Depression and the Placebo Effect Psychogenic Illness and Suggestion Hypnosis, Pain Reduction, and Adherence with

1. Depression and the Placebo Effect  Psychogenic Illness and Suggestion Hypnosis, Pain Reduction, and Adherence with Medical Instruction Irving Kirsch Faculty of Health and Social Work University of Plymouth

2. Common Theme: Suggestion Effects in Health Psychology

3. Depression and the Placebo Effect Irving Kirsch Faculty of Health and Social Work University of Plymouth

4. Suicides in Adults(Healy, 2003)

5. Suicides in Adults(Healy, 2003)

6. Are Antidepressants Effective? Listening to Prozac But Hearing Placebo (Kirsch & Sapirstein, 1999)

7. Pre-post Effect Sizes for Drug, Placebo, and No-treatment Controls 75% dup plac 25% dup NT -> 50% plac, 25% nat hist; 25% drug But reason suspect much or all 25% also plac effect OVERHEAD: r=.9075% dup plac 25% dup NT -> 50% plac, 25% nat hist; 25% drug But reason suspect much or all 25% also plac effect OVERHEAD: r=.90

8. Partitioning the Antidepressant Drug Response 75% dup plac 25% dup NT -> 50% plac, 25% nat hist; 25% drug But reason suspect much or all 25% also plac effect OVERHEAD: r=.9075% dup plac 25% dup NT -> 50% plac, 25% nat hist; 25% drug But reason suspect much or all 25% also plac effect OVERHEAD: r=.90

9. �This can�t be true�

10. The Emperor�s New Drugs:An Analysis of the FDA Data Set Fluoxetine (Prozac) Paroxetine (Seroxat/Paxil) Sertraline (Lustral/Zoloft) Venlafaxine (Effexor) Nefazodone (Dutonin/Serzone) Citalopram (Cipramil/Celexa)

11. Advantages of the FDA data set Includes unpublished trials Same outcome measure (HAM-D)

12. % of Trials Showing Significant Drug/Placebo Differences

13. Improvement Across Drugs Duplication by Placebo = 82% Mean HAM-D change = 1.80 points

14. FDA Dose-response Studies(10 Trials) How did the drugs get approved? Need two trials with sig diffs LOCF data Usually considered more stringent, but isn�t People who show early improvement (probably a placebo effect), but can�t tolerate side effects should be considered tx failures ANALYSIS OF LOCF vs OC Ignore degree of diff, only ask if stat significantHow did the drugs get approved? Need two trials with sig diffs LOCF data Usually considered more stringent, but isn�t People who show early improvement (probably a placebo effect), but can�t tolerate side effects should be considered tx failures ANALYSIS OF LOCF vs OC Ignore degree of diff, only ask if stat significant

15. Findings replicated by NICE Conclusion: The response to antidepressant medication is primarily a placebo effect

16. Psychogenic Illness and Suggestion Irving Kirsch Faculty of Health and Social Work University of Plymouth

17. Mass Psychogenic Illness Occurrence of physical symptoms in the absence of an identifiable pathogen Perceived threat of biochemical terrorism makes MPI more likely �Psychogenic� implies that symptoms are produced by psychological factors Diagnosis based mostly on failure to find a physical pathogen

18. Our StudyPurposes: Can typical MPI symptoms be produced in the lab? Investigate two psychological factors Expectancy Contagion by observation

19. Instructions to Participants �I am a Research Assistant and part of a Medical Psychology Research Team that is studying a suspected environmental toxin. This substance has been reported to produce a number of temporary symptoms in workplaces in the Northeast. The most frequently reported symptoms are headache, nausea, itchy skin and drowsiness. These symptoms seem to develop very quickly after exposure to this substance, but they are relatively mild, and they do not last very long--rarely more than an hour or so.�

20. Target symptoms Headache Nausea Itchy skin Drowsiness Non-target symptoms Watery eyes Scratchy throat Chest tightness Breathing difficulty

21. Design

22. Effect of Inhalation

23. Effect of Observation

24. Conclusions Expectancy can cause people to experience psychogenic symptoms. Effect of observation remains unclear CONCLUSIONS Expectancy Expectancy can cause people to experience psychogenic symptoms. Expectancy effected both Target and non-target symptoms, but effected Target symptoms to a greater degree There was a nocebo effect. This seems to have relevance to MPI Modeling Modeling did not significantly add to reported symptomology. Is This due to our methodology? Perhaps this tightly controlled experimental environment did not sufficiently replicate the experience of an MPI. For example, 1. There was only one confederate experiencing symptoms, not a group of people. 2. People are more likely to experience symptoms in MPI if they know the person who is displaying symptoms. We did not attempt to replicate this. CONCLUSIONS Expectancy Expectancy can cause people to experience psychogenic symptoms. Expectancy effected both Target and non-target symptoms, but effected Target symptoms to a greater degree There was a nocebo effect. This seems to have relevance to MPI Modeling Modeling did not significantly add to reported symptomology. Is This due to our methodology? Perhaps this tightly controlled experimental environment did not sufficiently replicate the experience of an MPI. For example, 1. There was only one confederate experiencing symptoms, not a group of people. 2. People are more likely to experience symptoms in MPI if they know the person who is displaying symptoms. We did not attempt to replicate this.

