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Dr. Anna Abraham
Treatment Evaluation
& Placebo Effects
Measuring the Impact of Interventions on Outcomes of Interest
BUSINESS
Intervention: Participation in a Leadership Training Program
Treatment Evaluation
Impact: Productivity of a Company
LAW
Intervention: Adding hard labour to sentences for minor crimes (stealing)
Impact: Crime rate for minor crimes
Measuring the Impact of Interventions on Outcomes of Interest
MEDICINE
Intervention: New Drug for Coughs
Treatment Evaluation
Impact: Cough Symptoms
BEHAVIORAL TRAINING
Intervention: Social training in Autism
Impact: Social Skills
A means to identify cause-and-effect relationships between events and/or behaviors
Follow a set of rules and guidelines that reduce the possibility of errors, biases & chance occurrences
Advantages:
(1) Less error/bias prone than case studies, surveys or observational methods
(2) Most reliable method for identifying cause-and effect relationships
Disadvantages:
(1) Problems in Generalization: Results from one situation may not apply to another situation
Treatment Evaluation:
EXPERIMENT
Are there Differences in the Emotional Reactions of Men and Women when
watching Thrillers versus Romantic Films?
0369
121518
0369
121518
0369
121518
Treatment Evaluation:
EXPERIMENT
What Else Could Explain The Results?
ACTIVATION OF GENDER STEREOTYPES?
GENDER Do you prefer co-ed or single-
sex floors for flat-sharing?
ETHNICITY How many generations of your family have lived in America?
NEUTRAL How satisfied are you with the university telephone service?
MATH TEST
Source: M. Shih, T. Pittinsky, & N. Ambady (1999), Psychological Science, 10 (1), 80-83.
Stereotype Susceptibility Study on female Asian-American college students
Treatment Evaluation:
EXPERIMENT
What Else Could Explain The Results?
ACTIVATION OF GENDER STEREOTYPES?
Stereotype Susceptibility Study on female Asian-American college students
30
35
40
45
50
55
60
FEMALE NEUTRAL ASIAN
Accuracy on Math Test
Source: M. Shih, T. Pittinsky, & N. Ambady (1999), Psychological Science, 10 (1), 80-83.
Treatment Evaluation:
EXPERIMENT
What Else Could Explain The Results?
! EFFECT OF EXPECTATIONS !
Closely related to the concept of
PLACEBO EFFECT
which is also expectancy-based
Treatment Evaluation:
EXPERIMENT
Is this new cough medicine effective in treating coughs?
0
20
40
60
80
100
COUGH SYRUP VITAMIN SYRUP
Inte
nsi
ty o
f C
ou
gh
Sym
pto
ms
0
20
40
60
80
100
COUGH SYRUP VITAMIN SYRUP
Inte
nsi
ty o
f C
ou
gh
Sym
pto
ms
COUGH SYRUP
VITAMIN SYRUP
Treatment Evaluation:
EXPERIMENT
0
20
40
60
80
100
COUGH SYRUP VITAMIN SYRUP
Inte
nsi
ty o
f C
ou
gh
Sym
pto
ms
What Else Could Explain The Results?
! EFFECT OF EXPECTATIONS !
Closely related to the concept of
PLACEBO EFFECT
which is also expectancy-based
Treatment Evaluation:
EXPERIMENT
PLACEBO
Treatment Evaluation
DEFINITION
Any therapy (or that component of any therapy) that is deliberately used for its non-specific psychological or psychophysiological effect,
OR that is used for its presumed effect on a patient, symptom, or illness,
BUT which, unknown to patient and therapist,
is without specific activity for the condition being treated.”
(Shapiro, 1971, p. 440)
PLACEBO
DEFINITION
Any therapy (or that component of any therapy) that is deliberately used for its non-specific psychological or psychophysiological effect,
OR that is used for its presumed effect on a patient, symptom, or illness,
BUT which, unknown to patient and therapist,
is without specific activity for the condition being treated.”
(Shapiro, 1971, p. 440)
Treatment Evaluation
PLACEBO
Treatment Evaluation
SUGAR PILLS (pure placebo)
ANTIBIOTICS (impure placebo)
TREATMENT EFFECT IS NON-SPECIFIC FOR COLDS!
