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Reference: Li, T., & Gal, D. (2023). Consumers prefer natural medicines more when treating psychological than physical conditions. Journal of Consumer Psychology 2023,

Date: February 23, 2024

Guest Skeptic: Ethan Milne is a Marketing PhD student at the Ivey Business School (Western University). He researches how moral outrage and status-seeking personalities motivate social media aggression, and how retribution can motivate consumer donations.

Case: A 20-year-old male presents to the emergency department with palpitations. After a good history, directed physical examination and appropriate investigations you suspect he is suffering from a major depressive disorder (MDD) with a comorbidity of anxiety.  He is not a threat to himself or others and wants assistance. You arrange for him to be followed up by his family physician to discuss possible treatment options which include medications. He expresses concern that taking a synthetic drug to treat his depression wouldn’t allow him to be his authentic self.

Background: Major Depressive Disorder, commonly known as depression, is a significant mental health condition. Depression is a leading cause of disability worldwide and is a major contributor to the overall global burden of disease. It affects an estimated 5-10% of the population at any given time, with variations depending on demographic factors such as age and gender. It is generally more common in women than in men and can occur at any age, although it often first appears during late adolescence to mid-20s [1].

The National Institute of Health (NIH) estimates that around 8.3% (21.0 million) of US adults over 18 have experienced a major depressive episode in the last year. Various factors can increase the risk of developing MDD, including genetic predisposition, personal or family history of depression, major life changes, trauma, stress, and certain physical illnesses and medications. Depression has been reported to be most prevalent among young women aged 12-17 (29.2%) [2].

The current diagnostic criteria for MDD are outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR). These criteria serve as a guideline for clinicians to diagnose depression. To be diagnosed with MDD, a person must experience at least one of the two symptoms for at least two weeks:

  • Depressed Mood: Most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful).
  • Loss of Interest or Pleasure: Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.

The person must also have five or more of the following symptoms during the same 2-week period, and these symptoms represent a change from previous functioning.

  • Significant Weight Loss or Gain (or decrease or increase in appetite nearly every day)
  • Insomnia or Hypersomnia: Trouble sleeping or sleeping too much nearly every day.
  • Psychomotor Agitation or Retardation: Noticeable by others, not merely subjective feelings of restlessness or being slowed down.
  • Fatigue or Loss of Energy: Nearly every day.
  • Feelings of Worthlessness or Excessive or Inappropriate Guilt: Nearly every day, not merely self-reproach or guilt about being sick.
  • Diminished Ability to Think or Concentrate (or indecisiveness, nearly every day)
  • Recurrent Thoughts of Death: Recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

These symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. They must not be attributable to the physiological effects of a substance or another medical condition. Also, the occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

There are several treatment options for MDD and often patients will do a combination of things. It can be a challenge to treat depression effectively and the evidence to support different treatments varies.

  • Lifestyle and Home Remedies:
    • Regular exercise, maintaining a healthy diet, getting enough sleep, and avoiding alcohol and drugs can help manage symptoms of depression.
  • Psychotherapy:
    • Cognitive Behavioral Therapy (CBT): This is a highly effective form of therapy that focuses on identifying and changing negative thought patterns and behaviours that contribute to depression.
    • Interpersonal Therapy (IPT): IPT focuses on improving interpersonal relationships and communication patterns.
    • Psychodynamic Therapy: This explores how unconscious emotions and past experiences contribute to current feelings and behaviours.
  • Medications:
    • Antidepressants: These are the most commonly prescribed medications for depression, including selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs). It may take several weeks to notice the benefits of these medications, and they may have side effects.
    • Other Medications: In some cases, doctors may recommend other types of medications, such as mood stabilizers or antipsychotic medications, especially if symptoms are severe or if the person has a co-occurring mental health disorder.
  • Other Non-Pharmaceutical Treatments:
    • Techniques such as meditation and mindfulness can be beneficial for some individuals when used in conjunction with traditional treatments.
  • Hospitalization:
    • In severe cases, especially where there is a risk of harm to oneself or others, hospitalization or participation in an intensive outpatient program may be necessary.
  • Electroconvulsive Therapy (ECT) and Transcranial Magnetic Stimulation (TMS):
    • For severe depression that hasn’t responded to other treatments, ECT can be effective. TMS is a newer treatment that uses magnetic fields to stimulate nerve cells in the brain and can be an option.

While the prevalence of depression has increased [3], the market for herbal supplements and other natural remedies has also grown with an expected industry value of $8.5 billion by 2025 [4]. The “natural preference” is a pervasive and culturally universal phenomenon [5]. It is defined as when consumers have a favourable attitude toward natural products [6,7].

The Food and Drug Administration (FDA) has not formally defined the term “natural” for labelling purposes. The FDA allows the term “natural” to be used when a food does not contain anything artificial that would not typically be expected in that food.

Clinical Question: They had four questions or hypotheses they were testing in this publication.

  1. Consumers demonstrate an overall preference for natural drugs over synthetic drugs.
  2. Consumers exhibit a general reluctance to treat psychological conditions compared with physical conditions.
  3. The relative preference for natural drugs over synthetic drugs is stronger when consumers are treating psychological conditions than physical conditions.
  4. The concern that synthetic drugs are more likely to alter the true self than natural drugs serves as a key mechanism connecting the type of health conditions and the preference for using natural drugs.

