Wiley & Sons A/S. Published by John Wiley & Sons Ltd All rights reserved ACTA PSYCHIATRICA SCANDINAVICA DOI: 10.1111/acps.12422
Editorial Do cultures influence placebo response? Placebos have been used as controls (9). Price et al. Introduction (10) define the placebo effect as the average Individuals are born in, work in and live in cul- placebo response in a group of individuals and a tures, which have a profound effect on their lives placebo response as the change in symptom or and functioning. Cultures determine cognitive condition occurring as a result of placebo. Media schema and also how individuals express and deal and lay interpretations of placebo play an impor- with distress – whether it is physical or emotional. tant role in its acceptance. Cultures determine explanatory models of illness Culture itself is described as the milieu within that individuals hold and allocate health resources which one is brought up and has distinct frame- as well as encourage individuals to follow certain works, values and systems which not only give the pathways into care and accept or reject health care. individual a sense of belonging but also provide a Cultural variations in presentation of various sense of world view and values. It is critical that we psychiatric disorders have been studied, but not bear in mind that individuals carry multiple cul- treatment responses as widely. tural identities or micro-identities, which may It is inevitable that dietary habits, simultaneous reflect in a number of ways, such as gender, institu- use of alternative and complementary medicines tions, workplace and sexual orientation. Cultures and other factors such as pharmacodynamics and determine cognitive schema and interpretation of pharmacokinetics play a major role in acceptance symbols of relevance and importance within that of pharmaceutical agents and treatment outcomes culture. This is the crux of understanding placebo across cultures. response. However, this aspect of placebo response In various cultural settings, patients and their must be seen in the context of how patients per- carers have varying expectations. In this editorial, ceive their illness experiences – what names and we explore the role of placebo response. explanatory models they give to it, but also the actual therapeutic communication and encounter. It is clear that all these are strongly affected by Placebo response cultures. The placebo response itself is affected by a number Disease and illness: Doctors are trained to diag- of factors (1). These include colour, name, appear- nose and treat diseases, whereas the social impact ance, route of administration of drugs as well as of diseases is embedded in illnesses. Doctors focus personality traits of patients (2). Both classical on organs and their dysfunction, whereas patients conditioning (3) and information processing (4) see the impact of disease in their states of being have been described as influencing placebo effect. and social function (11). Diseases and illnesses do The term placebo derives from Latin, with its lit- not map distinctly onto each other (12). Thus, eral meaning being ‘I please’. Placebos have been seeing the social implications in the cultural con- used for millennia and the term carries multiple text is important. It is also likely that patients are meanings and interpretations (5). The term does keen to seek healing for their illnesses and these carry negative meanings as well (6). It has been may be more attractive because they take into argued that in spite of its perceived ‘inertness’, account individual models of distress (13). Cul- patients do get better (7). These authors note that tures also influence explanatory models and Beecher’s original observation (8) that placebo Kleinman (13) noted that in Taiwan patients may work as a psychological instrument and as a expected allopathic doctors to provide injections, resource for the doctor and to study the mecha- whereas Chinese doctors were expected to provide nisms of drug action still stands. From the early herbal treatments, thus highlighting different days of randomised controlled trials where place- expectations. bos and ‘active’ medications were compared, the Culture and Placebo: It has been argued that actual impact of placebo has not been clear, and placebos affect the illness more than they affect the some of the reasons for this are described below. disease (14). Classical conditioning (15) and
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expectancy (16) are key aspects of placebo stimulating (24). De Craen et al. (25) confirmed response. Thompson et al. see expectancy as the that stimulation was associated with medicine patient’s level of expectation that they will be which was marketed in hot colours (red, orange, helped by the treatment. These authors argue that yellow), and antidepressants were marketed in cold expectancy is a fairly robust and comprehensive colours (blue, green, purple). In a study with vol- model, thereby recognising the importance of the unteer medical students, similar observations were therapeutic context through supporting expectancy made (26). Expectations thus drive the placebo and triggering a placebo effect. In order to kick off effect (27). Where patients see their illness as hot or such responses, verbal instructions play a role, thus cold, they will only accept medication which deals confirming the role of communication in therapeu- with the heat or cold. Buckalew and Coffield (23) tic engagement. In many cultures, patients expect demonstrated that white capsules were seen as their doctors to make the right decisions and look analgesics by Caucasians, but as stimulants by after them, making the responsibility clear, African Americans, whereas black capsules were whereas in others, patients want to be given infor- seen as stimulants by Caucasians and as analgesics mation and expect joint decision-making where by African Americans. Interestingly, among pas- they have equal say. Thompson et al. (7) suggest sive individuals who were intellectually oriented, that a related concept to expectancy is self-efficacy. sedative agents produced higher (than expected) This depends upon the belief that one can success- levels of sedation (2). fully perform actions needed to achieve valued Regrettably, in drug trials, these factors are outcomes. not taken into account. It has been demonstrated Caspi (17) puts forward a model which sees the that holidays and year of birth play a role in therapeutic relationship between clinician and patient responses (28), but drug trials do not patient as the key trigger to placebo response. appear to take these factors into account. Caspi (17) proposes that clinicians may thus use In clinical practice a few decades ago, Neki the process of the therapeutic encounter to re- et al. (29, 30) observed that African patients had frame the patient’s concerns and health status in varying expectations from psychiatrists in com- ways that can instil hope. Brody (18) argues that parison with shamans who offered traditional the practitioner plays a key role in providing an healing practices. In African cultures, there was explanation of what is wrong with the patient and a clearly observed discrepancy between the Afri- holding out a promise for the patient that no mat- can illness and expectations from European cli- ter how bad things are, they will get better. This nicians. The challenge for modern psychiatry is dealing with ambiguity and holding hope for the to look at cultural variations and cultural differ- patient are key responsibilities of the psychiatrist ences and place these in the context of clinical (19). The key is what meaning patients give to practice, patient expectations and therapeutic their experiences and distress which are culturally encounters. influenced. Two explanations have been offered in Ninnemann (31) raises some interesting points understanding the placebo effect – its dynamic about the role of ethnopsychopharmacology in effect and, secondly, that the placebo effect inter- placebo effects. There is no doubt that discussion acts synergistically with other therapeutic ele- of ethnic and racial differences and identities are ments (20). charged with irrational emotions. The emphasis on Placebo effect has also been seen as offering a genomics and development of psychopharmacoge- meaning response, which means the psychological nomics raises some significant issues, and cultural or physiological effects of meaning in treatment of differences therefore deserve further exploration in illness (21). Visual perceptions and world views dif- the cultural, sociological and anthropological fer across cultures, and the links between biology contexts. and culture require further exploration. It is possi- Kleinman (32) noted that, in spite of increasing ble that cultural variations in pharmacodynamics data from treatment outcome studies on the and pharmacokinetics will affect responses to effects of psychopharmacological medications, placebo. the evidence remains less impressive. He emphati- Colour of medication: Patients’ compliance of cally argues that cultural and psychosocial fac- medication and treatment is strongly influenced by tors deserve more and better attention. Thus, the role (they think) medicine plays (22). The size there is a clear challenge for regulators like the and colour of the tablets are significant factors. Federal Drug Administration that any drug trials Blue is seen as depressant-sedative, and yellow as take into account psychosocial impact of drug stimulant antidepressants (23). Blue preparations trials and focus on cultural relativism. We know are more soothing; and red, pink or yellow as more that drug trials previously conducted had
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recommended doses which were inappropriate for References
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