Deconstructing the placebo response: Why does it work in treating depression?

In the past three decades, the power of placebos has gone through the roof in treating major depressive disorder. In clinical trials for treating depression over that period of time, researchers have reported significant increases in patient’s response rates to placebos — the simple sugar pills given to patients who think that it may be actual medication.

New research conducted by UCLA psychiatrists helps explain how placebos can have such a powerful effect on depression.

“In short,” said Andrew Leuchter, the study’s first author and a professor of psychiatry at the UCLA Semel Institute for Neuroscience and Human Behavior, “if you think a pill is going to work, it probably will.”

The UCLA researchers examined three forms of treatment. One was supportive care in which a therapist assessed the patient’s risk and symptoms, and provided emotional support and encouragement but refrained from providing solutions to the patient’s issues that might result in specific therapeutic effects. The other two treatments provided the same type of therapy, but patients also received either medication or placebos.

The researchers found that treatment that incorporating either type of pill — real medication or placebo — yielded better outcomes than supportive care alone. Further, the success of the placebo treatment was closely correlated to people’s expectations before they began treatment. Those who believed that medication was likely to help them were much more likely to respond to placebos. Their belief in the effectiveness of medication was not related to the likelihood of benefitting from medication, however.

“Our study indicates that belief in ‘the power of the pill’ uniquely drives the placebo response, while medications are likely to work regardless of patients’ belief in their effectiveness,” Leuchter said.

The study appears in the current online edition of the British Journal of Psychiatry.

At the beginning and end of the study, patients were asked to complete the Hamilton Rating Scale for Depression, giving researchers a quantitative assessment of how their depression levels changed during treatment. Those who received antidepressant medication and supportive care improved an average of 46 percent, patients who received placebos and supportive care improved an average of 36 percent, and those who received supportive care alone improved an average of just 5 percent.

“Interestingly, while we found that medication was more effective than placebo, the difference was modest,” Leuchter said.

The researchers also found that people who received supportive care alone were more likely to discontinue treatment early than those who received pills.

People with major depressive disorder have a persistent low mood, low self-esteem and a loss of pleasure in things they once enjoyed. The disorder can be disabling, and it can affect a person’s family, work or school life, sleeping and eating habits, and overall health.

In the double-blind study, 88 people ages 18 to 65 who had been diagnosed with depression were given eight weeks of treatment. Twenty received supportive care alone, 29 received a placebo with supportive care and 39 received actual medication with supportive care.

The researchers measured the patients’ expectations for how effective they thought medication and general treatment would be, as well as their impressions of the strength of their relationship with the supportive care provider.

“These results suggest a unique role for people’s expectations about their medication in engendering a placebo response,” Leuchter said. “Higher expectations of medication effectiveness predicted an improvement in placebo-treated subjects, and it’s important to note that people’s expectations about how effective a medication may be were already formed before they entered the trial.”

Leuchter said the research indicates that factors such as direct-to-consumer advertising may be shaping peoples’ attitudes about medication. “It may not be an accident that placebo response rates have soared at the same time the pharmaceutical companies are spending $10 billion a year on consumer advertising.”

(Image credit: © Chris Lamphear)

(Image caption: An undated handout picture released by Japan’s Riken research institute and Foundation for Biomedical Research and Innovation, shows a retina sheet prepared from iPS cells of a woman for transplant surgery. Japanese researchers on Friday conducted the world’s first surgery to implant “iPS” stem cells in a human body in a major boost to regenerative medicine, two institutions involved said. — PHOTO: AFP/RIKEN AND FOUNDATION FOR BIOMEDICAL RESEARCH AND INNOVATION. Adapted from: The Straits Times)

Japanese doctors test method for restoring impaired vision

Japanese doctors have successfully carried out the first ever implantation of a retina grown from induced pluripotent stem cells (iPS).

The recipient was a 70-year-old woman suffering from macular degeneration.

The procedure took place Friday at the Institute of Biomedical Research and Innovation in the southern city of Kobe, under the direction of a group of scientists from the Riken Institute.

Researchers extracted skin samples from women to grow iPS cells capable of serving as retinal tissue, which then were used to surgically replace part of the macula, the main photo-receptor layer of the retina.

