Monday, August 13, 2012

The Dark Side of Diagnosis by Brain Scan


Daniel Amen: Pioneer or profiteer?: Psychiatrist Daniel Amen uses brain scans to diagnose mental illness. Most peers say that’s bonkers.


Right on the heels of a Molecular Psychiatry paper that asked, "Why has it taken so long for biological psychiatry to develop clinical tests and what to do about it?" (Kapur et al., 2012) comes this provocatively titled article in the Washington Post about neurohuckster Dr. Daniel Amen and his miraculous SPECT scans:
Daniel Amen is the most popular psychiatrist in America. To most researchers and scientists, that’s a very bad thing.

By , Published: August 9.

NEWPORT BEACH, Calif. — Daniel Amen is, by almost any measure, the most popular psychiatrist in America.

. . .

He has arisen, like a modern-day American myth, from the fields northeast of San Francisco, where he ran a small-town clinic, to become the creator, chairman and CEO of the Amen Clinics, an empire that includes a string of psychiatric practices, a line of nutritional supplements, book publishing, DVD sales, and television and speaking engagements.

. . .

Amen’s career is very troubling, for one of two things must be true.

One, Daniel Gregory Amen, born in 1954 in Encino, Calif., son of Lebanese immigrants, is 20 years ahead of virtually the entire psychiatric field (he says about three dozen other clinics use SPECT scans, but few as profusely as he does), and the establishment has failed to recognize a historic breakthrough.

Or, two, the man has grown fabulously wealthy — he lives in a $4.8 million mansion overlooking the Pacific Ocean — by selling patients a high-priced service that has little scientific validity, yet no regulatory body has made a move to stop him.

SPECT (single photon emission computed tomography) is a relatively inexpensive cousin of PET scanning (positron emission tomography) with lower spatial resolution.1 There is no peer reviewed literature that establishes SPECT as a reliable method of diagnosing psychiatric disorders.

Amen is well-known to regular PBS viewers, because his informercial "Change Your Brain, Change Your Life" [and others] is on regular rotation during fund raisers.2 In a critical Salon.com piece by Robert Burton, one neuroimaging expert was quoted as saying:
"SPECT scans are not sufficiently sensitive or specific to be useful in the diagnosis of A.D.," neurologist Michael Greicius , who runs the Stanford University memory clinic, and has a special interest in the use of functional brain imaging in the diagnosis of A.D., tells me. "The PBS airing of Amen's program provides a stamp of scientific validity to work which has no scientific validity."

In his Washington Post article, author Neely Tucker assembled an impressive list of naysayers:
No major research institution takes his SPECT work seriously, none regards him as “the number one neuroscience guy,” and his revelations, which he presents to rapt audiences as dispatches from the front ranks of science, make the top tier of scientists roll their eyes or get very angry.

“In my opinion, what he’s doing is the modern equivalent of phrenology,” says Jeffrey Lieberman, APA president-elect, author of the textbook “Psychiatry” and chairman of Psychiatry at Columbia University College of Physicians and Surgeons. (Phrenology was the pseudoscience, popular in the early 19th century, that said the mind was determined by the shape of the skull, particularly its bumps.) “The claims he makes are not supported by reliable science, and one has to be skeptical about his motivation.”

“I think you have a vulnerable patient population that doesn’t know any better,” says M. Elizabeth Oates, chair of the Commission on Nuclear Medicine, Board of Chancellors at the American College of Radiology, and chair of the department of radiology at the University of Kentucky.

“A sham,” says Martha J. Farah, director of the Center for Neuroscience & Society at the University of Pennsylvania, summing up her thoughts on one of Amen’s most recent scientific papers.

“I guess we’re all amateurs except for him,” says Helen Mayberg, a psychiatry, neurology and radiology professor at Emory School of Medicine and one of the most respected researchers into depression and brain scanning. “He’s making claims that are outrageous and not supported by any research.”

“I can’t imagine clinical decisions being guided by an imaging test,” says Steven E. Hyman, former director of the National Institute of Mental Health and current director of the Stanley Center for Psychiatric Research at the Broad Institute of MIT and Harvard.

