By Jessy Shallcross
The focus of my dissertation is Major Depressive Disorder (MDD). From a critical neuro-geographical perspective, it examines recent cognitive neuroscience research on MDD. It utilises discourse analysis to explore the experimental methodologies mobilised in this research and asks what kind of depressed subject is presumed, and how this subject is subsequently imagined. This project foregrounds a theoretical approach of ‘slowing down science’ (Stengers, 2018), in relation to unpicking neuroscientific approaches to mental health. It also utilises affect theory to critically examine the neuroscientific molecularization of mental health that has occurred over the last few decades. This blog piece picks up a strand of my reading on MDD: that of placebo in clinical research. It thus examines how the meaning of placebo is historically and culturally mediated, shaped by conflicting forces, and public discourse.
Figure 1: Placebo. Image source: https://innerself.com/content/living/health/healing-disciplines/9677-the-healing-power-of-the-placebo-effect-is-it-real.html
Over the last few decades there has been a growing interest in research and public discourse on the effect of placebos (Harrington, 2006; Marchant, 2016). At the same time, there has been a medicalisation of mental health. Conventionally, a placebo is thought to be an inert substance that is used in clinical research. Generally, in a drugs trial, there will be two groups, one will receive a placebo and the other will receive the drug being tested; this method is intended to demonstrate the efficacy of the new drug on the tested subjects (Marchant, 2016). However, since the 1970s, placebos are no longer only viewed as the ‘control’ in Randomised Control Trials (RCTs), whereby patients do not know if they have been given a placebo or not, there has since been movement towards the study of the role that placebo actually has in treatment, particularly in holistic practice (Harrington, 2006). This opens up discussion on the multitude of ways that a placebo treatment can affect the human: whether this is due to biochemical effects, traditionally thought of as in the body, or psychological effects, such as, the feeling of being cared for (ibid). In public discourse over the last decade, there has been a plethora of articles surrounding placebo’s healing effects, the nature of the placebo and its effects has ‘suddenly become a very public discussion’ (Harrington, 2006, p.183). Articles with diverging opinions on the effect of placebo are circulating in a way that could be attributed to ‘fast science’, which denotes the relationship between the knowledge economy and science in contemporary culture – whereby scientific research is valued on the speed of its publication and citation count (Stengers, 2018). Within these discussions, there also remains the shadow of ‘Big Pharma’: if placebos start to be accepted by healthcare professionals and the public, as a form of holistic treatment, then this will have significant adverse effects on multinational pharmaceutical companies – this is demonstrative of the entanglement of science, medicine and capitalism (Marchant, 2016).
In order to unpick the recent turn towards researching the potential ‘use’ of placebo in treatment, this next section will provide a historical excursion into the lineage of placebo. To begin, the Oxford English Dictionary (OED) (2018, n.p.) provides a triage of definitions:
“1. A medicine or procedure prescribed for the psychological benefit to the patient rather than for any physiological effect.
1.1 A substance that has no therapeutic effect, used as a control in testing new drugs.
1.2 A measure designed merely to humour or placate someone.
Late 18th century: from Latin, literally ‘I shall be acceptable or pleasing’, from placere ‘to please’.”
The emphasis in the main definition is on the psychological effect of placebo on the subject, inferring an effect that is centred on the psyche of the patient, rather than any apparent physiological effect on the subject’s body or brain. The division between psychological and physiological effect is demonstrative of the dogged mind-body dualism. The secondary definition is deterministic, representing the notion of placebo since the introduction of RCTs in the 1950s (Harrington, 2006). Within this framing, the placebo is only the control and has no other use or effect, it solely acts as a tool for assessing the success of the medication under scrutiny. Thus, this one definition, provides a plurality of meanings. The struggle over the definition of placebo has caused controversy within science and public discourse; the outcome of what definition is adopted has a compelling effect on how placebos are perceived by the academic community, medical practitioners and the public alike (Harrington, 2006).
Moving onto academic debate on placebos and the multiple meaning of ‘placebo’, for Harrington (2006, p.182), the placebo effect has three definitions: an illusory impression, a control drug for trials and ‘a powerful mind-body phenomenon with a “real” biology of its own’. She elaborates that placebos were once used to expose fraud, as in the administration of fake medicine, and now they are used to prove validity (Harrington, 2006). This represented an important historic juncture, as the use of placebo changed to validating drugs that were being tested against a placebo. Concerns over producing medical knowledges became entangled with moral concerns; the notion of suggestion, circulating in a power-relationship between the authority of a doctor and the ‘impressionable patient’ became apparent, this represented the ‘making of the idea of the placebo effect’ (Harrington, 2006, p.185). This making of the idea of the placebo effect and the multiple meanings that placebo can have for many different actors at once has long been acknowledged. In 1906 Cabot stated that, ‘“we give a placebo with one meaning; the patient receives it with quite another. We mean him to suppose that the drugs act directly on his body, not through his mind…Placebo giving is quackery”’ (cited in Harrington, 2006, p.187). Thus, despite this notion of different meanings for different actors has been acknowledged since at least 1906, it is only recently that the actual mind-body effects of the placebo have been discussed in clinical and populist scientific discourse. The reason for the multitude of existing definitions is that there is more than one ‘we’ imbricated within placebos: various researchers, scientists, academics, producers and consumers (Harrington, 2006, p.187). This problematises the use of placebo in scientific research and opens it up to a multitude of subjective meanings and causes.