The scientists said that their priority was not to attempt to restore the patient’s sight, but to determine if there are any unforeseen side effects, such as tumours, arising from the procedure.

According to the researchers, who will study the patient’s evolution over the next four years, since the patient will have already lost most of the cells responsible for vision, a transplant may bring only slight improvement or merely slow down the rate of degeneration.

Macular degeneration is an age-related disease that currently affects about 700,000 people in Japan and is the principal cause of blindness in the world.

Say ‘ahh’ to let your smartphone check for Parkinson’s disease

Smartphones are designed to be curious. Having already learned about your friendships, your family and the pattern of your daily routine, designers are now interested in your health and fitness.

A new crop of apps and wearable devices continuously measure and analyse vital signs such as movement and heart rate, claiming to count calories, optimise sleep quality and guide diet. While cynics might be tempted to dismiss these products as glorified pedometers for lycra-clad smartphone addicts, new research shows that the hardware inside existing consumer devices can already reliably detect degenerative, life-changing disorders, including Parkinson’s disease.

Parkinson’s currently affects between seven to 10m people worldwide, and there is no cure. The disease can be diagnosed from a number of characteristic symptoms, including muscle tremor, changes in speech and difficulty of movement. However, diagnosis is challenging and usually involves regular visits to the doctor. It is estimated that one in five people with Parkinson’s are never diagnosed. Even if diagnosed, it can be difficult to accurately assess the how efficient treatment is in managing the disease.

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Research Shows How Brain Can Tell Magnitude of Errors

University of Pennsylvania researchers have made another advance in understanding how the brain detects errors caused by unexpected sensory events. This type of error detection is what allows the brain to learn from its mistakes, which is critical for improving fine motor control.  

Their previous work explained how the brain can distinguish true error signals from noise; their new findings show how it can tell the difference between errors of different magnitudes. Fine-tuning a tennis serve, for example, requires that the brain distinguish whether it needs to make a minor correction if the ball barely misses the target or a much bigger correction if it is way off.

The study was led by Javier Medina, an assistant professor in the Department of Psychology in Penn’s School of Arts & Sciences, and Farzaneh Najafi, then a graduate student in the Department of Biology. They collaborated with postdoctoral fellow Andrea Giovannucci and associate professor Samuel S. H. Wang of Princeton University.

It was published in the journal eLife.

Our movements are controlled by neurons known as Purkinje cells. Each muscle receives instructions from a dedicated set of hundreds of these brain cells. The instructions sent by each set of Purkinje cells are constantly fine tuned by climbing fibers, a specialized group of neurons that alert Purkinje cells whenever an unexpected stimulus occurs.

“An unexpected stimulus is often a sign that something has gone wrong,” Medina said, “When this happens, climbing fibers send signals to their related Purkinje cells that an error has occurred. These Purkinje cells can then make changes to avoid the error in the future.”

These error signals are mixed in with random firings of the climbing fibers, however, and researchers were long mystified about how the brain tells the difference between this noise and the useful, error-related information it needs to improve motor control.

Medina and his team showed the mechanism behind this differentiation in a study published earlier this year. By using a non-invasive microscopy technique that could monitor the Purkinje cells of awake and active mice, the researchers could measure the level of calcium within these cells when they received signals from climbing fibers.

The unexpected stimuli in this experiment were random puffs of air to the face, which caused the mice to blink. The researchers located Purkinje cells that control the mice’s eyelids and saw that calcium levels necessary for neuroplasticity, i.e., the brain’s ability to learn, were greater when the mice got an error signal triggered by a puff of air than they were after a random signal.

While being able to make such a distinction is critical to the brain’s ability to improve motor control, more information is needed to fine-tune it.  

“We wanted to see if the Purkinje cells could tell the difference not just between random firings and true errors signals but between smaller and bigger errors,” Medina said.

In their new study, the researchers used the same experimental set-up, with one key difference. They used air puffs of different durations: 15 milliseconds and 30 milliseconds.

What they found was that the eyelid-associated Purkinje cells filled with different amounts of calcium depending on the length of the puff; the longer ones produced larger spikes in calcium levels.        

In addition, the researchers saw that different percentages of eyelid-related Purkinje cells respond depending on the length of the puff.  