PLACEBO
DEFINITION
Any therapy (or that component of any therapy) that is deliberately used for its non-specific psychological or psychophysiological effect,
OR that is used for its presumed effect on a patient, symptom, or illness,
BUT which, unknown to patient and therapist,
is without specific activity for the condition being treated.”
(Shapiro, 1971, p. 440)
Treatment Evaluation
PLACEBO
DEFINITION
Any therapy (or that component of any therapy) that is deliberately used for its non-specific psychological or psychophysiological effect,
OR that is used for its presumed effect on a patient, symptom, or illness,
BUT which, unknown to patient and therapist,
is without specific activity for the condition being treated.”
(Shapiro, 1971, p. 440)
Treatment Evaluation
Is this new cough medicine effective in treating coughs?
0
20
40
60
80
100
COUGH SYRUP VITAMIN SYRUP
Inte
nsi
ty o
f C
ou
gh
Sym
pto
ms
0
20
40
60
80
100
COUGH SYRUP VITAMIN SYRUP
Inte
nsi
ty o
f C
ou
gh
Sym
pto
ms
0
20
40
60
80
100
COUGH SYRUP VITAMIN SYRUP
Inte
nsi
ty o
f C
ou
gh
Sym
pto
ms
COUGH SYRUP
VITAMIN SYRUP
Treatment Evaluation
Does arthoscopic knee surgery actually relieve knee pain from osteoarthritis?
All Patients: Anesthesia & Incisions
DEBRIDEMENT: Shaved off thin
layers of damaged cartilage
LAVAGE: Flushed out knee
joint & disposed off unhealthy tissue
PLACEBO: No knee surgery was performed
Treatment Evaluation
PLACEBO
DEFINITION
Any therapy (or that component of any therapy) that is deliberately used for its non-specific psychological or psychophysiological effect,
OR that is used for its presumed effect on a patient, symptom, or illness,
BUT which, unknown to patient and therapist,
is without specific activity for the condition being treated.”
(Shapiro, 1971, p. 440)
Treatment Evaluation
PLACEBO
DEFINITION
Any therapy (or that component of any therapy) that is deliberately used for its non-specific psychological or psychophysiological effect,
OR that is used for its presumed effect on a patient, symptom, or illness,
BUT which, unknown to patient and therapist,
is without specific activity for the condition being treated.”
(Shapiro, 1971, p. 440)
Treatment Evaluation
PLACEBO
Treatment Evaluation
St John’s Wort Bleeding Royal Touch Animal parts
Very long history since the dawn of medicine (Herbs, Preparations, Procedures, Interventions)
PLACEBO
Treatment Evaluation
Very long history since the dawn of medicine (Herbs, Preparations, Procedures, Interventions)
Used to treat a wide variety of disorders (Physical Health & Mental Health)
PLACEBO
Treatment Evaluation
Source: M. Choliz & A. Capafons (2012), Theory Psychology, 22, 513.
PLACEBO EFFECT DEMONSTRATED IN Depression Anxiety Phobias Asthma Sedation
Postoperative Pain Ischemic Pain
Chronic Headaches Physiological Arousal
Tobacco Addiction Motor Performance
PLACEBO
Treatment Evaluation
Source: M. Choliz & A. Capafons (2012), Theory Psychology, 22, 513.
PLACEBO EFFECT DEMONSTRATED IN
Depression Anxiety Disorders
ADHD Asthma, Cough Hypertension
Pain Nausea, Swelling
Parkinson’s Disease Irritable Bowel Syndrome
Tobacco Addiction Language & Behavioral Problems
…
PLACEBO
Treatment Evaluation
Very long history since the dawn of medicine (Herbs, Preparations, Procedures, Interventions)
Used to treat a wide variety of disorders (Physical Health & Mental Health)
Are not always pharmacologically inert (for example, sugar pills versus antibiotics)
PLACEBO
Treatment Evaluation
SUGAR PILLS
Pharmacologically Inert
ANTIBIOTICS
NOT Pharmacologically
Inert
PLACEBO
Treatment Evaluation
Source: M. Choliz & A. Capafons (2012), Theory Psychology, 22, 513.
