All Publications

  • Implementation Challenges Using a Novel Method for Collecting Patient-Reported Outcomes After Injury JOURNAL OF SURGICAL RESEARCH Rosenberg, G. M., Shearer, E. J., Zion, S. R., Mackey, S. C., Morris, A. M., Spain, D. A., Weiser, T. G. 2019; 241: 277–84
  • Differences among Asian/Asian American, and Caucasian breast and gynecologic cancer patient reported survivorship needs, symptoms, and illness mindsets (N=220). Schapira, L., Hofmeister, E., Kurian, A. W., Zion, S., Shen, H., Torres, T., Berek, J. S., Palesh, O. AMER SOC CLINICAL ONCOLOGY. 2019
  • Targeting Mindsets, Not Just Tumors Trends in Cancer Zion, S. R., Schapira, L., Crum, A. J. 2019
  • Mindsets Matter: A New Framework for Harnessing the Placebo Effect in Modern Medicine. International review of neurobiology Zion, S. R., Crum, A. J. 2018; 138: 137–60


    The clinical utility of the placebo effect has long hinged on physicians deceptively administering an objective placebo treatment to their patients. However, the power of the placebo does not reside in the sham treatment itself; rather, it comes from the psychosocial forces that surround the patient and the treatment. To this end, we propose a new framework for understanding and leveraging the placebo effect in clinical care. In outlining this framework, we first present the placebo effect as a neurobiological effect that is evoked by psychological processes. Next, we argue that along with implicit learning and expectation formation, mindsets are a key psychological process involved in the placebo effect. Finally, we illustrate the critical role of the social environment and treatment context in shaping these psychological processes. In doing so, we offer a guide for how the placebo effect can be understood, harnessed, and leveraged in the practice of modern medicine.

    View details for PubMedID 29681322

  • Side effects can enhance treatment response through expectancy effects: an experimental analgesic randomized controlled trial PAIN Berna, C., Kirsch, I., Zion, S. R., Lee, Y. C., Jensen, K. B., Sadler, P., Kaptchuk, T. J., Edwards, R. R. 2017; 158 (6): 1014–20


    In randomized controlled trials, medication side effects may lead to beliefs that one is receiving the active intervention and enhance active treatment responses, thereby increasing drug-placebo differences. We tested these hypotheses with an experimental double-blind randomized controlled trial of a nonsteroidal anti-inflammatory drug with and without the addition of atropine to induce side effects. One hundred healthy volunteers were told they would be randomized to either combined analgesics that might produce dry mouth or inert placebos. In reality, they were randomized double blind, double-dummy to 1 of the 4 conditions: (1) 100 mg diclofenac + 1.2 mg atropine, (2) placebo + 1.2 mg atropine, (3) 100 mg diclofenac + placebo, or (4) placebo + placebo, and tested with heat-induced pain. Groups did not differ significantly in demographics, temperature producing moderate pain, state anxiety, or depression. Analgesia was observed in all groups; there was a significant interaction between diclofenac and atropine, without main effects. Diclofenac alone was not better than double-placebo. The addition of atropine increased pain relief more than 3-fold among participants given diclofenac (d = 0.77), but did not enhance the response to placebo (d = 0.09). A chain of mediation analysis demonstrated that the addition of atropine increased dry mouth symptoms, which increased beliefs that one had received the active medication, which, in turn, increased analgesia. In addition to this indirect effect of atropine on analgesia (via dry mouth and beliefs), analyses suggest that among those who received diclofenac, atropine directly increased analgesia. This possible synergistic effect between diclofenac and atropine might warrant future research.

    View details for DOI 10.1097/j.pain.0000000000000870

    View details for Web of Science ID 000402431700005

    View details for PubMedID 28178072

    View details for PubMedCentralID PMC5435545

  • Efficacy and Safety of Selective Serotonin Reuptake Inhibitors, Serotonin-Norepinephrine Reuptake Inhibitors, and Placebo for Common Psychiatric Disorders Among Children and Adolescents: A Systematic Review and Meta-analysis. JAMA psychiatry Locher, C., Koechlin, H., Zion, S. R., Werner, C., Pine, D. S., Kirsch, I., Kessler, R. C., Kossowsky, J. 2017; 74 (10): 1011–20


    Depressive disorders (DDs), anxiety disorders (ADs), obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD) are common mental disorders in children and adolescents.To examine the relative efficacy and safety of selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and placebo for the treatment of DD, AD, OCD, and PTSD in children and adolescents.PubMed, EMBASE, PsycINFO, Web of Science, and Cochrane Database from inception through August 7, 2016.Published and unpublished randomized clinical trials of SSRIs or SNRIs in youths with DD, AD, OCD, or PTSD were included. Trials using other antidepressants (eg, tricyclic antidepressants, monoamine oxidase inhibitors) were excluded.Effect sizes, calculated as standardized mean differences (Hedges g) and risk ratios (RRs) for adverse events, were assessed in a random-effects model.Primary outcomes, as defined by authors on preintervention and postintervention data, mean change data, and adverse event data, were extracted independently by multiple observers following PRISMA guidelines.Thirty-six trials were eligible, including 6778 participants (3484 [51.4%] female; mean [SD] age, 12.9 [5.1] years); 17 studies for DD, 10 for AD, 8 for OCD, and 1 for PTSD. Analysis showed that SSRIs and SNRIs were significantly more beneficial compared with placebo, yielding a small effect size (g = 0.32; 95% CI, 0.25-0.40; P < .001). Anxiety disorder (g = 0.56; 95% CI, 0.40-0.72; P < .001) showed significantly larger between-group effect sizes than DD (g = 0.20; 95% CI, 0.13-0.27; P < .001). This difference was driven primarily by the placebo response: patients with DD exhibited significantly larger placebo responses (g = 1.57; 95% CI, 1.36-1.78; P < .001) compared with those with AD (g = 1.03; 95% CI, 0.84-1.21; P < .001). The SSRIs produced a relatively large effect size for ADs (g = 0.71; 95% CI, 0.45-0.97; P < .001). Compared with participants receiving placebo, patients receiving an antidepressant reported significantly more treatment-emergent adverse events (RR, 1.07; 95% CI, 1.01-1.12; P = .01 or RR, 1.49; 95% CI, 1.22-1.82; P < .001, depending on the reporting method), severe adverse events (RR, 1.76; 95% CI, 1.34-2.32; P < .001), and study discontinuation due to adverse events (RR, 1.79; 95% CI, 1.38-2.32; P < .001).Compared with placebo, SSRIs and SNRIs are more beneficial than placebo in children and adolescents; however, the benefit is small and disorder specific, yielding a larger drug-placebo difference for AD than for other conditions. Response to placebo is large, especially in DD. Severe adverse events are significantly more common with SSRIs and SNRIs than placebo.

    View details for PubMedID 28854296

    View details for PubMedCentralID PMC5667359

  • The Placebo Effect in the Clinical Setting: Considerations for the Pain Practitioner Principles and Practice of Pain Medicine Berna, C., Zion, S. R., Kelley, J. M. McGraw-Hill Education Medical. 2015; 3: 162–169