“Though there is a large population of climbing fibers that can give error-related information to the relevant Purkinje cells when they encounter something unexpected, not all of them fire each time,” Medina said. “We saw that there is information coded in the number of climbing fibers that fire. The longer puffs corresponded to more climbing fibers sending signals to their Purkinje cells.”

Their study could help explain how practice makes perfect, even when errors are imperceptibly small.

“If you felt a short puff and a long puff, you might not be able to say which one was which, but Purkinje cells can tell the difference,” Medina said. “The difference between a ‘very good’ and an ‘awesome’ tennis serve rests on being able to distinguish errors even as tiny as that.” 

Nerve impulses can collide and continue unaffected

According to the traditional theory of nerves, two nerve impulses sent from opposite ends of a nerve annihilate when they collide. New research from the Niels Bohr Institute now shows that two colliding nerve impulses simply pass through each other and continue unaffected. This supports the theory that nerves function as sound pulses. The results are published in the scientific journal Physical Review X.

Nerve signals control the communication between the billions of cells in an organism and enable them to work together in neural networks. But how do nerve signals work?

Old model

In 1952, Hodgkin and Huxley introduced a model in which nerve signals were described as an electric current along the nerve produced by the flow of ions. The mechanism is produced by layers of electrically charged particles (ions of sodium and potassium) on either side of the nerve membrane that change places when stimulated. This change in charge creates an electric current.

This model has enjoyed general acceptance. For more than 60 years, all medical and biology textbooks have said that nerves function is due to an electric current along the nerve pathway. However, this model cannot explain a number of phenomena that are known about nerve function.

New model

Researchers at the Niels Bohr Institute at the University of Copenhagen have now conducted experiments that raise doubts about this well-established model of electrical impulses along the nerve pathway.

“According to the theory of this ion mechanism, the electrical signal leaves an inactive region in its wake, and the nerve can only support new signals after a short recovery period of inactivity. Therefore, two electrical impulses sent from opposite ends of the nerve should be stopped after colliding and running into these inactive regions,” explains Thomas Heimburg, Professor and head of the Membrane Biophysics Group at the Niels Bohr Institute at the University of Copenhagen.

Thomas Heimburg and his research group conducted experiment in the laboratory using nerves from earthworms and lobsters. The nerves were removed and used in an experiment which allowed the researchers to stimulate the nerve fibres with electrodes on both ends. Then they measured the signals en route. 

“Our study showed that the signals passed through each other completely unhindered and unaltered. That’s how sound waves work. A sound wave doesn’t stop when it meets another sound wave. Both waves continue on unimpeded. The nerve impulse can therefore be explained by the fact that the pulse is a mechanical wave in the form of a sound pulse, a soliton, that moves along the nerve membrane,” explains Thomas Heimburg.

The theory is confirmed

When the sound pulse moves through the nerve pathway, the membrane changes locally from a liquid to a more solid form. The membrane is compressed slightly, and this change leads to an electrical pulse as a consequence of the piezoelectric effect.

“The electrical signal is thus not based on an electric current but is caused by a mechanical force,” points out Thomas Heimburg.

Thomas Heimburg, along with Professor Andrew Jackson, first proposed the theory that nerves function by sound pulses in 2005. Their research has since provided support for this theory, and the new experiments offer additional confirmation for the theory that nerve signals are sound pulses.

Zebrafish Model of a Learning and Memory Disorder Shows Better Way to Target Treatment

Using a zebrafish model of a human genetic disease called neurofibromatosis (NF1), a team from the Perelman School of Medicine at the University of Pennsylvania has found that the learning and memory components of the disorder are distinct features that will likely need different treatment approaches. They published their results this month in Cell Reports.

NF1 is one of the most common inherited neurological disorders, affecting about one in 3,000 people. It is characterized by tumors, attention deficits, and learning problems. Most people with NF1 have symptoms before the age of 10. Therapies target Ras, a protein family that guides cell proliferation. The NF1 gene encodes neurofibromin, a very large protein with a small domain involved in Ras regulation.

Unexpectedly, the Penn team showed that some of the behavioral defects in mutant fish are not related to abnormal Ras, but can be corrected by drugs that affect another signaling pathway controlled by the small molecule cAMP. They used the zebrafish model of NF1 to show that memory defects – such as the recall of a learned task — can be corrected by drugs that target Ras, while learning deficits are corrected by modulation of the cAMP pathway. Overall, the team’s results have implications for potential therapies in people with NF1.

