Is the placebo powerless? An analysis of clinical trials comparing placebowith no treatment.

Background: Placebo treatments have been reported to help patients with man y diseases, but the quality of the evidence supporting this finding has not been rigorously evaluated. Methods: We conducted a systematic review of clinical trials in which patie nts were randomly assigned to either placebo or no treatment. A placebo cou ld be pharmacologic (e.g., a tablet), physical (e.g., a manipulation), or p sychological (e.g., a conversation). Results: We identified 130 trials that met our inclusion criteria. After th e exclusion of 16 trials without relevant data on outcomes, there were 32 w ith binary outcomes (involving 3795 patients, with a median of 51 patients per trial) and 82 with continuous outcomes (involving 4730 patients, with a median of 27 patients per trial). As compared with no treatment, placebo h ad no significant effect on binary outcomes, regardless of whether these ou tcomes were subjective or objective. For the trials with continuous outcome s, placebo had a beneficial effect, but the effect decreased with increasin g sample size, indicating a possible bias related to the effects of small t rials. The pooled standardized mean difference was significant for the tria ls with subjective outcomes but not for those with objective outcomes. In 2 7 trials involving the treatment of pain, placebo had a beneficial effect, as indicated by a reduction in the intensity of pain of 6.5 mm on a 100-mm visual-analogue scale. Conclusions: We found little evidence in general that placebos had powerful clinical effects. Although placebos had no significant effects on objectiv e or binary outcomes, they had possible small benefits in studies with cont inuous subjective outcomes and for the treatment of pain. Outside the setti ng of clinical trials, there is no justification for the use of placebos. ( N Engl J Med 2001;344:1594-602.) Copyright (C) 2001 Massachusetts Medical S ociety.