But wait! Didn't The Neurocritic just write a post that expressed some degree of optimism about the prospect of a "stratified psychiatry" of phenotypic or genotypic subtypes at some unspecified future date?

But beware! This is not the same thing as using a SPECT scan to devise a treatment plan. In his NIMH Director's Blog, Dr. Thomas Insel singles out Amen and warns, Brain Scans – Not Quite Ready for Prime Time.


Where Are the Clinical Tests for Psychiatric Disorders?

In their paper, Kapur, Phillips, and Insel (2012) were careful to distinguish their projections for the future from diagnostic tests:3
The prospects of ‘diagnostic tests’ for DSM entities remain distant for reasons articulated above, and it seems unlikely that we will replace the 300-disorder taxonomy of the DSM-5 with an alternative biologically based classification system anytime soon. Therefore the real opportunity for psychiatry is to use the emerging advances in genetics, molecular biology, imaging and cognitive science to supplement, rather than replace, the symptom-driven diagnosis.

Dr. Amen is not so circumspect, in fact he's rather bullish:
He says he has taught himself — by scanning 45,000 people a total of 70,000 times — to apply SPECT, alongside clinical evaluations, as a diagnostic tool in 90 percent of his patients.

The brain activity he says he sees in these scans — areas of high and low activity — allows him to target those areas with specific treatments and medication, he says. A full initial session, including two scans, costs about $3,500.

Amen says this method has helped him identify new subtypes of anxiety, depression and attention deficit disorder, categories far more specific than even the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the benchmark of the field.

This is heady stuff — using brain imaging to find biomarkers for mental illnesses has been the great hope of psychiatry for at least two decades...


And what are those treatments and medications? Exercise, healthy diet, supplements from his product line [e.g., Serotonin Mood Support], and prescription refills in some cases.




"Due to overwhelming popularity we are now offering the Brain on Joy Bar by the case (18 bars)."


Am I blue, Dr. Amen?

The SPECT scans often seem to be used as either a scare tactic or a form of reassurance:

Amen’s first scan patient, back in the early 1990s, was Sandy.

She was 40, had ADD and had tried to kill herself the night before their initial meeting. In his telling — it is his Genesis story, and he has told it many times — the resulting scan showed a precipitous drop in activity in her prefrontal cortex, the brain’s decision-making center, when she tried to concentrate.

When he showed her the scan, she wept. “You mean it’s not my fault?”

Realizing it was a “biological, not moral” problem, she accepted the diagnosis, took her medications and was greatly helped.

“I thought, ‘Whoa. Pictures matter. You get great compliance,’ ” Amen says.
Another patient said, “The results [of the scan] were a little disconcerting, but I’m glad to have it.”

And here's Amen's colleague Earl Henslin: “If at all possible, I’m motivating my patients to get that scan at the first session. They see that scan and they’re willing to take responsibility.”


A Picture Is Worth a Thousand Dollars

That's the title of a 2009 editorial by Dr. Martha Farah in the Journal of Cognitive Neuroscience. She argues that cognitive neuroscientists have a responsibility to speak out when clinical [and legal] applications of brain imaging are being misrepresented by for-profit companies such as the Amen Clinics:
Tens of thousands of individuals, many of them children, have been exposed to the radiation of two SPECT scans and paid thousands of dollars out of pocket (because insurers will not pay) against the advice of many experts... The Amen Clinics are now marketing their services outside the medical arena, advising couples with marital problems and even “prescreening” couples.

People are swayed by colorful brain images, whether they're in the classroom, the courtroom, or the clinic. Or on reality TV. SPECT scans should not be used for diagnostic or entertainment purposes; there's no scientific evidence for the former and the latter is unethical.


Further Reading

This Is the Presidential Candidates' Brains On...

On Amen's Dec. 2007 editorial in the Los Angeles Times advocating SPECT scans for presidential candidates.

Celebrity Neurostigma
On celebrity SPECT scans from celebrity patients in the reality show Celebrity Rehab with Dr. Drew. Also a lesson in medical ethics. Special guest appearance by Dr. Amen.

Dennis Rodman-Mindy McCready Mind Meld
On the startling similarities in the SPECT scans of Celebrity Rehab participants Dennis Rodman and Mindy McCready.


