What Do Placebo and Nocebo Effects Have to Do With Health Equity? The Hidden Toll of Nocebo Effects on Racial and Ethnic Minority Patients in Clinical Care

Abstract

A placebo effect is a positive clinical response to non-specific elements of treatment with a sham or inert replica of a drug, device, or surgical intervention. There is considerable evidence that placebo effects are driven by expectation of benefit from the intervention. Expectation is shaped by a patient’s past experience, observations of the experience of others, and written, verbal, or non-verbal information communicated during treatment. Not surprisingly, expectation in the clinical setting is strongly influenced by the attitude, affect, and communication style of the healthcare provider. While positive expectations can produce beneficial effects, negative information and experiences can lead to negative expectations, and consequently negative or nocebo effects. Key components identified and studied in the placebo and nocebo literature intersect with factors identified as barriers to quality care in the clinical setting for Black patients and other patients of color, including poor patient-clinician communication, medical mistrust, and perceived discrimination. Thus, in the context of discrimination and bias, the absence of placebo and presence of nocebo-generating influences in clinical settings could potentially reinforce racial and ethnic inequities in clinical outcomes and care. Healthcare inequities have consequences that ripple through the medical system, strengthening adverse short- and long-term outcomes. Here, we examine the potential for the presence of nocebo effects and absence of placebo effects to play a role in contributing to negative outcomes related to unequal treatment in the clinical encounter.

Moderators of the response to deep TMS for smoking addiction

“…Further, in a study which factored in financial strain and educational attainment, no difference in smoking cessation between African–Americans and Whites was observed ( 31 ). The observed higher placebo quit rate in African–American at 18 weeks may be due to racial disparities in placebo effects ( 32 , 33 ) or due to small N.…”

Sharing online clinical notes with patients: implications for nocebo effects and health equity

“…Bridging evidence about communication disparities in care, a range of conceptual and empirical papers drawing predominantly on data conducted in the USA recently proposed that some patient populations may be both less susceptible to placebo effects, and/or more at risk of experiencing nocebo effects during patient–clinician encounters 51 52 75 76. For example, in this journal in 2018, drawing on evidence of inequalities in clinical encounters relating to race/ethnicity, income and health diagnoses, Friesen and Blease proposed that differences in expressions of clinician warmth and empathy, and perceived support might diminish experienced placebo effects among these patients 51.…”

“…This line of reasoning presents a novel research hypothesis which suggests communication breakdowns in clinic visits, which disrupt trust or lead to diminished patient trust in clinicians, may induce higher levels of nocebo effects. Extending this perspective, in 2021, Yetman et al argued that, because expectation in the clinical setting is strongly influenced by clinician attitude, affect and communication style, differences in quality of care in the clinical setting for black patients and other patients of colour, including inferior patient–clinician communication, mistrust and anticipated/perceived discrimination, might also yield increased nocebo effects 52…”

“…Extending this perspective, in 2021, Yetman et al argued that, because expectation in the clinical setting is strongly influenced by clinician attitude, affect and communication style, differences in quality of care in the clinical setting for black patients and other patients of colour, including inferior patient-clinician communication, mistrust and anticipated/perceived discrimination, might also yield increased nocebo effects. 52 Although an overshadowed research agendum for many years, experimental studies in the USA have begun to explore the connection between health disparities and placebo/nocebo effects, and patient-doctor interactions. For example, in 2020, Okusogu et al investigated placebo effects in healthy participants and participants with chronic pain with a diagnosis of temporomandibular disorder, who self-identified as either black or white.…”

“…Since the quality of patient–clinician relations can differ among patients, researchers argue we might thereby expect to see an uneven distribution of placebo and/or nocebo effects 51 52. For example, some patients may receive more detailed information about their side effects or receive fewer expressions of support, thereby facilitating more negative expectancies and increased risk of nocebo effects.…”