Can Pill Placebo Augment Cognitive-Behavior Therapy for Panic Disorder?
Background: In a number of drug and psychotherapy comparative trials, psychotherapy-placebo combination has been assumed to represent psychotherapy. Whether psychotherapy plus pill placebo is the same as psychotherapy alone is an empirical question which however has to date never been examined systematically.
Methods: We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) that directly compared cognitive-behavior therapy (CBT) alone against CBT plus pill placebo in the treatment of panic disorder.
Results: Extensive literature search was able to identify three relevant RCTs. At the end of the acute phase treatment, patients who received CBT plus placebo had 26% (95%CI: 2 to 55%) increased chances of responding than those who received CBT alone. At follow-up the difference was no longer statistically significant (22%, 95%CI: -10% to 64%).
Conclusion: The act of taking a pill placebo may enhance the placebo effect already contained in the effective psychotherapeutic intervention during the acute phase treatment. Theoretically this is an argument against the recently claimed null hypothesis of placebo effect in general and clinically it may point to some further room for enhancing the psychotherapeutic approach for panic disorder.
The observed treatment effect, i.e. the change from baseline till endpoint, is traditionally thought to be due to four factors: regression towards the mean, natural course of disease, placebo effect i.e. non-specific effects of the therapist and the setting in which therapy takes place, and specific effects of physical or psychological intervention on the target condition.
When a specific therapy for a certain disorder exists, we therefore assume that it realizes all these four components through its administration. Cognitive-behavior therapy (CBT) for panic disorder is one such instance, because it has demonstrated its superiority in the rigorously internally calibrated, drug-sensitive group of patients vis-à-vis the pill placebo arm and also against a non-specific psychological intervention.
Whether adding pill-placebo to specific psychotherapy enhances its effectiveness is an empirically and theoretically interesting question. Some may assume that a specifically effective treatment has already realized all the above-mentioned four components of treatment effect and therefore addition of a pill placebo cannot enhance its effect. On the other hand, some may suspect that addition of pill placebo may subtract from psychological treatment because it may undermine the active commitment of the patient to follow psychological interventions. Or, some may argue that psychotherapy placebo and pharmacotherapy placebo work through different psychological mechanisms and can therefore be additive or synergistic.
While conducting a comprehensive systematic review of randomized controlled trials (RCT) of the combined psychological and drug treatment for panic disorder, we had a unique opportunity to compare the psychotherapy alone versus the psychotherapy plus pill placebo arms and would like to repot the results.
Background: In a number of drug and psychotherapy comparative trials, psychotherapy-placebo combination has been assumed to represent psychotherapy. Whether psychotherapy plus pill placebo is the same as psychotherapy alone is an empirical question which however has to date never been examined systematically.
Methods: We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) that directly compared cognitive-behavior therapy (CBT) alone against CBT plus pill placebo in the treatment of panic disorder.
Results: Extensive literature search was able to identify three relevant RCTs. At the end of the acute phase treatment, patients who received CBT plus placebo had 26% (95%CI: 2 to 55%) increased chances of responding than those who received CBT alone. At follow-up the difference was no longer statistically significant (22%, 95%CI: -10% to 64%).
Conclusion: The act of taking a pill placebo may enhance the placebo effect already contained in the effective psychotherapeutic intervention during the acute phase treatment. Theoretically this is an argument against the recently claimed null hypothesis of placebo effect in general and clinically it may point to some further room for enhancing the psychotherapeutic approach for panic disorder.
The observed treatment effect, i.e. the change from baseline till endpoint, is traditionally thought to be due to four factors: regression towards the mean, natural course of disease, placebo effect i.e. non-specific effects of the therapist and the setting in which therapy takes place, and specific effects of physical or psychological intervention on the target condition.
When a specific therapy for a certain disorder exists, we therefore assume that it realizes all these four components through its administration. Cognitive-behavior therapy (CBT) for panic disorder is one such instance, because it has demonstrated its superiority in the rigorously internally calibrated, drug-sensitive group of patients vis-à-vis the pill placebo arm and also against a non-specific psychological intervention.
Whether adding pill-placebo to specific psychotherapy enhances its effectiveness is an empirically and theoretically interesting question. Some may assume that a specifically effective treatment has already realized all the above-mentioned four components of treatment effect and therefore addition of a pill placebo cannot enhance its effect. On the other hand, some may suspect that addition of pill placebo may subtract from psychological treatment because it may undermine the active commitment of the patient to follow psychological interventions. Or, some may argue that psychotherapy placebo and pharmacotherapy placebo work through different psychological mechanisms and can therefore be additive or synergistic.
While conducting a comprehensive systematic review of randomized controlled trials (RCT) of the combined psychological and drug treatment for panic disorder, we had a unique opportunity to compare the psychotherapy alone versus the psychotherapy plus pill placebo arms and would like to repot the results.
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