Abnormal Psychology

Researching Abnormality 187

But members of nonindustrialized societies are not the only ones who are sus-

ceptible to such cultural forces. In Western cultures over the past two decades,

people diagnosed with depression who are enrolled in studies to evaluate various

medications have responded progressively more strongly to placebos (Walsh et al.,

2002). Over that same two decades, pharmaceutical companies have increasingly

advertised their medications directly to potential consumers, informing them about

the possible benefi ts of the drugs. It is possible that the participants in these studies

became more likely to believe that medication will be helpful than were participants

30 years ago, before direct advertising to consumers.

Feedback Loops in Action: The Placebo Effect

Successful treatments (including placebos) that target one type of factor in turn

affect other types of factors; for example, medication (which targets neurological

factors) affects symptoms related to psychological and social factors. Moreover,

all types of treatment make use of a social factor—cultural norms about what

kinds of interventions are appropriate, be they healer-induced possession trance

or cognitive restructuring. In turn, these norms about appropriate treatment pro-

mote the patient’s beliefs and expectations (psychological factor) regarding how

effective the treatments are. Such beliefs and expectations then infl uence neuro-

logical and social factors, as well as other psychological factors. For example, a

meta-analysis of studies on antidepressant treatments found that about 75–80%

of the antidepressant’s positive effects could be attributed to a placebo response,

leaving at most only about 25% of the response due to the active ingredients

of the medications. Thus, expectations that symptoms will improve may account

for the lion’s share of the positive response to an antidepressant (Kirsch & Lynn,

1999; Kirsch et al., 2002; Kirsch & Sapirstein, 1999; Walach & Maidhof, 1999).

Indeed, more than half of studies of antidepressants that were funded by drug

companies (which, if anything, may have biased the results towards supporting

the effects of medication) found that a placebo was just as effective as the medica-

tion (Kirsch et al., 2002; Kirsch, Scoboria, & Moore, 2002; Moncrieff & Kirsch,

2005). In studies in which the placebo was designed to mimic the side effects of

an antidepressant, the effects of the medication and the placebo were even more

similar (Greenberg & Fisher, 1989).

These results do not necessarily show that placebos and actual antidepressant

drugs have the same effects. Depressed people who responded well to SSRI medication,

for instance, had a different pattern of brain activity than did patients who responded

successfully to a placebo (Leuchter et al., 2002). Again, a patient’s personal beliefs

(psychological factor) about the effects of medication affect what happens in the brain,

and these factors both affect, and are affected by, social factors.

Do the results regarding the placebo effect and antidepressants imply that

depressed people should throw away their medication because they don’t need it

to attain the benefi t? No! Not taking any medication is not the same as taking a

placebo medication. There is something about the act of taking the medication that

engages parts of the mind and brain to reduce depressive symptoms; without the

placebo, these parts of the brain do not become active. There can’t be a placebo

effect without a placebo. So, if an antidepressant works for a patient, not taking

it isn’t at all the same as taking a placebo. (However, other nonmedical treatments

may also be helpful for depression; we will discuss such treatments for that disorder

in Chapter 6.)

What about Carlos and your hypotheses about loss and depression? As in the

discovery of PANDAS, your observations about Carlos led you to identify questions

about the etiology of his depression and about possible treatments. If you were inter-

ested in researching these matters, the particular design and procedure of your study

would depend, in part, on the specifi c question you want to ask and hypothesis you

want to test. You would use the scientifi c method to collect data (after obtaining

approval from an IRB) and refi ne your hypothesis or formulate a theory.

P S

N