Footnotes

1 In case you're interested in learning more about how the method works, this review chapter (by the Committee on the Mathematics and Physics of Emerging Dynamic Biomedical Imaging, National Research Council) is one place to start.

2 In fact, I can tell when there's a PBS fundraiser because the number of visitors from a search of daniel amen quack increases.

3 However, new research applies machine learning algorithms to neuroimaging data in an attempt to classify patients with neurological and psychiatric disorders (Orrù et al., 2012).


References

Farah MJ. (2009). A picture is worth a thousand dollars. J Cogn Neurosci. 21:623-4.

Kapur S, Phillips AG, & Insel TR (2012). Why has it taken so long for biological psychiatry to develop clinical tests and what to do about it? Molecular psychiatry PMID: 22869033

Orrù G, Pettersson-Yeo W, Marquand AF, Sartori G, Mechelli A. (2012). Using Support Vector Machine to identify imaging biomarkers of neurological and psychiatric disease: a critical review. Neurosci Biobehav Rev. 36:1140-52.

WaPo link via @vaughanbell.

Subscribe to Post Comments [Atom]

20 Comments:

At August 13, 2012 4:11 AM, Blogger Neuroskeptic said...

good post, the radiation exposure is perhaps the most scandalous part of all this. I don't know exactly what the risk of inducing a fatal tumour is for Amen's scans. But for comparison, a PET study I am involved in at the moment, has an estimated risk of about 1 in 4000 per subject. Which would make an estimated 18 cancer deaths if we had an n of 70000.

 
At August 13, 2012 10:54 AM, Anonymous Joshua Gowin said...

I agree--this man presents a danger to patients and a threat to the credibility of the field. Although diagnosis by brain scan is a fascinating and plausible future application, we currently do not have enough information to assess mental illness through SPECT, PET, or MRI. I say that as someone who works in a lab actively trying to improve our ability to use MRI to estimate likelihood of relapse for abstinent, dependent drug users. Raising this issue is an important step in keeping the public informed of such hucksterism, so thanks for bringing it up.

 
At August 13, 2012 7:40 PM, Anonymous Anonymous said...

Wait - he's "taught himself" by scanning 45,000 people 70,000 times - at their own expense?

How is this not such an egregious ethics violation as to compromise his license?

It would clearly not pass an IRB. And yes, the radiation is a not insignificant risk here.

 
At August 13, 2012 7:47 PM, Anonymous Altostrata said...

I know a psychiatrist who advised Amen when he was just starting out. He is incensed Amen is hyping SPECT scans in this fashion, and making a fortune at it.

By the way, treatments at the Amen Clinics are not particularly creative. They make up diagnoses and prescribe arbitrary drug cocktails just like any run-of-the-mill psychiatric clinic.

If you read the Yelp.com reviews of the various Amen clinics, you'll see lots of dissatisfied customers and interesting reports of half-baked treatment regimens.

 
At August 14, 2012 10:04 AM, Blogger The Neurocritic said...

Thanks for your comments. Two of you (along with Martha Farah) have mentioned radiation as a concern, so certainly that's troublesome. Reading Yelp reviews of the Amen clinics sounds like an... interesting way to pass the time. I wonder if anyone reviewed the "Brain on Joy Bar"? Once I found his online store, it was hard to avoid going off on a tangent about his products.

The short clips below from Celebrity Rehab are really instructive about how Dr. Drew and Dr. Amen practice medicine in the limelight, without regard for the privacy of patients:

Dr. Drew's Neuroanatomy Lesson
Companion Piece to Celebrity Neurostigma

Mindy McCready's Neuroanatomy Lesson
Mindy McCready Teaches Dr. Drew and Dr. Amen About Traumatic Brain Injury

 
At August 27, 2012 8:02 AM, Blogger Seth said...

Great blog! This topic is one that's close to my heart (http://sethgillihan.com/brainscans/). The distance between the science and what clinics like Amen's are offering is startling.

 
At September 04, 2012 1:13 PM, Anonymous Anonymous said...

Amen to that!

 
At September 14, 2012 1:20 AM, Blogger HappyLove said...

