Can Positive Framing Reduce Nocebo Side Effects? Current Evidence and Recommendation for Future Research

Abstract

Although critical for informed consent, side effect warnings can contribute directly to poorer patient outcomes because they often induce negative expectations that trigger nocebo side effects. Communication strategies that reduce the development of nocebo side effects whilst maintaining informed consent are therefore of considerable interest. We reviewed theoretical and empirical evidence for the use of framing strategies to achieve this. Framing refers to the way in which information about the likelihood or significance of side effects is presented (e.g., negative frame: 30% will experience headache vs. positive frame: 70% will not experience headache), with the rationale that positively framing such information could diminish nocebo side effects. Relatively few empirical studies (k = 6) have tested whether framing strategies can reduce nocebo side effects. Of these, four used attribute framing and two message framing. All but one of the studies found a significant framing effect on at least one aspect of side effects (e.g., experience, attribution, threat), suggesting that framing is a promising strategy for reducing nocebo effects. However, our review also revealed some important open questions regarding these types of framing effects, including, the best method of communicating side effects (written, oral, pictorial), optimal statistical presentation (e.g., frequencies vs. percentages), whether framing affects perceived absolute risk of side effects, and what psychological mechanisms underlie framing effects. Future research that addresses these open questions will be vital for understanding the circumstances in which framing are most likely to be effective.

Unethical informed consent caused by overlooking poorly measured nocebo effects

“…Those who received the positively framed PIL reported fewer side-effects (n=40 vs n=55). Other studies have reported similar findings 46. Full disclosure about the risks is conveyed in both types of frames.…”

Nocebo, Aufklärung und Arzt-Patienten-Kommunikation

“…Nocebo-Effekte können z. T. auch durch den gewählten Bezugsrahmen ("Framing") verringert werden, indem die Risikowahrscheinlichkeit positiv formuliert wird: "90 % der Patienten vertragen das Medikament gut" statt "Bei 10 % tritt eine Nebenwirkung auf " [2]. Dabei sollten Negationen ("Bei 90 % tritt diese Nebenwirkung nicht auf ", "Die meisten Patienten haben keine Schmerzen") vermieden werden, weil sich starke negative Suggestionen nicht mit einem "nicht" auslöschen lassen [11].…”

Experimental Assessment of Nocebo Effects and Nocebo Side Effects: Definitions, Study Design, and Implications for Psychiatry and Beyond

“…These two types of control conditions are not exhaustive. For example, as indicated in Table 1 , other variations could include giving participants a treatment with “standard” or usual care information in order to test the effect of other information provision strategies, for example, standard information versus positive framing of information about adverse outcomes, which focuses on the proportion of patients who will not experience these unpleasant outcomes (16, 17). Of most importance, however, is that researchers consider carefully their hypotheses and relevance to clinical practice, consider which factor(s) differ between their chosen conditions, and utilize appropriate control conditions in experimental designs that will allow them to most appropriately test their research question.…”