Wired Magazine writer-psychiatrist Daniel Carlat came to our clinic for a scan. He was working on a negative article about how useless brain imaging is in clinical practice. He took on fMRI, SPECT and qEEG. He was not up front with his us about intent. You can read the article online this month at wired.com\wired. I wanted to post my response here and let you decide what you think. Feel free to post your thoughts here and at wired.com.
I am saddened that Dr. Carlat could actually write at the end of his article that “My journey through the land of functional neuroimaging has helped me to understand how spectacularly meaningless these images are likely to be.”
Maybe for someone like Danny who is not currently clinically depressed, the pictures have no meaning, but what about the patients with brain trauma, early dementia, toxic exposure, anoxia, or resistant psychiatric disorder that come through our offices that psychiatrists just missed because no one bothered to look at brain function.
Or what about the boy who I saw two weeks ago who spent 18 months in a residential treatment facility and 30 days in a drug treatment program at a cost of more than $100,000 who had a tennis ball sized cyst in the left side of his brain, who had a normal neurological exam? A neurosurgeon drained it at UCLA last week. Dr. Carlat would have diagnosed him as a character disorder after the boy threatened to kill his mom and dad. I was hoping for a much more thoughtful article.
I wonder why Dr. Carlat decided not to talk with many of the other people in my field who have been doing clinical brain imaging work for years, such as Ismael Mena, the grandfather of clinical imaging, or Mike Uszler at UCLA or Joe Wu at the University of California, Irvine or Jim Merikangas who used to be the president of the American Neuropsychiatric Association or Harold Bursztjan at Harvard who is director of the psychiatry and law program. Dr. Bursztjan correctly says that scans do not give you the answer, they teach you to ask better questions.
Psychiatrists make diagnoses today the same way they did in 1840 when Abraham Lincoln was depressed, through talking to patients and looking for symptom clusters. Psychiatrists are the only medical specialists that never look at the organ they treat. Isn’t that a scam…to make diagnoses of brain dysfunction without ever looking at the brain?
No question we have a long way to go and a lot more research to do, but to continue as most psychiatrists currently practice is not only backwards it is downright hurtful to people.
Dr. Rubin’s assessment of my work misses the mark completely. I am not interested in what your brain looks like as part of a group of depressed patients. I am looking at what your own brain specifically looks like. I am looking at an N of 1, your brain. Illnesses like depression will never have a singular finding on scans because they are not a singular disease. There are many different types that need an individual approach, that is where scans help…what does your brain look like, so that I can target treatment specifically to your brain.
Thomas Insel, Director of the National Institutes for Mental Health said in 2005 at the American Psychiatric Association that “Brain imaging in clinical practice is the next major advance in psychiatry…Trial and error diagnosis will move to an era where we understand the underlying biology of mental disorders….We are going to have to use neuroimaging to begin to identify the systems pathology that is distributed in each of these disorders and think of imaging as a biomarker for mental illnesses…The DSM-IV has 100%reliability and 0% validity. We need to develop biomarkers, including brain imaging, to develop the validity of these disorders….We need to develop treatments that go after the core pathology, understood by imaging…The end game is to get to an era of individualized care.”
Dr. Insel believed in 2005 that brain imaging in clinical practice would be a reality in 5 years. I think that brain imaging in clinical practice is long overdue. You can try to kill yourself in virtually every major city in the world, and no one will look at your brain!
One of the pieces of information that Dr. Carlat left out of his article is that he came to our clinic and refused to fill out our intake questionnaires. He wanted me to act like a palm reader and tell him what the scans said without much clinical information. That is not how we practice. That is not how any reputable physician operates. We want all of the information, clinical information and scan information, before we make a diagnosis and prescribe a treatment plan. Yet having said that, I was right! He admits that his scan did in fact fit his clinical presentation. He says it was because I am a good doctor (thanks Danny). I would say it is because I am a good doctor with more information. Don’t you want your doctor to have as much information before he goes about changing your brain?
Here are two responses that patients have posted on the Wired site.
From Lauralee:
I was referred to the Amen Clinic in Newport Beach, CA, by Dr. Earl Henslin for a SPECT scan 5 ½ years ago. At the time, I had to leave my job as Operations Manager with a company that I had been with for 23 years. I had no idea what was wrong with me other than I thought that I was losing my mind. In addition, I could not eat which caused my weight to drop to a very unhealthy level. I also became agoraphobic after having traveled the world. I had reached a point where it was more peaceful to be asleep than awake. I never thought that anything like this would ever happen to me. Thanks to Dr. Amen’s pioneering research and development of the SPECT scan, I learned that I was severely depressed which was a symptom completely on the other end of the spectrum for me as I was always happy (or so I thought). I had anxiety that was off the chart for which I was using large doses of Xanax in an attempt to unsuccessfully control. After the SPECT scan reading, the appropriate medications and dosages were prescribed along with psychotherapy. I can say that there is no way psychotherapy in and of itself would have ever helped me. SPECT scans and psychotherapy definitely go hand in hand. It only makes sense that psychiatrists and therapists would use a tool to help them ‘see’ the brain and make appropriate recommendations for treatment just as physicians have a myriad of tools to help them with a diagnosis elsewhere in the body. Are all tools used for medical diagnosis perfect? No. Are all methods of treatment perfect? No. Do we know everything that there is to know about the brain? No. Is the technology for this perfected? No. But, some information is better than none and SPECT scans do provide this. As with any cutting edge technology, the means of understanding the workings of the brain will evolve and become perfected. If we never took the chance of using new technology in the beginning, thousands of people would not be blessed with longer and healthier lives in so many arenas. SPECT scans take out some of the ‘guess work’ made by psychiatrists who have no concrete medical evidence on which to write prescriptions. I owe my life to Dr. Amen and Dr. Earl Henslin and cannot say whether I would be here if it were not for the two of them. I am now a happier person and look forward to the day ahead. My husband acknowledges how much happier I am and even says that I now have a great sense of humor. In addition, along the way I discovered my true passion in life which is photography for which I have won awards (and I never won anything in my life!). Thank you Dr. Amen and Dr. Henslin!!!
From Kirsten:
After reading your article about brain scans I found it necessary to comment from a consumers perspective. Two years ago I took my father to the Amen Clinic out of desperation. He had been diagnosed with early onset Alzheimer’s disease, severe clinical depression, and was living as a recluse in a single room. After a thorough assessment Dr. Amen explained that my father did not have Alzheimer’s disease and was on combination of medication that was essentially toxic. Today my father is working, volunteers at the local church and is once again living on his own and able to drive.Since then I have referred four friends to the Amen clinic. Three out four of those friends reported dramatic changes and improvement in the way they felt afterwards. One of those friends took her teenage son to the have a scan as a last resort after he was arrested and placed on probation for drugs. Upon seeing the effects that his drug use has had on his brain he decided he no longer wants to have a brain that looks like “swiss cheese” and has not done drugs since. Maybe a picture really is worth a thousand words.
Kirsten
