Year : 2019  |  Volume : 61  |  Issue : 5  |  Page : 539--540

Placebo in psychotherapy of childhood depression

Tarun Verma 
 Clinical Psychologist, PsyClinic, Delhi, India

Correspondence Address:
Tarun Verma
Clinical Psychologist, PsyClinic, Delhi

How to cite this article:
Verma T. Placebo in psychotherapy of childhood depression.Indian J Psychiatry 2019;61:539-540

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Verma T. Placebo in psychotherapy of childhood depression. Indian J Psychiatry [serial online] 2019 [cited 2020 Jun 5 ];61:539-540
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A recent study[1] provided an interesting look into the treatment of childhood depression through the introduction of a novel approach “Fake, Fake, and Duchenne Smile” along with improvisation of pleasurable activities. The study describes the effective use of a psychosocial intervention on 9–12-year-old children (n = 6), where the combined use of both the Duchenne smile and pleasant activities was made. However, the study has serious limitations and it makes ambitious claims about the effectiveness of this approach. The authors have utilized a pre–post design to analyze the data using only the Children's Depression Inventory (CDI) which showed 2–7 times reduction in scores of CDI over a 10-week period. The period is too large to assess the effects of intervention through only one measure, as many covarying factors may have played a role in causing these effects. There were no intermediate assessments to show the relative efficacy of the intervention through a span of 10 weeks. Positive affect was not measured anywhere. It is quite possible that such large effects may have been achieved within 1–2 weeks[2] for the majority of the children. It is not possible to draw conclusions with such a small sample size. Inflation in results is highly probable.

Studies on the treatment of childhood depression have shown that placebo shows greater effects than even pharmacological treatments.[3] In psychosocial interventions, the role of a therapist is even greater as the direct relationship between the child and the therapist enhances the self-esteem of the child and identification with the adult figure, which helps in restoring attachment and in seeking security. The effects of therapeutic alliance are higher among children and adolescents as compared to the adult population. The developmental and risk factors among children are different than adults, especially the impact of adverse events is not internalized deeply at a tender age and depressed states are amenable to modifications by relationships than core cognitions of adulthood. The general psychopathology in depression is differentiated from anxiety or other disorders more among youth, rendering the treatment of depression more prone to nonspecific factors such as relationship with the therapist. Cohen et al.[3] suggest various reasons that are specifically responsible for higher placebo effects among young individuals. For example, the “positive mirror” provided by the therapist intensifies transference formation among children. As a result, the child is able to restore his/her feelings of worth and confidence in the adult world, irrespective of the therapeutic orientation of the clinician. All psychotherapies intend to change despair to hope, fear to courage, powerlessness to mastery, and demoralizing interpretations to favorable ones, which make youth sensitive to basic support and security provided by therapy.

In light of the above views, it seems necessary that any research on the effectiveness of a specific intervention among depressed children must have a control and/or a placebo group. Despite its conceptual merits, the current study[1] does not provide any convincing evidence about the efficacy of the combination of Duchenne smile and improvised pleasant activities. The pleasant activities based on the child's interests and intrinsic motivation do not account for any specific major impact as such tasks are common to any intervention with children or even adults. Smiling is a significant predictor of therapeutic alliance and intervention success[4] that is employed by all mental health professionals as part of the rapport formation process. Although the Duchenne smile was an important component of treatment, the authors have not measured the smiling episodes separately that could provide some insights on the relevance of smile; hence, the efficacy of the intervention is questionable from the methodological point of view.

In conclusion, the effects of the interventions in this study appear to be producing inflated results possibly due to the placebo effects as well as the influence of unmeasured variables which require careful scrutiny.

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Conflicts of interest

There are no conflicts of interest.


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