Placebo, Nocebo, and the Power of Expectation: What a Scoping Review Means for Everyday Care

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In the ED, your words can be as powerful as your meds. In this episode, PGY-3 Dr Kotei unpacks the science of placebo and nocebo, showing how communication shapes patient outcomes—and how small shifts in framing, empathy, and reassurance can turn talk into treatment.

THE PODCAST

A SUMMARY

The study at a glance

  • What it is: A scoping review of 306 published systematic reviews and meta-analyses on placebo/nocebo across clinical and healthy populations.

  • Goal: Identify determinants of placebo/nocebo across four domains: individual, clinical, psychological, contextual.

Why this matters

Placebo and nocebo aren’t “soft science.” They’re expectation-driven effects that can change symptoms, shape trial outcomes, and influence what happens at the bedside. Specifically, think of expectations are active ingredients: they can relieve symptoms (placebo) or amplify them (nocebo), affecting both trial results and everyday care. Until recently, most insights came from single RCTs. A new scoping review of these concepts steps back to map the bigger picture.

What they found: the research landscape

  • Of these 306 identified systematic reviews or meta-analyses: 

    • 83% (≈ 254) were meta-analyses and 17% (≈ 52) were systematic reviews. 

    • Placebo-focused publications numbered approximately 240 (≈ 78.4% of the total). Within that group: ~195 addressed placebo responses, ~36 placebo effects, and ~9 both responses & effects.  

  • Nocebo-focused publications were about 49 (≈ 16.0% of the total). Among them: ~41 addressed nocebo responses, ~8 nocebo effects.  

  • The majority of the research was in medical specialties (≈ 81.7%), particularly psychiatry and neurology. 

  • The review authors flagged that nocebo-specific systematic reviews remain relatively few and much less developed than placebo research. 

As found by the study — Determinants that matter for considering utility of placebo / nocebo on individual patient care

  • Individual: Factors like age can modulate responses (direction varies by context).

  • Clinical: Baseline symptom severity often predicts magnitude of response.

  • Psychological: Expectations—positive or negative—are powerful drivers.

  • Contextual: Design and delivery (e.g., blinding, how information is framed, how treatments are administered) shape outcomes.

Where the gaps are?

Under-explored groups (e.g., some demographics, pediatrics),

  • Long-term trajectories of placebo/nocebo

  • Personalized response patterns that could guide tailored care.

Why it matters for (future) trials?

  • The authors emphasize that understanding placebo and nocebo dynamics isn’t just theoretical—it has direct implications for future trials and clinical practice. Many existing studies fail to measure or control patient expectations, which can skew outcomes.  

  • By incorporating expectation assessments, transparent communication scripts, and standardized framing in trial design, researchers can better isolate true treatment effects.  

  • For emergency medicine, this opens the door to studying how our words influence pain, satisfaction, and medication use—essentially turning communication into a measurable intervention. 

Why it matters for clinicians?

  • Realistic, positive framing works. Set helpful expectations about benefits and timelines; normalize benign sensations.

  • Avoid negative suggestion. Listing rare side effects without context can heighten symptoms (nocebo).

  • Brief, warm communication: small, repeatable gains in pain, anxiety, satisfaction, adherence.

  • Personalize the message. Align with patient concerns, literacy, and culture

  • High-yield scenarios in the emergency department: migraine/MSK pain, procedures (I&D, LA), nausea/anxiety, pediatrics, functional syndromes.

Strengths of the Study

  • Breadth: Brings together 306 high-level syntheses across conditions and settings.

  • Useful framework: Integrates individual/clinical/psychological/contextual determinants into a practical lens for both trials and care.

 Limitations of the Study

  • Secondary-only: No new primary data; conclusions inherit the biases and heterogeneity of included reviews.

  • Imbalance: Nocebo remains underrepresented; field skew toward psychiatry/neurology limits generalizability.

  • Mechanisms & recency: Focus on outcomes over mechanisms; some summaries may lag behind the newest primary studies.

Micro-scripts for the clinician to try on the next shift:

  • Procedure: “You’ll feel a brief sting; I’ll talk you through it and keep it short.”

  • Benefit forecast: “Most feel relief within ~30 minutes; I’ll recheck and adjust.”

  • Side-effects: “About 2 in 100 feel jittery; it’s brief and we can treat it if it happens.”

Bottom line

Expectations and context aren’t window dressing—they’re active ingredients. This scoping review maps where they matter most and where we still need answers. For now, the wins are practical and ethical: clear, optimistic (truthful) framing; context-savvy delivery; and attention to individual patient needs. Small changes, repeated often, can move the needle.

AUTHORSHIP

Written by: Charlene Kotei, MD, PGY-3 University of Cincinnati Department of Emergency Medicine

Editing, Posting, and Audio Editing by Anita Goel, MD Adjunct Associate Professor, University of Cincinnati Department of Emergency Medicine.

Cite as: Kotei, C., Goel, A. Placebo, Nocebo, and the Power of Expectation: What a Scoping Review Means for Everyday Care. TamingtheSRU.com. www.tamingthesru.com/blog/journal-club-placebo-and-nocebo-use-in-the-emergency-department. 10/22/2025.