A PLACEBO MAY BE PHARMACOLOGICALLY INERT BUT
NOT PSYCHOLOGICALLY OR THERAPEUTICALLY INERT
Expectancies Conditioning Personality Motivation Persuasion
Goal Activation
Physician-Patient Interactions Circumstances of Treatment
PLACEBO
Treatment Evaluation
Source: M. Choliz & A. Capafons (2012), Theory Psychology, 22, 513.
A PLACEBO MAY BE PHARMACOLOGICALLY INERT BUT
NOT PSYCHOLOGICALLY OR THERAPEUTICALLY INERT
Expectancies Conditioning Personality Motivation Persuasion
Goal Activation
Physician-Patient Interactions Circumstances of Treatment
PLACEBO
Treatment Evaluation
Source: M. Choliz & A. Capafons (2012), Theory Psychology, 22, 513.
A PLACEBO MAY BE PHARMACOLOGICALLY INERT BUT
NOT PSYCHOLOGICALLY OR THERAPEUTICALLY INERT
Expectancies Conditioning Personality Motivation Persuasion
Goal Activation
Physician-Patient Interactions Circumstances of Treatment
MIND-BODY CONNECTION
PLACEBO
Treatment Evaluation
CONDITIONING
Unconditioned response
Conditioned response
PLACEBO
Treatment Evaluation
PLACEBO: Expectancy vs. Conditioning
Treatment Evaluation
Source: Shiv, Carmon & Ariely (2005), Journal of Marketing Research, XLII, 383-393.
PLACEBO
Treatment Evaluation
Source: M. Choliz & A. Capafons (2012), Theory Psychology, 22, 513.
A PLACEBO MAY BE PHARMACOLOGICALLY INERT BUT
NOT PSYCHOLOGICALLY OR THERAPEUTICALLY INERT
Expectancies Conditioning Personality Motivation Persuasion
Goal Activation
Physician-Patient Interactions Circumstances of Treatment
PLACEBO
Treatment Evaluation
Source: M. Choliz & A. Capafons (2012), Theory Psychology, 22, 513.
A PLACEBO MAY BE PHARMACOLOGICALLY INERT BUT
NOT PSYCHOLOGICALLY OR THERAPEUTICALLY INERT
Expectancies Conditioning Personality Motivation Persuasion
Goal Activation
Physician-Patient Interactions Circumstances of Treatment
Treatment Evaluation
Sources: M. Pecina et al. (2012) Neuropsychopharmacology; Schweinhardt et al. (2009) Journal of Neuroscience
PLACEBO: Personality
When a placebo is administered during a painful experience, altruistic, resilient, and
straightforward people show greater activity in brain regions associated with reward
and are more likely to enjoy pain relief
Thrill-seekers or novelty seeking personality types enjoy a stronger placebo response than
people with quiet or reserved personalities
PLACEBO
Treatment Evaluation
Source: M. Choliz & A. Capafons (2012), Theory Psychology, 22, 513.
A PLACEBO MAY BE PHARMACOLOGICALLY INERT BUT
NOT PSYCHOLOGICALLY OR THERAPEUTICALLY INERT
Expectancies Conditioning Personality Motivation Persuasion
Goal Activation
Physician-Patient Interactions Circumstances of Treatment
PLACEBO
Treatment Evaluation
Source: M. Choliz & A. Capafons (2012), Theory Psychology, 22, 513.
A PLACEBO MAY BE PHARMACOLOGICALLY INERT BUT
NOT PSYCHOLOGICALLY OR THERAPEUTICALLY INERT
Expectancies Conditioning Personality Motivation Persuasion
Goal Activation
Physician-Patient Interactions Circumstances of Treatment
PLACEBO
Treatment Evaluation
Very long history since the dawn of medicine (Herbs, Preparations, Procedures, Interventions)
Used to treat a wide variety of disorders (Physical Health & Mental Health)
Are not always pharmacologically inert (for example, sugar pills versus antibiotics)
The placebo is non-specific in that it with without specific activity for the condition being treated
PLACEBO
Treatment Evaluation
DEPRESSION
75% of the effectiveness of anti-depressant medication
is due to the placebo & other non-specific effects
Difference between drug and placebo not clinically significant except in cases
of very extreme depression
Source: Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT (2008) PLoS Medicine, 5(2):e45
PLACEBO
Treatment Evaluation
Very long history since the dawn of medicine (Herbs, Preparations, Procedures, Interventions)
Used to treat a wide variety of disorders (Physical Health & Mental Health)
Are not always pharmacologically inert (for example, sugar pills versus antibiotics)
The placebo is non-specific in that it with without specific activity for the condition being treated
Can occur even when a person is aware that they are taking a placebo
PLACEBO
Treatment Evaluation
IRRITABLE BOWEL SYNDROME
Source: Kaptchuk TJ, Friedlander E, Kelley JM, Sanchez MN, et al. (2010) PLoS ONE 5(12): e15591.
