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Blaming Amen: Nuclear Psychiatry or Unclear Medicine?

September 20, 2010 34 comments

The latest American Journal of Psychiatry arrived in the mail last week, and when I got around to the letters section, I found a letter from Daniel Amen objecting to a critique of his work following a review of his book from last year. Apparently his book, Healing the Hardware of Your Soul, was criticized pretty harshly in the original review, published in AJP in March 09. Amen’s liberal use of nuclear brain imaging, primarily SPECT scans, to diagnose and guide treatment of psychiatric conditions took some pretty heavy fire.

The original review of his book, which I missed last year when it came out, was pretty clear in its criticism of his claims:

For each of the vignettes Dr. Amen presents, many psychiatrists would have chosen treatments similar to those he used when confronted with the particular symptoms he describes, based solely upon clinical judgment. There is no systematic analysis of the 45,000 imaging studies to demonstrate how Dr. Amen’ s approach is superior to treatment-as-usual by a psychiatrist. Thus, there is also no evidence presented to justify exposing patients to the radiation of a SPECT scan and to support the considerable expense to patients, families, and their insurers.

Things were apparently quiet, and the review attracted little attention until May of this year, when two writers in the letters section decided to pile on. They entitled the letter “Scientifically Unfounded Claims in Diagnosing and Treating Patients” and began by reiterating the claims of others that Amen has scanned thousands of patients unnecessarily. They went on to accuse him of endangering the profession of psychiatry, because his work could discredit the use of psychiatric functional imaging and prove to be a setback to others who are presumably doing more “legitimate” work. They end the letter with a sort of threat:

It is therefore incumbent upon all of us to monitor and regulate our field. We encourage physicians to remain vigilant of unproven approaches practiced by our peers and to immediately report these trespasses to their state medical boards.

I guess Amen felt he had to respond to this one, because in the current AJP he writes in, defending his work and attempting to cite other evidence that supports his use of imaging. His arguments are selective, however, and I don’t think he quite succeeds in proving his point. The editors of AJP apparently don’t either. After his letter, they printed the response of the original letter-writers who pretty much take apart each of Amen’s points. And then there’s a note by the editor-in-chief of AJP, which ends with:

Commercialization of a diagnostic test, even if the underlying procedure such as brain imaging or DNA analysis is approved for human use, strongly indicates to physicians and families that the test adds significant new information to guide clinical judgment. We have published this exchange of letters as part of our responsibility to readers to point out when a procedure may lack sufficient evidence to justify its widespread clinical use.

In case you’re not familiar with Dr. Amen, his books, or the Amen clinic, you can think of him as the Neuropsychiatry equivalent of Dr. Oz. Whenever Oz or someone like Andrew Weil or Dr. Drew comes up in a conversation among doctors, there is often a collective sigh or rolling of eyes. Yes, these are real physicians, but they are thought to have lost their academic edge, or even a bit of their medical integrity, by pushing the envelop of evidence-based medicine to endorse dubious treatments, sell their own products, or sensationalize otherwise legitimate treatments. Mostly the supplements, alternative medicine modalities, and exercise regimens they tout are at worst harmless and in many cases may in fact be beneficial. The harm they do is more implicit: their statements as doctors imply that their endorsement of the benefits of astragalus root, say, have the same weight of evidence behind them as the aspirin for secondary prevention of heart attack that the TV viewer’s own doctor is likely recommending.

In Amen’s case, it’s his contention that SPECT scans are an important addition to the routine diagnosis and treatment of mental illness. For several thousand dollars, you can visit his clinic, have a SPECT scan, and then have a treatment plan recommended which is supposedly informed by your SPECT. The objection that most psychiatrists have is that Amen’s recommendations are not much different than what a psychiatrist would do without having a SPECT to look at. The SPECT scans give his practice a veneer of scientific legitimacy that is misleading. Not many people would pay $3375 out of pocket and travel out of state for a psychiatric consultation, even if the psychiatrist is said to be quite good. But a psychiatrist who uses high-tech imaging your local doctors won’t offer, who can “look into” your brain and make recommendations based on a striking color image instead of by just talking to you? This gets some people excited, and I’m sure that Amen has better than average treatment response, at least in the short term, because he has motivated patients and offers them a strong placebo.

Overall, I think people like Oz and Weil are earnest and encourage people to be engaged in their own healthcare, which is certainly good. I think that their work, however, would be more respectable if they held their TV statements to the same level of credibility that we hold statements in peer-reviewed journals. This is a tall order, because in science, accuracy means ambiguity, and ambiguity doesn’t make good television compared to the Shocking New Finding that isn’t really as significant as it sounds. We know that it’s possible to be a good physician-commentator: I think Sanjay Gupta does pretty well, and Rich Besser at ABC and Darshak Sanghavi are top-notch. I don’t have a very good feeling about Amen, however. He’s not in the business of spreading valid information and making sound recommendations to help people interpret health care news or their own illness. It’s more like he’s making dubious self-serving claims at the expense of a vulnerable group of people: those with mental illness who feel they haven’t had adequate treatment. I think that’s what bothers me the most.

So where does Dr. Amen sit in the spectrum between conservative academic and self-serving sensationalist? Clearly I think he’s closer to the latter, and the reviewers at AJP appear to agree. I firmly believe that we will someday be able to use neuroimaging, both functional and structural, to diagnose and guide treatment of psychiatric disorders. That’s in part why I became a neuropsychiatrist. I don’t know, however, when that will come to be, or even if it will be during my career or lifetime. On the other hand, Dr. Amen knows, or claims to know, that that time is now. He uses functional neuroimaging to help diagnose and treat mental illness, and appears to make a good living at it. I truly hope that what he’s selling will indeed be available some day, but nobody, Amen included, has provided adequate evidence that nuclear imaging can do what he says it does. There are certainly valid uses for SPECT scans today, for example in assessing damage after a traumatic brain injury or clarifying a diagnosis of dementia. For the vast majority of psychiatric illness, however, having a SPECT scan at the Amen clinic or anywhere else will only add a small dose of radiation to your lifetime exposure and large hit to your wallet.

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