Reference: Li, T., & Gal, D. (2023). Consumers prefer natural medicines more when treating psychological than physical conditions. Journal of Consumer Psychology 2023,

  • Population: Participants were recruited from MTurk, which is an online platform owned by Amazon that allows anyone to sign up and begin completing surveys, experiments, or other tasks in exchange for monetary compensation. For a detailed breakdown of MTurk demographics, see Huff & Tingley (2015).
  • Intervention: Synthetic drugs for psychological or physical conditions
  • Comparison: Natural drugs for psychological or physical conditions
  • Outcome:
    • Primary Outcome: Preference for synthetic vs. natural drugs
    • Secondary Outcome: Process evidence for true self-concern as the mediator
  • Type of Study: Online survey

Authors’ Conclusions: “while consumers have a general preference for natural drugs over synthetic drugs, this preference is stronger when the goal is to treat psychological rather than physical conditions. Process evidence indicates an important mechanism that explains the amplified natural preference for treating psychological conditions: Consumers are more concerned about their true selves being altered when treating psychological conditions, and they perceive natural drugs to be less likely than synthetic drugs to affect their true selves.”

Quality Checklist for Reporting of Survey Studies (CROSS):

Results: This paper was comprised of seven studies. Study 1 was an archival study, and the remaining studies were experimental.

  • Study 1: In this archival study, the researchers identified a set of 10,158 individuals (out of 34,525 total respondents) who reported using at least one type of CAM treatment in the past year. Participants were asked if they pursued CAM because it was natural or not. The researchers then categorized the different illnesses participants identified using CAM to treat as either psychological (e.g., depression, senility, etc.) or physical (e.g., arthritis, diabetes, etc.). Rates of endorsement for using CAM due to “naturalness” were compared between psychological and physical conditions.
  • Study 2: In this experimental study, the researchers employed a 2 (drug type: natural vs. synthetic) x 2 (condition: psychological vs. physical) mixed design. Participants were asked to imagine experiencing a pain level of 7 and were randomized to be told this pain was either psychological or physical. They were then asked to rate their willingness to use a synthetic treatment, and their willingness to use a natural treatment on a 1—7 scale.
  • Study 3: In this experimental study, the researchers employed a 2 (drug type: natural vs. synthetic) x 2 (condition: psychological vs. physical) within-subjects Unlike study 2, the condition was not randomized between subjects — instead, participants were asked to imagine both psychological and physical ailments in sequence. Unlike Study 2, participants were also given different indicators of physical or psychological condition: in all conditions, participants were asked to imagine throbbing headaches, and this was either described as being downstream of anxiety and stress, or a sinus inflammation due to seasonal allergies. Participants rated willingness to use synthetic and natural drugs for each condition variation on a 1—7 scale.
  • Study 4: In this experimental study, the researchers employed a 2 (drug type: natural vs. synthetic) x 2 (condition: psychological vs. physical) mixed design. As in Study 2, the condition was randomized between-subjects, whereas drug type was presented within-subjects. Participants in all conditions imagined stomach churning at a discomfort level 6 (out of 10). In the physical condition, this churning was described as being a result of local cuisine, and in the psychological condition, this churning was described as being due to being in a new environment. Participants then rated willingness to use synthetic and natural drugs on a 1—9 scale.
  • Study 5a: In this experimental study, the researchers employed a 2 (drug type: natural vs. synthetic) x 2 (condition: psychological vs. physical) within-subjects design similar to Study 3. The physical condition was itchiness, and the psychological condition was mood swings. Participants rated their true-self-alteration concern on a 1—7 scale, as well as their likelihood of using a synthetic and a natural drug on a 1—7 scale.
  • Study 5b: In this experimental study, the researchers employed a 2 (drug type: natural vs. synthetic) x 2 (condition: psychological vs. physical) mixed design similar to Study 2, with condition randomized between participants. This study operationalizes true self as a mediator in a different way than Study 5a — rather than participants rating true-self-alteration concern, participants instead rated their belief that each of synthetic or natural medicines would alter their true self on a 1—7 scale. They then rated their willingness to use natural and synthetic medicines on a 1—7 scale.
  • Study 6: In this experimental study, the researchers employed a one-factor two-level (condition: psychological vs physical) within-subjects design. In the psychological condition, participants imagined feeling down “due to an imbalance of neurotransmitters” and could choose between a synthetic SSRI or a natural drug called 5-HTP. In the physical condition, participants were asked to imagine having allergies and taking either synthetic Vitamin D or a natural drug called Rhodiola. Participants reported on a 1—7 scale if they preferred the synthetic drug (1) or the natural drug (7), with the midpoint of the scale representing indifference. Participants also completed a short-scale measure of self-alienation concern, and the idea was that if true self alteration was a mediator of the effect they were investigating, then participants who were more concerned with self-alienation would exhibit a stronger bias for natural products for psychological conditions.