25. Hypnosis, Pain Reduction, and Adherence with Medical Instruction Irving Kirsch Faculty of Health and Social Work University of Plymouth

26. Hypnotic analgesia Correlated with suggestibility 75% show substantial relief Reduces need for medication Accompanied by changes in the brain Surgery without drugs But Seldom used

27. The Effects of Hypnotic and Nonhypnotic Imaginative Suggestion on Pain (Milling, Kirsch, Allen, & Reutenauer, in press)

28. Pain Stimulus Forgione-Barber Strain Gauge Pain Stimulator

29. Suggestion: Imagine that your hand is insensitive and numb, as if you were wearing a thick glove

30. Procedure

31. Pain Reduction by Hypnotic and Nonhypnotic SuggestionMilling et al. (in press)

32. Pain Reduction by Hypnotic and Nonhypnotic SuggestionMilling et al. (in press)

33. Hypnosis and Adherence Types of non-adherence Voluntary Involuntary Methods of enhancing voluntary adherence Specifying time and place Hypnotic suggestion to enhance memory �The idea of�will come easily to mind�

34. Study 1Compliance with Pill Taking Instructions

35. Study 2Compliance with Exercise Instructions

36. Conclusions Suggestion can reduce pain and enhance adherence to medical instruction The effect on pain does not require the induction of hypnosis The effect on compliance depends on the person�s suggestibility

37. Mid-life women�s health and the menopause Pamela A. Jacobs School of Psychology University of Plymouth

38. Aim & Studies Using a quality of life perspective � to examine the psycho-social aspects of women�s mid-life health during the menopause. To evaluate the impact of declining sex hormone levels on memory in elderly women Qualitative methods : focus groups and interviews Cross-sectional questionnaire based studies Planning stage of experimental study Recruitment through health authority patient lists. 2 large scale studies: SW and national. Advertising � women�s magazines, libraries, chemists, health food shops, university, social services. random sample from telephone directories

39. Measures MQOL scale: 48 items, 7 domains, energy, sleep, appetite, cognition, mood, social interaction, symptom impact. Minor health complaints: 5 domains, respiratory, atopic, gastro, Indicators, fungal. Diet Prescription drug use in the last 2 months Physical fitness indicator Relevant medical history i.e. hysterectomy, history of menstrual cycle problems. History of HRT use Menopausal status and SRMS Psychological measures; LOC & Stress level indicator CAM use scale Biographical information i.e. employment, education, age, marital status

40. Our Previous Studies Development of a Menopausal Quality of Life Scale. Domains: sleep, energy, social interaction, symptom impact, cognition, mood, appetite. Alpha scores ranged from .69 - .91 for each domain. Convergent validity r =.66. Determinants of quality of life: work status, health status and menopausal status,. Determinants of HRT use: menopausal status, QOL ( symptom impact, cognition), hysterectomy, health status.

41. Previous Studies Many women took HRT for only a short time, mean use 8 months range of 2 weeks to 8 years. Role of Hormones and prescription drugs in QOL Prescription drug use was higher in HRT user groups than non users HRT users who also took prescription based drugs had significantly lower mean length of HRT use. Significant association between length of HRT use and health Those who took HRT plus SSRI�s reported significantly better QOL than those who took SSRI�s alone

42. Current Studies Mid-life women�s use of Complementary & Alternative Medicine to improve QOL Mid-life women�s diet and minor health complaints � analysis of data Health scares and hormone use � how have women and GP�s reacted to information about HRT?

43. Future studies The impact of hormone levels on cognitive functioning. System effect ( attention) or specific effects ( verbal memory ) Window of opportunity for supplement use to bring beneficial effects? Do all estrogens have the same effect on memory?