“We now know that learning and memory defects in NF1 are distinct and potentially amenable to drug therapy,” says co-senior author Jon Epstein, MD, chair of the department of Cell and Developmental Biology. “Our data convincingly show that memory defects in mutant fish are due to abnormal Ras activity, but learning defects are completely unaffected by modulation of these pathways. Rather these deficits are corrected with medicines that modulate cAMP.”

Over the last 20 years, zebrafish have become great models for studying development and disease. Like humans, zebrafish are vertebrates, and most of the genes required for normal embryonic development in zebrafish are also present in humans. When incorrectly regulated, these same genes often cause tumor formation and metastatic cancers.

Zebrafish have also become an ideal model for studying vertebrate neuroscience and behavior. In fact, co-senior author Michael Granato, PhD, professor of Cell and Developmental Biology, has developed the first high-throughput behavioral assays that measure learning and memory in fish. For example, Granato explains, “normal fish startle with changes in noise and light level by bending and swimming away from the annoying stimuli and do eventually habituate, that is get used to the alternations in their environment. But, NF1 fish mutants fail to habituate. However, after adding cAMP to their water, they do learn, and then behave like the non-mutant fish.”

This clearly indicates that learning deficits in the NF1 mutant fish are corrected by adding various substances that boost cAMP signaling. “Our data also indicate that learning and memory defects are reversible with acute pharmacologic treatments and are therefore not hard-wired, as might be expected for a defect in the development of nerves,” says Epstein. “This offers great hope for therapeutic intervention for NF1 patients.”

The interactive brain

Neuroscientist explores mechanism that can cause deficit in working memory

Amy Griffin, associate professor of psychological and brain sciences at the University of Delaware, has received a five-year, $1.78 million grant from the National Institute of Mental Health to support her research into the brain mechanisms of working memory.

A neuroscientist, Griffin has been interested for some time in the interaction between the prefrontal cortex, located at the front of the brain, and the hippocampus, a region in the temporal lobe of the brain. When the two areas fail to work together, that failure appears to be correlated with deficits in working memory, a condition that commonly occurs in schizophrenia, general anxiety and other psychiatric disorders.

The hippocampus is the portion of the brain responsible for memory, while the prefrontal cortex controls executive function, a term that includes such cognitive abilities as problem-solving, planning and abstract thinking.

“These are two areas of the brain that are far apart, but their oscillations [rhythmic activities] are synchronized,” Griffin said. “When one area is active, so is the other.”

Working memory, sometimes called short-term memory, is “the kind of memory that fails when you walk into a room and forget why you came there,” she said.

When the oscillations in the hippocampus and prefrontal cortex are out of sync, deficits of working memory occur. In those cases, Griffin said, “both regions are active, but they’re not talking to each other.” The mechanism that causes that lack of communication has not been well explored, and her research will seek to do that.

Griffin and her research team plan to conduct two types of experiments. One will inhibit activity in a brain region called the nucleus reuniens, a region that is hypothesized to synchronize the hippocampus and prefrontal cortex and is expected to cause impairments with working memory. In the other experiment, researchers will activate the nucleus reuniens to increase synchrony, hoping to learn if that improves working memory.

The research will employ a cutting-edge technique called optogenetics, a process that uses proteins to make neurons sensitive to light and then uses light to control them. 

“Optogenetics is becoming a common technique,” Griffin said. “It’s a way to study these processes on a millisecond timescale.” 

A 2013 article in the journal Nature Neuroscience said optogenetics “is transforming the field of neuroscience. For the first time, it is now possible to use light to both trigger and silence activity in genetically defined populations of neurons with millisecond precision.”

Griffin, using a rat model, will inject the light-sensitizing substance — a harmless virus — into the nucleus reuniens and then use a laser to inhibit or activate this brain region. The rats then perform tasks that assess their working memory. Synchronization between the hippocampus and prefrontal cortex will also be recorded, with the prediction that the degree of the working memory impairment will be correlated with reductions in synchrony.

“Our experiments will not be interfering with the activities of the hippocampus or the prefrontal cortex within themselves,” Griffin said. “We want to affect only the ability of the structures to talk to each other.”