Key Result: Consumers generally prefer natural to synthetic remedies, and this effect is strengthened when considering remedies that act on psychological (rather than physical) aspects of themselves.

  • Secondary Outcomes: The observed effect in the primary outcome is mediated by concerns over synthetic remedies altering true selves.

1. Methodology: There were some good things in this paper and at least one curious thing.

  • Pre-Registration and Open Data: Having (almost) all experimental studies pre-registered and having replication data published in an open-access database is extremely rare for psychology and marketing papers.
  • Repeated Studies: The authors repeated an entire study because they accidentally capitalized the letter “A” where it shouldn’t have been. The authors fully replicated their results in the grammatically correct version.
  • Switching Scales: Added results table and some summaries of each study. Noticed some weirdness with scale-switching (using 7-point scales for natural/synthetic in one study, and a 9-point scale in another). No explanation could be found for having two scales.

2. Hawthorne Effect: The nature of online lab experiments means that participants are completing studies in exchange for financial compensation. Prior research on the Hawthorn effect suggests that knowing one is observed can change how one responds to surveys.

3. Data Analysis: They did a couple of things with their analysis. One was within-participant analysis. While the authors generally report results as differences between repeated experimental conditions, they also provide a supplementary table (Table 2) wherein they analyze their data at a participant level, showing the percentage of participants who did and did not act according to the researchers’ hypothesis.

The other thing was bootstrapping the results. The authors use different bootstrapping samples across their studies. For example, Study 5A uses Hayes’ & Memore (2017) MEMORE macro with 10,000 bootstrap samples, whereas Study 5B uses Hayes PROCESS model 4 with 5,000 bootstrap samples.

4. Imagined vs. Real: Another aspect to consider is that participants were asked to imagine being ill vs. someone who was ill. How do participants know what a “pain level 7 out of 10” feels like? Would their response be different if they had a physical or mental illness?

5. Appeal to Nature: This research points out the potential issue of an appeal to nature. This is an informal logical fallacy where you argue something is good because it is natural or bad if it is not natural. Many things in nature are not good for you like arsenic, cyanide, and uranium. If you are looking for medical therapy, it would be better to determine the potential benefits and harms rather than whether it is considered natural.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusions.

SGEM Bottom Line: Patients are more likely to prefer natural remedies to synthetic ones for psychological conditions. We need to design good interventions to educate patients on the relative safety of synthetic remedies, as well as the potential harms of unregulated and untested natural remedies.

Case Resolution: You inform the patient about your provisional diagnosis of depression with anxiety. You point him to a reputable website for more information. He is also given the local crisis phone number to call if he feels worse and wants to talk.  You also send a brief letter to his primary care physician informing them of the EM visit and asking them to follow up to discuss outpatient management. 

Ethan Milne

Clinical Application: There are systematic biases in the way patients evaluate potential treatments, particularly for psychological conditions. Funding agencies and researchers should identify ways to mitigate these biases to best help patients make informed decisions about their treatment.

What Do I Tell the Patient? I think your palpitations were a result of depression with anxiety. This is very common and I’m glad you came to the emergency department to get checked out. I hear what you are saying about taking medication. Other patients have similar concerns. You may not need pharmaceutical treatments. However, just because something is synthetic does not make it bad. Here is some information from the Mayo Clinic you could read. It is a good place to start learning about depression. Talk with your primary care physician to determine what is the best way forward for you.

Keener Kontest: There were many responses to last week’s question but no winner. The answer we were looking for was Dr. Henry Janeway. He was an American Anesthesiologist practicing at Bellevue Hospital in New York. Dr. Janeway is credited as the pioneer of the first handheld direct laryngoscope with a distal light source and battery power within the handle.

Listen to the SGEM podcast to hear this week’s keener question. The first correct answer will receive a cool skeptical prize.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics Guide to Emergency Medicine.

References:

  1. World Health Organization (WHO): Depressive disorder (depression) – Key Facts. Accessed February 21, 2024.
  2. National Institute of Health (NIH): Major Depression. Accessed February 21, 2024
  3. Goodwin RD, Dierker LC, Wu M, Galea S, Hoven CW, Weinberger AH. Trends in U.S. Depression Prevalence From 2015 to 2020: The Widening Treatment Gap. Am J Prev Med. 2022 Nov;63(5):726-733. doi: 10.1016/j.amepre.2022.05.014. Epub 2022 Sep 19. PMID: 36272761; PMCID: PMC9483000.
  4. Business Wire: Global $8.5 Billion Herbal Supplements Market by Product, Formulation, Consumer and Region – Forecast to 2025. Accessed February 21, 2024
  5. Rozin, P., Fischler, C., & Shields-Argelès, C. (2012). European and American perspectives on the meaning of natural. Appetite, 59(2), 448–455.
  6. Rozin, P. (2005). The meaning of “natural” process more important than content. Psychological Science, 16(8), 652–658.
  7. Rozin, P., Spranca, M., Krieger, Z., Neuhaus, R., Surillo, D., Swerdlin, A., & Wood, K. (2004). Preference for natural: Instrumental and ideational/moral motivations, and the contrast between foods and medicines. Appetite, 43(2), 147–154.