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Simpson and colleagues report their systematic review's finding that good adherence to placebos as well as to drug treatments is associated with reduced mortality.1 They hypothesise that this intriguing finding supports the concept of the “healthy adherer” effect, whereby adherence to drug treatment may be a surrogate marker for overall healthy behaviour.
The potential benefits of any new treatment regimen arise in the context of patients' powerful lifestyle habits and resources, as well as their health status and their histories of health behaviour. In addition, a patient brings to each brief meeting with a doctor their habits for drug adherence. It is quite possible, therefore, that people who adhere to healthy lifestyles also tend to take care of themselves by greater adherence to prescribed treatments.
Evidence on the placebo effect yields a complementary hypothesis, for the association between adherence to placebo and reduced mortality. Controlled trials have measured the positive effects of placebos on a range of physical outcomes for over half a century.2 Barrett and colleagues argue that healing lies not in the treatment but rather in patients' emotional and cognitive processes of “feeling cared for” and “caring for oneself.”3 The meanings people attach to the “pill” and “behaviour of the healer” are the key to the mind-body connection leading to health outcomes.
The association with lower mortality in the paper by Simpson and colleagues could arise from positive interaction between these healthy adherer and placebo related effects. If true, what would these hypotheses imply for doctors' decisions and the encounters they have with patients? Traditionally, the healer's greatest tool has been to listen and build on the patient's story and its meaning to determine the most appropriate healing ceremonies, rituals, and therapies. Coupled with other patient centred approaches, practice based on these hypotheses could yield extra value in treatment regimens that patients agree to, believe in, and will sustain over time. Patients' adherence to treatments would show that they were caring for themselves while their clinical encounters would reinforce that their doctors were caring for them.
Motivational interviewing may also be useful.4 For example, asking a patient, “What would make it worth while for you to take this medication in the next month?” may elicit the patient's most serious fears, valued outcomes, or social pressures. These can be used to shape prescribing decisions, to frame an open and truthful discussion of the treatment rationale, and to reinforce the value of the patient's choice to follow the regimen, and allow space for patients to discuss different values or weights that may arise over time and necessitate alterations to the treatment regimen later.
Competing interest: None declared.