I personally have a close relative that was walking the streets in a wedding dress out of their mind, shortly after head injury, while studying for a masters degree aboard. Several*** doctors of this field could barley help her motor control and her delusions....being commited was a real possible option. I was very skeptical but after visiting to the Amen clinic and a year later. I write this Weeping we have her back!!! and she has finished up Masters degree. For year before here visit to Amen she went to several neurologist and phys doctors with mutiple test and treatments. Now she is better and back with us WHOLE. So many times through history men/women are cast aside due to others dissatisfaction with ones pedigree, methods, and education. The proof is in the results... not conjecture. After dealing with my own mental behavior issues for several years (I had three head injuries by 13) and diagnose ADD/ADHD I had decided to visit the clinic also ..still skeptical even after seeing clinic's tremendous progress with my own relative. I just completed my second scan and meet with for the eval this Friday. For so many to judge without going there meeting any of the staff: or having some REAL first hand relatives or friends who has gone there and gotten thier Love, Life, and Laugh back. The tone seems one a witch hunt of the methods rather than one of understanding that medicine and technology is in a continual discovery - development-research.

Wish me well...I will try write an follow up to diag/treatment.

 
At January 23, 2013 3:27 PM, Anonymous Anonymous said...

If mental illnesses have chemical basises and can be treated with drugs then it follows that if someone's "depression" or "anxiety" or what have you was based on a different chemistry than usual then the drugs won't work. Widespread use of brain scans could help stem wasteful and potentially harmful prescriptions. That doesn't invalidate the symptoms but it does mean trying to use the drug in question would probably be a waste of time. Brain scans could also be helpful in choosing where to start with medication rather than playing around with various things to find something that works.

 
At February 04, 2013 11:06 AM, Blogger Kevin Royce said...

I find it laughable that Psychiatry in general scoffs at this procedure as "not ready for prime time" or "not supported by the science"... It's hypocrisy at its finest. Psychiatrists look at symptoms during a brief snapshot in time and then make a "judgement" with no objective clinical tests that support it. Then they have the chutzpah to prescribe little understood meds that will literally change the person's fundamental brain chemistry with the prayer it might work - oftentimes with disastrous results. Then they prescribe more meds to cover up the side effects of the first med which then have side effects of their own.
I have my own story of how this quackery has impacted the last 8 years of my life, but I won't bore you with it. Suffice it to say - no matter what you do - caveat emptor. Don't mess with the brain lightly...

 
At March 19, 2013 3:23 PM, Anonymous Anonymous said...

Hi there...i just picked up amen's book "healing anxiety and depression". ...i started reading it and was about to look into purchasing his services UNTIL i read your blog and the POWERFUL/CREDIBLE sources you identify. I just lost $18.00 on his book but that's far less worse than what i could have lost purchasing his services. THANK YOU VERY MUCH! Now i'm wondering what to do with his book...hmmm good for the fireplace? :) Cheers. Stan

 
At April 16, 2013 8:54 PM, Blogger OPAS said...

The basic question in clinical research is whether one has adequate evidence to reject the null hypothesis. The lack of evidence does not mean it isn't true.

If findings on a Spect scan help patients have better outcomes, then in many cases it is probably worthwhile despite the radiation risks and costs. I would expect that improved outcomes, which is what the patient wants, is likely a product of multiple factors including the therapeutic relationship. Any bonified psychiatrist I would hope acknowledges the therapeutic relationship as being important yet is it possible to prove it in any randomized double-blind controlled setting?

All medical treatments have risks which must be assessed in view of their potential benefits. Medical history is replete with all kinds of examples where physicians were helping patients for reasons poorly understood at the time. Before the pharisees crucify anyone I think the outcomes warrant scrutiny.

 
At May 14, 2013 7:05 AM, Anonymous Anonymous said...

I wish the field of Psychiatry would get it together. I want to help my daughter out of the dark pit she has fallen into, and Amen's ideas are the first I've heard that puts her depression into the realm of physiological illness in a way that makes sense to me. An X-ray is only useful if the person reading it knows what it means. Brain imaging is still developing, but if it can help people and save their lives, we need to continue pushing for it's continued refinement as a medical diagnostic tool. Taking psychiatric issues out of the realm of "character flaw" is vital. There are other diagnostic procedures that use radiation as well, but I don't hear many complaints about those.

