Placebo Effects in Medicine & It’s Application in Homoeopathy-A Review

: Placebo is the second-best remedy in Homoeopathy. In the day-to-day practice certain situation arise which lead us to prescribe placebo. Beginning from the case taking when the patient is taking some medicines, to the end of the treatment when homoeopathic aggravation occurs, in all that time physician requires placebo. In the middle of the treatment process placebo is needed during homoeopathic aggravation, improvement of the case. Certain disease conditions like Artificial Chronic Disease, Pseudo Chronic Disease, Mental diseases of emotional origin, Indisposition, Hypochondriac patients demand placebo. In randomized controlled trails with homoeopathic medicines the value of placebo is unquestionable.

The use of placebo is considered an important methodological tool in medical research [6] . One of the early concepts introduced about placebo is the patients know they are receiving a placebo continue to report subjective improvement in their condition, specifically when they are told that the placebo can make them feel better [5] . The effects are not determined by the known pharmacological properties of the substance: it is the psychological state of the individual at the time of its administration that determines the effects produced by the placebo [7].

Homoeopathy and Placebo:
Many people still believe that homoeopathy is a placebo. For them it must come as a surprise that Hahnemann unlike most of his contemporaries was already familiar with a phenomenon which we call today placebo effect. First, he differentiated clearly between the homoeopathic drugs administered in line with law of similars ("that is" similia similibus) curentur and such pharmaceutical substances he considered quite rightly as sham medicine ("for example" milk sugar). Second, as far as we know, he was the first physician who systematically used a single blinded approach in therapy [8] . In most instances Dr Hahnemann marked placebos with the paragraph symbol ( §) [9] . In aphorism 91, Hahnemann states, when the disease is of chronic character and patient has been taking medicine up to the time he is seen, the physician can leave him some days quite without medicine or meantime can administer something of an unmedicinal nature and defer to a subsequent period [10] . In case of hypochondriacs, when pure fabrication of symptoms comes, Hahnemann advises the physician "gives them nothing at all, or something quite unmedicinal" in footnote to aphorism 96 [11] . Aphorism 281, states that when the improvement begins, in order to be convinced of this, the patient is left without any medicine for eight, ten, fifteen days, meanwhile giving him only some powders of sugar of milk [11] . In the period between 1833 and 1835 more than half (54%) of Dr Hahnemann's prescriptions was placebo. [12] As observed in his case journals, the main reason for giving placebo by Dr Hahnemann was to please the impatient patient who was used to frequent medications in allopathic medicine, not only every day but sometimes also hourly. [13] Since its inception, there has been criticism against homoeopathy that it is nothing but a placebo and even in recent times recent times it has been stated through trail that the beneficial effects are due to consultation process and not the remedy. Although there are numerous studies which prove otherwise, due to poor methodological quality, these studies usually don't make it into meta-analysis. [14] Homoeopathy does not treat diseases, but only diseased individuals. Therefore, every case may need a different remedy although the individuals may be suffering from the same pathology [15] . This rule was violated by almost all the trails in most meta-analyses (16) . In the homoeopathic treatment of serious chronic pathology, if the remedy is correct usually a strong initial aggravation take place. [17] Such an aggravation may last from a few hours to a few weeks and even then, we may have a syndromeshift and not the therapeutic results expected. If the measurements take place in the aggravation period, the outcome will be classified negative. This factor was also ignored in most trials. At least sufficient time should be given in the design of the trial, in order to account for the aggravation period. [18] The contrary happened in a recent study, [19] where the aggravation period was evaluated as a negative sign and the homoeopathic group was pronounced worse than the placebo. [20] Utility of placebo: To determine a medication's part in the actual effect of a medication on the improvement in symptoms of a disease that has been tested with psychological effect of participating in a clinical trial and with the psychological effect of taking any kind of medication. [21] When improvement begins: It is necessary to stop the medicine prescribed. Here indicated medicine may be substituted by placebo till another dose of same medicine or other medicine is required . [22] Reduced anxiety: Taking the placebo and expecting to feel better may be soothing and reduce the levels of stress chemicals and body produces, such as adrenaline. [23] A change in behaviour: The placebo may increase a person's motivation that plays an important role to take better care of themselves. Improved diet, regular exercise or rest may be responsible for the easing of their symptoms. [23] Placebo effect and the brain: Functional imaging upon placebo analgesia shows activation of some areas in brain. High placebo responses link with dopamine activity. [24] Since the body brain response that controls the placebo effect is neurological, they work best for conditions controlled by the neurological system, such as pain, irritable bowel syndrome, depression, Parkinson's disease [25] During homoeopathic aggravation: symptoms are worse, but the patient says that mentally he feels better [26] so wait and watch method is necessary in that situation. At this stage any sort of medication will spoil the case, placebo may be prescribed instead. [2] During homoeopathic aggravation by LM potency: At the end of treatment few symptoms of the drug remain these symptoms disappear within few days, meanwhile the patient may be given only powder of sugar of milk. [27] The antipsoric medicine are repeated in long intervals and to fill up gaps, sugar of milk may be given every day at the usual time and usual manner [28] Placebos in therapeutic role: Placebos, have become a form of evidence-based medicine, with appropriate assessment of inert substances to inert structures [29] . Results of studies of placebos showed improvement in 56% of patients experiencing cancer related fatigue [30] , 70% of women experiencing menopausal hot flushes [31] , and 75% to 80% of the patients with depression [32] .

