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Dr. Amen’s Love Affair with SPECT Scans

Daniel Amen loves SPECT scans (Single Photon Emission Computed Tomography). And well he should. They have brought him fame and fortune. They have rewarded him with a chain of Amen Clinics, a presence on PBS, lucrative speaking engagements, a $4.8 million mansion overlooking the Pacific Ocean, and a line of products including books, videos and diet supplements (“nutraceuticals”).  He grossed $20 million last year.   Amen is a psychiatrist who charges patients $3,500 to take pretty colored SPECT pictures of their brains as an aid to the diagnosis and treatment of conditions including brain trauma, attention-deficit hyperactivity disorder (ADHD), addictions, anxiety, depression, dementia, and obesity. He even does SPECT scans as a part of marriage counseling and for general brain health checkups.

SPECT imaging uses an injected radioisotope to measure blood flow in different areas of the brain. Amen is exposing patients to radiation and charging them big bucks because his personal experience has convinced him SPECT is useful. So far, he has failed to convince the rest of the scientific medical community.

Amen has just published an article in the journal Alternative Therapies entitled “It’s Time to Stop Flying Blind: How Not Looking at the Brain leads to Missed Diagnoses, Failed Treatments, and Dangerous Behaviors.”  It amounts to poorly-reasoned apologetics with false analogies, testimonials, and pretty pictures that don’t prove what he thinks they prove.

Previous Criticism

I have written about Dr. Amen before, both on Quackwatch and on Science-Based Medicine.  Amen’s attorneys complained that my Quackwatch article was unfair; we responded to the attorneys by asking a series of questions, and I commented on their inadequate response. When you google “Daniel Amen,” “Amen Clinic” or even just “SPECT scans” my articles appear early in the list of hits.

It’s not just me. Amen has a lot of other critics. Psychiatrist Daniel Carlat wrote “Brain Scans as Mind Readers? Don’t Believe the Hype” in Wired Magazine, describing his own evaluation by Dr. Amen. Amen told Carlat his scans showed too little activity, a pattern of angst, and a predisposition to depression (that part was a slam dunk, since in taking a medical history Amen had already elicited the information that Carlat had had a short bout with depression). He recommended a multivitamin, gingko, less snowboarding, and more tennis. An expert at UCLA later reviewed the same scans and explained that the findings are meaningless because they haven’t been validated by controlled studies to determine their diagnostic specificity. Carlat likens Amen’s spiel to the cold readings of palm readers.

The Skeptic’s Dictionary has critiqued Amen’s PBS programs, calling them “infomercials.”  The PBS Ombudsman received a flurry of complaints about the use of Amen’s videos for fundraising drives, but weaseled out of taking any action by saying decisions were made by local stations and the programs were not officially endorsed by PBS.

Neurologist Robert Burton wrote an article called “Brain scam” in Salon.  The title says it all. Among other things, he is appalled that Amen claims to know how to prevent and treat Alzheimer’s.

In an article titled “Brain scans: not quite ready for prime time” Dr. Thomas Insel, the director of the National Institute for Mental Health, characterizes brain imaging as “still primarily a research tool.” He cautions that “entrepreneurial zeal capitalizing on scientific advances needs to be tempered by reality checks.”

In a 2012 article in The Washington Post, Neely Tucker reported:

Officials at major psychiatric and neuroscience associations and research centers say his SPECT claims are no more than myth and poppycock, buffaloing an unsuspecting public… the disconnect between Amen’s public image and professional reputation among the elite in the field has come to defy logic.

He includes a number of scathing quotations from those elite.

Amen’s New “Flying Blind” Article

Anecdotes. He starts with an anecdote about his nephew, who had attacked a little girl for no apparent reason. Amen did a SPECT scan and found a large arachnoid cyst; after surgery, the violent behavior stopped. This is a touching story, but anecdotes are not evidence. Cysts and other brain abnormalities are frequent incidental findings on brain imaging and arachnoid cysts are often asymptomatic even when large.  Even if the child’s violent behavior was due to the cyst, a SPECT scan was not necessary to find it. An MRI would have found it, with better anatomical detail and no need for radiation exposure.

He asks,

How could a child psychiatrist know what was going on in Andrew’s brain unless he or she actually looked at how it functioned?… psychiatry remains the only medical specialty that rarely looks at the organ it treats.

He suggests that if the brains of recent mentally ill mass murderers had been looked at, their crimes might have been prevented. That might be a persuasive argument if “looking at the brain” actually corresponded to understanding what the neurons were doing or had any predictive value. It doesn’t.

He presents more anecdotes: after an addict saw the “toxic pattern” on his scan, he stopped abusing alcohol and cocaine. After a depressed patient’s scan showed a pattern “consistent with brain injury,” further questioning led her to remember a fall from her bike a month before her symptoms began.

Defensiveness. Next he switches into defensive mode, trying to answer some of the criticisms that have been leveled against him.