Enrollment Flowchart Outcomes at the 21-Day Endpoint by Treatment Group
PLACEBO
Treatment Evaluation
IRRITABLE BOWEL SYNDROME
Source: Kaptchuk TJ, Friedlander E, Kelley JM, Sanchez MN, et al. (2010) PLoS ONE 5(12): e15591.
Feedback
PLACEBO – GENERAL FEATURES
Treatment Evaluation
Very long history since the dawn of medicine (Herbs, Preparations, Procedures, Interventions)
Used to treat a wide variety of disorders (Physical Health & Mental Health)
Are not always pharmacologically inert (for example, sugar pills versus antibiotics)
The placebo is non-specific in that it with without specific activity for the condition being treated
Can occur even when a person is aware that they are taking a placebo
PLACEBO
Treatment Evaluation
“The problem with the placebo effect is that it is regarded by most people as a
nuisance or fake.
But it isn't.
It is a practical and positive effect that acts by catalyzing the self-healing
mechanisms within a patient.”
Richard Tonkin, M.D. (Research Council for
Complementary Medicine)
PLACEBO
Treatment Evaluation
PAIN
Inject pain-inducing saline solution into jaw
every four minutes
Provide pain ratings every 15 seconds (0-100)
Pain relieving serum (placebo)
In those who reported less discomfort after the
placebo, body produced endogenous painkilling
endorphins
People who expected to get relief actually produced it!
Source: Zubieta JK, Bueller JA, Jackson LR, Scott DJ, Xu Y, Koeppe RA, Nichols TE, Stohler CS (2005). J Neuroscience 25(34):7754-62
PLACEBO
Treatment Evaluation
"Any therapeutic meeting between a conscious patient and a doctor has the potential of
initiating a placebo effect.“
(Asbjorn Hrobartsson)
The word “placebo” comes from the Latin, meaning "I will please"
By the 19th century, it was a medicine given "more to please than to benefit the patient"
(A.K. Shapiro)
PLACEBO
Treatment Evaluation
“He cures most successfully in whom the people have the most confidence“
(Galen, AD 129 – AD c. 216)
Physicians should provide patients with hope and comfort and “counteract the depressing
influence of maladies”
(Thomas Percival, 1803)
PLACEBO
A PLACEBO MAY BE PHARMACOLOGICALLY INERT BUT
NOT PSYCHOLOGICALLY OR THERAPEUTICALLY INERT
Expectancies Conditioning Personality Motivation Persuasion
Goal Activation
Physician-Patient Interactions Circumstances of Treatment
Treatment Evaluation
Source: M. Choliz & A. Capafons (2012), Theory Psychology, 22, 513.
PLACEBO
Treatment Evaluation
Source: M. Choliz & A. Capafons (2012), Theory Psychology, 22, 513.
A PLACEBO MAY BE PHARMACOLOGICALLY INERT BUT
NOT PSYCHOLOGICALLY OR THERAPEUTICALLY INERT
Expectancies Conditioning Personality Motivation Persuasion
Goal Activation
Physician-Patient Interactions Circumstances of Treatment
PLACEBO
Treatment Evaluation
“The life of a sick person can be shortened not only by the acts, but also the words or the manner of a physician. It is therefore, a sacred duty to guard
himself carefully in this respect, and to avoid all things which have a tendency to discourage the patient and depress his spirits.”
(AMA – American Medical Association’s first Code of Ethics in 1847)
“ … deal honestly with patients”
(AMA – American Medical Association’s Code of Ethics in 1980)
PLACEBO
Treatment Evaluation
INFORMED CONSENT DOCTRINE
Focus on patient autonomy.
Every person has a right to determine what is done to his own body.
Before providing medical treatment, a physician must explain to the patient the nature and purpose of a proposed treatment, the probable risks and benefits, the probability of success, the availability of reasonable alternative courses of action, and, in many cases,
the risk of refusing treatment.