How do these multiple meanings operate in terms of clinical practice? Wilson (2015, p.130) argues that there is a heterogeneity of evidence for the use of placebos in research – there is an ambivalence within different strands of science as to what the effect of the placebo is, this is apparent across various studies and trials. The notion of the placebo being a control is problematised as in research there are so many variables to control for: ‘…variables align, disassociate, repeat, correlate, and proliferate in a mosaic of causal relations’ (Wilson, 2015, p.130). She further argues that the separation of placebo from medication is in some way arbitrary, as we can never control for the variability in the drug-placebo relationship, we can’t separate drug from placebo (Wilson, 2015, p.131). Moreover, how do we account for a difference in response from one subject to another, whilst considering the myriad of subjective differences in flux at the same time: social, environmental, cultural and biological.
To illustrate why there are multiple meanings of ‘placebo’ and to unpick the effects of this, it is interesting to explore the etymology of the term. In her chapter ‘Bastard Placebo’ in Gut Feminism, Wilson (2015) contends that ‘placebo’ emerged from Latin, denoting ‘Vespers’ that were employed to sing to the dead, these people were known as placebos – sham mourners – and it was from this that the word placebo became a medical term for sham treatment (Wilson, 2015, p.132). Further, Wilson (2015, p.133) refers to a different archaic use of the term ‘placebo’, one that doesn’t get as much traction in the literature. In the 15th to 17th centuries, to call someone a ‘placebo’ was to, ‘describe that person as a flatterer, a sycophant, or a parasite.’ (Wilson, 2015, p.133). Generally, we think of a parasite as taking something from another, to the receiver’s degradation, living off another organism. However, in biology, parasite has another meaning, it denotes a variety of ‘codependent relationships’ (ibid.). Here the emphasis is on mutual dependency, relations between two organisms, as opposed to a solely extractive process. Thus, a parasite in biological terms is something that performs symbiotic relations with another species, this can be a two-way street with both organisms feeding one another, creating relations with one another for shared nutritional interest (ibid.).
In relation to mental health, Wilson (2015) uses this biological etymological excursion to highlight how despite the historical lineage of ‘placebo’ and ‘parasite’, the relations between antidepressant medication and placebo in clinical literature is not assessed, it is actively dismissed, when, perhaps, ‘…drug and placebo might have coevolved and now exist in a mutually beneficial alliance’ (ibid). A relationality of parasitic behaviour may be at play in the digestion of placebos and antidepressant medication in the body. Further, the psycho-social effects that are thought to be exterior to the body, are also imbricated in this web of causality. Wilson (2015, p.136) goes as far to say that antidepressant medication, ‘can only fully be itself – when it has been adulterated by placebo.’ Therefore, the relations between placebo and antidepressant medication within the body, understood as physiological, psychological and affective at the same time, needs to be analysed, rather than just the placebo effect, and then the antidepressant effect, in isolation:
“A more comprehensive theory of causality is needed to explain the data – one that doesn’t pitch physiology against suggestion, or divide pharmacological effects from treatment-related effects, but instead understands how ingestion of pills, physiological activity, mood, and therapeutic alliance are systemically aligned. That is, the origin of placebo response (and thus the origin of drug response) is to be found not in a particular location (a gene, a trait) but dispersed across a network of psycho-genetic-institutional-pharmacological action.” – Wilson, 2015, p.138
The unpacking of the ontology of medication such as antidepressants is therefore necessary; its reactions with other medications, whether that is placebo or not, and its interactions with the subject’s body, organs, and their body-environment relations – we cannot separate these, instead we need to view them as an entangled web of interactions (Wilson, 2015). With this complexity in mind, a relational approach is adopted in my dissertation in conceptualising the interactions and co-dependency of affective, somatic, psychological and environmental facets of major depressive disorder, and the way that this translates in experimental neuroscientific research.
Harrington A. (2006) ‘The many meanings of the placebo effect: where they came from, why they matter’: BioSocieties, 1(2), 181-193
Marchant J. (2016) Interview with Jo Marchant for The Observer, 15th February – Available: https://www.theguardian.com/science/2016/feb/15/jo-marchant-mind-body-health-medicine-science – First accessed: 1st July 2018
OED (2018) ‘Placebo’ – Available: https://en.oxforddictionaries.com/definition/placebo – First accessed: 25th June 2018
Stengers I. (2018) Another Science is Possible: A Manifesto for Slow Science, Polity Press: Cambridge
Wilson E. A. (2015) Gut Feminism, Duke University Press: London