A molecular basis for the placebo effect.

Several popular articles point to work I wish I had been more aware off. Gary Greenberg in the NYTimes, and Cari Romm in The Atlantic, point to work of Kathryn Hall and collaborators showing that placebo responses are strongest in patients with a variant of a gene (COMT, which regulates the amount of dopamine in the brain) that causes higher levels of dopamine, which is linked to pain the the good feeling that come with reward. Irritable bowel syndrome patients with the high-dopamine version of the gene were more likely to report that the placebo treatment had relieved their symptoms, an effect that was even stronger in the group that had received their treatment from a caring provider. Variations in the COMT gene locus are unlikely to fully account for a complex behavior like the placebo response, but contribute to the puzzle. Here is the abstract from the Hall et al. paper:

• Predisposition to respond to placebo treatment may be in part a stable heritable trait. 

• Candidate placebo response pathways may interact with drugs to modify outcomes in both the placebo and drug treatment arms of clinical trials. 

• Genomic analysis of randomized placebo and no-treatment controlled trials are needed to fully realize the potential of the placebome.

Placebos are indispensable controls in randomized clinical trials (RCTs), and placebo responses significantly contribute to routine clinical outcomes. Recent neurophysiological studies reveal neurotransmitter pathways that mediate placebo effects. Evidence that genetic variations in these pathways can modify placebo effects raises the possibility of using genetic screening to identify placebo responders and thereby increase RCT efficacy and improve therapeutic care. Furthermore, the possibility of interaction between placebo and drug molecular pathways warrants consideration in RCT design. The study of genomic effects on placebo response, ‘the placebome’, is in its infancy. Here, we review evidence from placebo studies and RCTs to identify putative genes in the placebome, examine evidence for placebo–drug interactions, and discuss implications for RCTs and clinical care.