PLACEBO: INFLUENCES
A PLACEBO MAY BE PHARMACOLOGICALLY INERT BUT
NOT PSYCHOLOGICALLY OR THERAPEUTICALLY INERT
Expectancies Conditioning Personality Motivation Persuasion
Goal Activation
Physician-Patient Interactions Circumstances of Treatment
Treatment Evaluation
Source: M. Choliz & A. Capafons (2012), Theory Psychology, 22, 513.
NOCEBO
Treatment Evaluation
NOCEBO
Treatment Evaluation
Negative consequences (harmful, unpleasant, or undesirable)
resulting from the administration of a placebo.
Illustrates the role of patient expectations in perceived side effects
Unwanted side effects (antipsychotic medication, heart disease, even death)
THROUGH EXPERIMENTS
HOW TO ASSESS/CONTROL
FOR PLACEBO EFFECTS?
A means to identify cause-and-effect relationships between events and/or behaviors
Follow a set of rules and guidelines that reduce the possibility of errors, biases & chance occurrences
Advantages:
(1) Less error/bias prone than case studies, surveys or observational methods
(2) Most reliable method for identifying cause-and effect relationships
Disadvantages:
(1) Problems in Generalization: Results from one situation may not apply to another situation
EXPERIMENT
EXPERIMENT:
SCIENTIFIC METHOD
Rule 1: Ask State the question & formulate a hypothesis
Rule 2: Identify how best to test this hypothesis Independent variable (IV): What a researcher manipulates or controls
(TREATMENT) Dependant variable (DV): Participants’ measured behavior
(TREATMENT EFFECT)
Rule 3: Choose Select participants to test the hypothesis
(RANDOM SELECTION)
Rule 4: Assign Participants to different groups
(EXPERIMENTAL group) (CONTROL group)
Rule 5: Manipulate Administer the different treatments to the different groups
Rule 6: Measure Measure how different treatments (IV) affect behavior (DV) => DATA
Rule 7: Analyze Statistical analyses are carried out to determine whether the observed differences in the behaviors (DV) are due to the treatment effect (IV) or due to chance/error
QUESTION: Does Coffee Intake Improve your Ability
to Concentrate on a Difficult Math Problem?
EXPERIMENT:
SCIENTIFIC METHOD
Rule 1: Ask State the question & formulate a hypothesis
(expectation)
HYPOTHESIS: Coffee Intake Improves the Ability to Concentrate on a Difficult Problem!
(because Caffeine is a stimulant)
EXPERIMENT:
SCIENTIFIC METHOD
TREATMENT or INDEPENDENT VARIABLE (IV):
1. Coffee (with caffeine) EXPERIMENTAL 2. Coffee (caffeine-Free) PLACEBO-CONTROL 3. Water NONPLACEBO-CONTROL
Rule 2: Identify how best to test this hypothesis Independent variable (IV): What a researcher manipulates or controls
(TREATMENT)
EXPERIMENT:
SCIENTIFIC METHOD
TREATMENT EFFECT or DEPENDENT VARIABLE (DV):
1. Time Taken to complete the Task WHY? Because if you can concentrate better, you should be able to focus on the task better and work faster
Rule 2: Identify how best to test this hypothesis Independent variable (IV): What a researcher manipulates or controls
(TREATMENT) Dependant variable (DV): Participants’ measured behavior
(TREATMENT EFFECT)
EXPERIMENT:
SCIENTIFIC METHOD
Rule 3: Choose Select participants to test the hypothesis
(RANDOM SELECTION)
Sample characteristics:
1. Total number of participants = 1800 2. Equal number of male & female participants 3. Age = Young adults (18-25 years)
EXPERIMENT:
SCIENTIFIC METHOD
Rule 4: Assign Participants to different groups
(EXPERIMENTAL group) (CONTROL group)
Coffee (with caffeine)
EXPERIMENTAL
Coffee (without caffeine)
PLACEBO-CONTROL
Water (without caffeine)
NON- PLACEBO-CONTROL
EXPERIMENT:
SCIENTIFIC METHOD
Rule 4: Assign Participants to different groups
(EXPERIMENTAL group) (CONTROL group)
Coffee (with caffeine)
EXPERIMENTAL
Coffee (without caffeine)
PLACEBO-CONTROL
Water (without caffeine)
NON- PLACEBO-CONTROL
300
300
300
300
300