Doctors attitude towards placebo prescription:
A systematic review found that estimates of the lifetime prevalence of prescribing pure placebos among doctors ranged from 17% to 80% [33] and it seems that doctors prescribe impure placebos more frequently than pure placebos. [34] Pure placebos are substances or forms of treatment that have no pharmacological effect, "for example" Sugar pills or saline infusions. Impure placebos have pharmacological effects, but the effect on the specific disease the substance is prescribed for not been proven or is uncertain.

Patient's attitude towards being prescribed placebo:
Hull and colleagues surveyed adults in the USA to determine the acceptability of placebo treatments and found that most, but not all, respondents thought it was acceptable for doctors to use placebos under some circumstances. However, although a significant number of patients ( that placebos were not acceptable under any circumstances. [35] Finding of another study [36] suggest that people who find placebo prescribing unacceptable do so because of beliefs that: • Placebos are ineffective, which leads to the view that a doctor who prescribes placebos is not to be trusted, and that patient's involvement in their own healthcare is compromised. • Patients that respond to placebos are gullible, foolish, childish leading to the view that they themselves would not want to be treated in this way. On the other hand, people who find placebo prescribing acceptable seem to do primarily because they believe placebos can be effective and they prioritize such patient benefit over other concerns.

Physiological Effect of Placebo:
A ground breaking study in the late 70's showed for the first time that a placebo could trigger the release of Endorphins (the body's natural painkillers), just as certain active drugs do. In the study, Jon Levine, gave placebos instead of pain medication, to 40 dental patients who had just had their wisdom teeth removed. Not surprisingly, because the patients thought they were getting medicine that would indeed relieve their pain, most reported relief. But then the researches gave the patients an antidote to morphine, which chemically blocks the receptor sites for both Endorphins and Morphine in the brain. [37] When the researches administered it, the patients pain returned. This proved that by taking the placebos, the patients have been creating their own endorphins-their own natural pain relievers. It was the milestone in placebo research, because it meant that the relief the study subjects experienced wasn't all in their minds; it was in their minds and their bodies-in their state of being. [37] In a study, participants are given a placebo but are told it is a stimulant. When the participants take that pill, their blood pressure and pulse rate were increased, and their reaction speeds are improved. However, when the same people are given the same placebo and told it will help to relax and sleep, they experiencing relaxation instead. If a person expert a treatment to do something, its definitely possible that the body's own chemistry will cause effects similar to what a medication might have caused. [38] Conclusion: Hahnemann states, our mission is to cure the patient not to hurt them. It is very much better to give placebo than an unwanted or wrong medicines. Bruce H. Lipton states that, if the brain expects that a treatment will work. It sends healing chemicals into the bloodstream, which facilitates that. That's why the "placebo" effect is so powerful for every type of healing. and the opposite is equally true and equally powerful: when the brain expects that the therapy will not work, it is called the "nocebo" effect. The placebo response is about being healed by thought alone. In current scenario, the placebo is mandatory not only in homoeopathy but in all types of medical systems, in situations where a real medicine is not needed.