 
At October 04, 2013 3:14 PM, Anonymous Anonymous said...

“I can’t imagine clinical decisions being guided by an imaging test,” says Steven E. Hyman, former director of the National Institute of Mental Health and current director of the Stanley Center for Psychiatric Research at the Broad Institute of MIT and Harvard.

Imaging tests, across the board, guide clinical decisions in medical practice. If someone has a ruptured disc, broken bone, bleeding in the stomach...clinical decisions are based upon imaging tests and treatment is determined by them. So why wouldn't images guide decisions regarding the brain, out of which comes every function in the human body? I would rather one make a decision based on biology and assume the risk of some radiation. That risk's undertaken in every other practice. When it comes to thoughts and behavior, learning and emotion these are funadamental things that made a person "themself". How can we get past the elephant in the room that the Amen Clinics have not just good, but great results?

 
At October 05, 2013 11:13 AM, Blogger The Neurocritic said...

Anonymous of October 04, 2013 3:14 PM --

Are there any peer reviewed papers where we can read about these great results? Any double-blind controlled clinical trials? It would be helpful if you could point us in the direction of these studies and the resulting published literature.

 
At October 18, 2013 8:34 AM, Blogger SeaGlassDreamin said...

As a parent of two children who were diagnoses with BiPolar Disorder at the age of 6 and treated with anti psychotic, anti-epileptic,mood stabilizers,(all off-label uses of course)by researchers at Mass. General Hospital (leaders in Bipolar disorder treatment)I have this advice: Be Wary, be Cynical, be Self Advocating and be Educated on many modes of treatment for any disorder. Bipolar Disorder Diagnosis was the flavor of the 90 's along with ADHD. The Pharmaceutical Research alone made billionaires out of researchers, encouraging layering of medications with little efficacy and many adverse side affects. After 12 years of medications with little result. I took my kids of all and taught them coping and life skills that allowed them to develop into well functioning adults. As a very wise Psychologist once told me, "no matter what advise you receive, remember it is just someone's opinion." Priceless statement to carry with you always! There are no definitive tests for mental illnesses, no blood test, MRI,etc. that solidify a diagnosis.
Many people are round pegs trying to fit into square holes. Medications do not accommodate individual genetics.If all you have is a Hammer, everything looks like a Nail! So be aware that what you present to any Dr. as symptoms can and will in most cases fit an easy diagnosis that accommodates the 12 minutes your insurance allows your Dr to spend with you. As consumers we seemingly will try anything the promises a quick fix. Society insists we conform to norms in schools, on the job, etc. So it's a catch 22. Be Careful, Slow down and Think carefully before follow any mode of medicine. In hindsight I realized my children had severe anxiety! Not bipolar at all....live and learn. But try to learn first if you can.

 
At November 09, 2013 1:24 PM, Anonymous Anonymous said...

However, you fail to say that no one is willing to do the double blind trials to prove it one way or another. As far as I can see, he only uses spect scans as a part of a total diagnostic work up. I had memory problems and was subjected to a CT sac and an MRI and have had dozens of X-rays over the years. No doctor ever worried about how much radiation I was getting. I'm now booked for another X-ray and MRI.

The medical community needs to respond to Dr Amen's claims and do the studies, not slam him as a huckster. However, I have a hard time trusting any medical establishment in the US that is nothing more than a big money making machine anyway. How ludicrous for professional doctors who make hundreds of thousands of dollars a year in a free market medical industry to call one of their own a huckster. Do the studies and when you've got the evidence, then say honestly, it is not a valid diagnostic tool.

 
At June 02, 2014 10:26 AM, Anonymous Anonymous said...

I find Dr. Amen's approach very intriguing. I think he is way ahead of his time and because he relies on a different approach than the rest of the psychiatric community he is labeled as a "quack".

When I attended a community college in the early "70's I worked at a pediatric clinic. One of the physician's specialized in allergies. He had parents that brought their children from all over the US to go through days of allergy skin testing to determine what was causing their skin problems, sinus conditions, hyperactivity, etc. Many considered him a quack because the testing was very expensive but he had very positive results with the patients that received the injections for their allergies. He too was considered way ahead of his time. We read everyday now how allergies from so many different things can derail our bodies.

