Sorting out the causes of unexplained adverse effects from psychotropic medications can be challenging. Treatment may be further complicated by ‘nocebo’ effects, which are adverse effects based on the patient’s conscious and unconscious expectations of harm. Having strategies for managing nocebo effects can help clinicians better understand and treat patients who have complex medication complaints. When your patient experiences nocebo effects, consider the following 4 psychosocial factors.1
Pills. The impact of a medication is not solely based on its chemical makeup. For example, the appearance of a medication can affect treatment outcomes. Substituting generic medications for branded ones has been shown to negatively impact patient adherence and increase reports of adverse effects that have no physiologic cause.2 Educating patients about medication manufacturing and distribution practices may decrease such consequences.
Patient. A sense of powerlessness is fertile ground for nocebo effects. Patients with an external locus of control may unconsciously employ nocebo effects to express themselves when other outlets are limited. Having a psychosocial formulation of your patient can help you anticipate pitfalls, offer pertinent insights, and mobilize the patient’s adaptive coping mechanisms. Also, clinicians can bolster their patients’ self-agency by encouraging them to participate in healthy activities.
Provider. Irrational factors in the clinician, such as countertransference, may also affect medication outcomes. Unprocessed countertransference can contribute to clinician burnout and impact the therapeutic relationship negatively. Nocebo effects may indicate that the clinician is not “tuned in” to the patient or is acting out harmful unconscious thoughts. Additionally, countertransference can lead to unnecessary prescribing and polypharmacy that confounds nocebo effects. Therefore self-care, consultation, and supervision may be vital in promoting therapeutic outcomes.
Partnership. The doctor–patient relationship can contribute to nocebo effects. A 2016 Gallup Poll found that Americans had low confidence in the honesty and ethics of psychiatrists compared with other healthcare professionals.3 It is important to have conversations with your patients about their reservations and perceived stigma of mental health. Such conversations can bring a patient’s ambivalence into treatment so that it can be further explored and addressed. Psychoeducation about treatment limitations, motivational interviewing techniques, and involving patients in decision-making can be useful tools for fostering a therapeutic alliance and positive outcomes.
Take an active approach
Evidence demonstrates that psychosocial factors significantly impact treatment outcomes.1 Incorporating this evidence into practice and attending to the 4 factors discussed here can enhance a clinician’s ability to flexibly respond to their patients’ complaints, especially in relation to nocebo effects.