Shaping expectations in care: A scoping review of experimental and clinical evidence on communication strategies to reduce the nocebo effect.

Abstract

The nocebo effect refers to adverse symptoms driven by negative expectations and contextual cues rather than the pharmacological properties of treatment. Communication plays a central role in shaping treatment expectations, yet strategies to mitigate nocebo-related harm have not been comprehensively synthesized. This scoping review aimed to identify and categorize empirically tested communication strategies designed to reduce nocebo-related effects and to explore their effectiveness and implementation considerations. This scoping review followed the PRISMA-ScR guidelines. PubMed, Scopus, and PsycInfo were searched from inception to July 2025. Eligible studies used experimental or controlled clinical designs and explicitly evaluated a communication strategy targeting nocebo-related outcomes. Two reviewers independently screened studies and extracted data on study characteristics, communication strategies, intervention conditions, and nocebo-related outcomes. Findings were synthesized descriptively, and strategies were grouped according to their proposed mechanisms. Thirty-eight studies met the inclusion criteria. Most were randomized controlled trials conducted in experimental settings with healthy participants, whereas eleven were conducted in clinical settings. Nine communication strategies were identified, including nocebo education, attribute framing, contextual framing, choice over treatment, empathetic communication, message framing, nondisclosure, personalization, and reassuring wording. Interventions more consistently influenced cognitive and affective outcomes, such as side-effect expectations, symptom attribution, perceived threat, and coping beliefs, than symptom intensity or frequency itself. Nocebo education and attribute framing were the most frequently studied approaches and showed potential for modifying treatment expectations. Interpersonal strategies, such as empathy and reassuring wording, demonstrated context-dependent benefits. Nondisclosure reduced reported side effects in some clinical trials but raised ethical concerns. Communication is a modifiable determinant of nocebo-related outcomes. Several strategies appear beneficial, particularly for modifying expectations and coping beliefs, but stronger theory-informed clinical evidence is needed. Expectation-focused education, careful risk framing, and empathic communication may reduce nocebo-related harm while maintaining ethical standards of informed consent.