I have a 27 year old son that was diagnosed with ADD at age 6. He responded well to stimulants at an early age but he wouldn't continue the medication because of the side effects. His real troubles did not begin until middle school. He suffered from lack of attention and organization, always losing things, impulsiveness and unknown to his parents bullying. We were told by his teachers that he would outgrow it but that has not been the case. The schools downplay this problems and I still don't think to this day it is treated as a huge risk factor for potential problems with children like it should be. As a result we did not seek any outside guidance for him. We had to pull him out of school in 9th grade due to him threatening to drop out and homeschooled him for the rest of his high school years.

Fast forward now 8 years later and our son has been diagnosed with Crohns Disease, struggling with binge drinking, suicidal thoughts, anger, hostility, extreme anxiety, depression, and sleep disorder. We had to move our son back in with us to attempt to help him get his life in order. Finding a reputable psychiatrist and counselor is like finding a needle in a haystack! Asking for referrals for mental illness is not like getting good referrals for a primary care doctor. Psychiatry has advanced a lot but it still has a long way to go.

I am a nurse and I research thing thoroughly before coming to an educated decision about things. I did hear about Dr. Amen on PBS and was very encouraged. When you read that Dr. Amen is just in this business for the money red flags do go up. But what we all have to realize is that he started out small and was committed to something he believed in and when you read the success rates his clinics have, one must come to the conclusion that they are doing some positive things. Families that have dealt years with a troubled child with ADD/ADHD will try anything to help their child improve their life no matter what age they are. I will continue to research the clinics before deciding to encourage my son to go there.

 
At June 21, 2014 7:44 AM, Anonymous Anonymous said...

Amen clinics dont file insurance. They do provide codes so you can find out what your insurance will reimburse you for. They also provide you the individual cost for each procedure or appt. My experience with psychiatrist costs,tell me his are in line with the norm in GA. Costs of scans are customary & similar cost at other facility's . My insurance covers 50% out of network,80% in network. I'm not in agreement with Obama Care,but at this time in my life there are benefits. Your insurance has to cover preexisting conditions & psychiatric care. Most insurance companies didn't before. If they did it was a token a lot only. I'm already paying a psychiatrist. So what do I have to lose really? People invest in a lot of different things & loose money. Radiation ? Really!! It's done all the time,if a Dr deems it necessary. Most dont give it a second thought.

 
At July 11, 2014 8:19 PM, Blogger Scotttt said...

The Washington Post article states, "Researchers say, SPECT has largely since been surpassed by technologies such as PET and functional MRIs, which give images of far greater clarity. It’s no longer viewed as cutting edge." I can only speak form my own experience which is purely anecdotal. After I had radiotherapy which included part of my head many years ago, I became convinced that I had brain damage. I had many MRI's and a PET scan as well as extensive neuropsychological testing. None showed any abnormalities. After I saw Dr. Amen's first PBS broadcast in the 1990s, I made an appointment to have a SPECT scan done at his clinic in Newport Beach. At last I was able to see in the images (I still have copies), EXACTLY what I had long suspected. I had vastly decreased blood-flow in the area of my brain that had been irradiated. Yet these other "superior" imaging techniques showed absolutly nothing abnormal. So much for SPECT being surpassed. As for greater clarity, I recently had a SPECT scan done at a major hospital here in Los Angeles because I am now on Medicare and cannot afford Dr. Amen. I requested a CD of the images and they were vastly inferior to the images I received from Amen's clinic. Clearly then, there is a difference in the equipment and methodology being used. All these highly qualified critics who claim SPECT is not sufficiently sensitive need to compare notes on methodology, not who has the most exposure on PBS. They are clearly unwilling to cooperate with him, they are just trying to debunk him. There is nothing more vicious than professional jealously. As one journalist put it (I don't remember in which publication), "Debunkers will throw anything at the wall and see what sticks." Well they can live with faeces covered walls in there own lives but they have not affected mine. I am more skeptical of them (and you) than I am of him.

 

Post a Comment

Links to this post:

Create a Link

<< Home

eXTReMe Tracker