44. Respiratory Psychology: The LINQ Plymouth Respiratory Research Group: The LINQ group: Rupert Jones, Michael Hyland, Karen Hanney

45. History Focus groups on compliance Driven by clinical need Information needs versus knowledge Iterative process of questionnaire construct using focus groups QUESTIONS CONSTRUCTED BY PATIENTS Quantitative examination of the data

46. Sample question Which of the following statements best describes what will happen to you over the next few years? TICK ONE ONLY Now that my disease is being treated, I will probably get better Now that my disease is being treated, I will probably stay the same  I will get worse I have no idea

47. Sample question Are you satisfied with the information doctors and nurses have given you about your inhalers or medicines? TICK ONE ONLY I understand everything I need to know I understand what I have been told but I would like to know more I am slightly confused about my medicines I am very confused about my medicines

48. Sample question What sentence best describes what you have been told to do if your breathing gets worse? TICK ONE ONLY "(e.g., take two puffs instead of one)" I have been told what to do and the doctor/nurse has given me written instructions I have been told but it is not written on paper I haven't been told but I know what to do I haven't been told and I don�t know what to do

49. Sample question Have you been told when you should call an ambulance if your breathing worsens? TICK ONE ONLY I have been told what to do and the doctor/nurse has given me written instructions I have been told but it isn't written on paper I haven't been told but I know what to do I haven't been told and I am uncertain when an ambulance should be called

50. Sample question Has a doctor or nurse told you how much physical activity you should do? Yes and I know what to do Yes but I am unsure what to do Yes but I am unable to do it No

51. Sample question How much physical activity do you do? As little as possible I make an effort I push myself as much as I can

52. Scoring: 5 domains disease knowledge (DK), medicines (MED), self-management (SM), smoking (S), exercise (EX) diet (D)

53. Findings High levels of information needs Information needs related to staff contact Specialist nurse Inpatient Physiotherapist Rehabilitation

54. Future National collaboration International collaboration Italy Japan Evaluation of rehabilitation Outcome Information needs

55. Acknowledgements Thanks to Boehringer Ingelheim

56. Research areas 1. Posttraumatic stress disorder (PTSD) 2. Stress/burnout Posttraumatic stress disorder (PTSD) To investigate the extent to which people experience PTSD responses following traumatic events (e.g. accidents, injury, life-threatening illness) To identify whether personality factors and coping strategies are risk factors associated with these traumatic reactions

57. PTSD following technological disasters: personality and coping Completed and published King�s Cross fire Marchioness disaster Train crash (Stafford) & plane crash (Coventry) General findings: 39% high PTSD severity Neuroticism and emotion-focused coping were associated with PTSD symptoms and general health problems.

58. PTSD following spinal cord injury: personality and coping Submitted to publication The relationship between locus of control and post-SCI PTSD Type of spinal cord injury, trauma recency and previous traumatic life events in patients General findings: 44% PTSD Internal locus of control was associated with post-SCI PTSD external locus of control was associated with general health problems

59. PTSD following myocardial infarction: personality and coping Completed The relationship between emotion/problem-focused coping, big five personality factors and post-MI PTSD General findings: 31% PTSD problem-focused coping was associated with post-MI PTSD Patients with high severity of post-MI PTSD tend to be more neurotic and less agreeable.

60. PTSD following asthma attack: personality and coping Completed The relationship between alexithymia and post-asthma attack PTSD General findings: 2% high PTSD severity Severity of asthma attack was a predictor to PTSD no relationship between alexithymia traits and post-asthma attack PTSD was found

61. PTSD following anaphylactic shock: personality and coping Completed The relationship between emotion/focused coping and post-anaphylactic shock PTSD General findings: 13% high PTSD severity Emotion-focused coping was associated with PTSD

62. PTSD following homicide: personality and coping Completed The relationship between dissociation and PTSD following the act of homicide 59% high PTSD severity High dissociation was associated with high PTSD symptoms

63. PTSD and ongoing studies PTSD and chronic obstructive pulmonary disease (COPD): interface between previous traumatic experiences, PTSD severity and rehabilitation PTSD and falling: interface between disability, fear of falling and PTSD severity PTSD and urticaria: perceived stress, previous traumatic life events, coping, personality and severity of urticaia PTSD and stroke: coping and personality (cross-cultural study)

64. Health Psychology: Complementary and Alternative Medicine (CAM) Michael Hyland, Janet Richardson, Jennifer Millward, Alistair McConnon

65. The problem Double blinded clinical trials Clinical experience Specific effects Non-specific effects

66. Theoretical rationale Entanglement theory versus the therapeutic alliance Expectancy, therapeutic bond shared goals Application of quantum mechanics to macro-systems Paradigm shift Methodological problems Explains absence/small effects in RCTs but also therapeutic effects in �real life� Therapists are more important than therapies

67. Studies Studies conducted in Freiburg Spatially separated people, electromagnetic and acoustic shielding EEG response of one person to stimulus presentation of another

69. Flower essence studies Personality predicts outcome after controlling for expectancy

70. Therapist effect studies Difficult to conduct Some therapists have consistently good non-specific effects (psychotherapy literature) What are the contextual factors that affect medical treatment What are the contextual factors that are important in CAM?