ethics of Placebo Use in Clinical Care. The Lancet, 362(9388), 999
Meissner, K., Höfner, L., Fässler, M., & Linde, K. (2012). Widespread Use of Pure and Impure
Placebo Interventions by Gps in Germany. Family Practice, 29(1), 79-85.
Shere-Wolfe, K. D. & et al. (2013). Infectious diseases physicians’ attitudes and practices related to
complementary and integrative medicine: results of a national survey. Evidence-Based
Complementary and Alternative Medicine, 2013.
Thomas, K. B. (1994). The Placebo in General Practice. Lancet, 344(8929), 1066-1067
Živčić, D., Racz, A., & Naletilić, D. (2014). Differences in attitudes towards/beliefs on
complementary and alternative medicine witnessed between physiotherapists,
nurses/paramedics and physicians. African Journal of Traditional, Complementary and
Alternative Medicines, 11(6), 57-65.