300
RANDOM ASSIGNMENT
EXPERIMENT:
SCIENTIFIC METHOD
Coffee (with caffeine)
EXPERIMENTAL
Coffee (without caffeine)
PLACEBO-CONTROL
Water (without caffeine)
NON- PLACEBO-CONTROL
300
300
300
300
300
300
Rule 5: Manipulate Administer the different treatments to the different groups
Double - Blind procedure
EXPERIMENT:
SCIENTIFIC METHOD
Coffee (with caffeine)
EXPERIMENTAL
Coffee (without caffeine)
PLACEBO-CONTROL
Water (without caffeine)
NON- PLACEBO-CONTROL
300
300
300
300
300
300
Rule 6: Measure Measure how different treatments (IV) affect behavior (DV) => DATA
EXPERIMENT:
SCIENTIFIC METHOD
Rule 7: Analyze Statistical analyses are carried out to determine whether the observed differences in the behaviors (DV) are due to the treatment effect (IV) or due to chance/error
Coffee (with caffeine)
EXPERIMENTAL
Coffee (without caffeine)
PLACEBO-CONTROL
Water (without caffeine)
NON- PLACEBO-CONTROL
0
2
4
6
8
10
0
2
4
6
8
10
0
2
4
6
8
10
RESULT:
Experimental group take LESS time to solve Math
problem than Placebo control group &
Non-Placebo control group
HYPOTHESIS: Coffee Intake Improves the Ability to Concentrate on a
Difficult Problem! (As Caffeine is a stimulant)
EXPERIMENT:
SCIENTIFIC METHOD
Rule 7: Analyze Statistical analyses are carried out to determine whether the observed differences in the behaviors (DV) are due to the treatment effect (IV) or due to chance/error
Coffee (with caffeine)
EXPERIMENTAL
Coffee (without caffeine)
PLACEBO-CONTROL
Water (without caffeine)
NON- PLACEBO-CONTROL
0
2
4
6
8
10
0
2
4
6
8
10
0
2
4
6
8
10
RESULT:
Experimental group take SAME time to solve Math
problem as Placebo-control group
HYPOTHESIS: Coffee Intake Improves the Ability to Concentrate on a
Difficult Problem! (As Caffeine is a stimulant)
EXPERIMENT:
SCIENTIFIC METHOD
Rule 1: Ask State the question & formulate a hypothesis
Rule 2: Identify how best to test this hypothesis Independent variable (IV): What a researcher manipulates or controls
(TREATMENT) Dependant variable (DV): Participants’ measured behavior
(TREATMENT EFFECT)
Rule 3: Choose Select participants to test the hypothesis
(RANDOM SELECTION)
Rule 4: Assign Participants to different groups
(EXPERIMENTAL group) (CONTROL group)
Rule 5: Manipulate Administer the different treatments to the different groups
Rule 6: Measure Measure how different treatments (IV) affect behavior (DV) => DATA
Rule 7: Analyze Statistical analyses are carried out to determine whether the observed differences in the behaviors (DV) are due to the treatment effect (IV) or due to chance/error
Treatment Evaluation: RCT (Randomized Controlled Trial)
The key distinguishing feature of the typical RCT is that study subjects, after assessment of eligibility and recruitment, but before the intervention to be studied begins, are randomly allocated to receive one or other of the alternative treatments under study. Random allocation in real trials is complex, but conceptually, the process is like tossing a coin. After randomization, the two (or more) groups of subjects are followed in exactly the same way, and the only differences between the care they receive, for example, in terms of procedures, tests, outpatient visits, follow-up calls etc. should be those intrinsic to the treatments being compared. The most important advantage of proper randomization is that it minimizes allocation bias, balancing both known and unknown prognostic factors, in the assignment of treatments.
Source: Moher D, Hopewell S, Schulz KF, Montori V, Gøtzsche PC, Devereaux PJ, Elbourne D, Egger M, Altman DG (2010). "CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials". Br Med J 340: c869.
Treatment Evaluation: RCT (Randomized Controlled Trial)
Double - Blind procedure
Dr. Anna Abraham
Treatment Evaluation
& Placebo Effects