  1. Scans will not give an accurate psychiatric diagnosis. He admits this is true, but argues that a diagnosis doesn’t tell us if the brain is overactive and needs to be calmed or underactive and needs stimulation. He gives another anecdote of a patient with hallucinations: SPECT scanning showed areas of increased activity, leading him to investigate further and diagnose Lyme disease. He says “In my psychiatric group’s experience, success rates increase when psychiatrists use clinical histories plus scans.” [Emphasis added.] Remember that Mark Crislip has called “in my experience” the three most dangerous words in medicine.
  2. Not enough research has occurred. He admits that more work is needed, but switches into tu quoque mode, saying that only 11% to 14% of the recommendations of other specialties are supported by A-level scientific evidence.
  3. Scans are expensive. He says they cost about the same as MRI scans. But the cost of an MRI varies, and only the highest prices correspond to what Amen routinely charges for SPECT. And MRIs are arguably done for reasons that are better grounded in evidence. No other psychiatrist routinely orders MRIs on every patient. And MRI scans don’t use radiation.
  4. The scans use radiation.  He argues that CT scans do too. But CT scans are arguably done for reasons that are better grounded in evidence. They are not done routinely on every patient.
  5. SPECT is not ready for clinical use and should be left in the hands of researchers. He argues that a useful medical procedure should not be withheld from patients just because researchers haven’t chosen to study it, and that there are no financial incentives for such research, since the imaging tools already exist. (I don’t think I need to point out what is wrong with that reasoning.)

Ignoring the real criticisms. He is really responding to a straw man characterization of what his critics have said. He ignores other criticisms like these:

  1. Patients should not be subjected to the radiation and expense of a SPECT scan without credible evidence (from controlled, peer-reviewed studies) that it is likely to help them.
  2. He is relying on experience and anecdote rather than on acceptable scientific evidence.
  3. He has not validated that scans show what he claims they show.
  4. He uses unscientific terminology like “your brain is cool at rest.”
  5. He has not shown that his outcomes are better than those of doctors who do not do SPECT scans.
  6. He has created his own idiosyncratic classifications of illness based on scan results, classifications that go beyond the DSM and that have not been validated elsewhere. For instance, he divides ADHD into classic, inattentive, over-focused, temporal lobe, limbic and “ring of fire,” and obesity into compulsive, impulsive, impulsive convulsive, sad, and anxious.
  7. He prescribes inadequately tested natural remedies, irrational mixtures of nutritional diet supplements, hyperbaric oxygen, and other questionable treatments.

A riff on traumatic brain injuries. He goes on to talk about unrecognized damage from traumatic brain injuries, recommending that SPECT scans be routinely used on military personnel and those at risk of sports injuries. But he has only his own anecdotal impressions that SPECT scans can add anything useful to the usual diagnostic process for TBI, which already includes CT and MRI scans.

Conclusion

Amen fails to make his case that “Not Looking at the Brain leads to Missed Diagnoses, Failed Treatments, and Dangerous Behaviors.” He accuses conventional doctors of “flying blind.” But maybe he is the one flying blind, blinded by delusions born of exalting personal experience above rigorous scientific testing and allowing the lure of celebrity and riches to cloud his judgment. Isn’t it curious that while he claims to be at the cutting edge of scientific medicine, this article was published in an alternative medicine journal?

Posted in: Neuroscience/Mental Health

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27 thoughts on “Dr. Amen’s Love Affair with SPECT Scans

  1. drdavemd says:

    Thanks Dr. Hall. In my field of cardiology there is great interest to find ways at reducing radiation exposure and informing doctors about the appropriateness of tests (http://www.choosingwisely.org/). Astonishing to think that this technology is being used in this fashion without an adequate evidence base to justify the small, but non-negligible risks associated with radiation exposure from SPECT radiotracers.

  2. windriven says:

    ” He says “In my psychiatric group’s experience, success rates increase when psychiatrists use clinical histories plus scans.” [Emphasis added.] Remember that Mark Crislip has called “in my experience” the three most dangerous words in medicine.”

    In this country we allow physicians very wide latitude in diagnosing and treating patients. Should the practice of medicine instead be purely algorithmic? Should no new approach be tried until a dozen RCTs have demonstrated safety and efficacy to high statistical probability?

    Where should the line be drawn? Who should draw it? Once drawn, how should the line be enforced?

  3. windriven says:

    I hope Dr. Crislip will weigh in again on the three most dangerous words. His epigram has been used widely and perhaps not always in the way he intends. I take it, in essence, to caution against confirmation bias – as Dr. Hall has used it here.

  4. mousethatroared says:

    windriven “. Should the practice of medicine instead be purely algorithmic? Should no new approach be tried until a dozen RCTs have demonstrated safety and efficacy to high statistical probability.”

    Something that occures to me. Doing something can have health and safety consequences, doing nothing can have health and safety consequences. What is a reasonable approach to balancing the possibilities between risks/consequences of the two.

  5. windriven says:

    @mouse

    Precisely the question.

    @Jeff

    There is peer review and there is peer review. The Journal of Psychoactive Drugs (formerly Journal of Psychedelic Drugs) has an impact factor of 0.72. To put that in perspective, the Journal of Clinical Oncology has an impact factor of 18.372.

  6. Janet says:

    I have often offered personal tales here of some of my close calls with alt med, especially when I lived in a couple of little towns that were New Age “vortexes” (read hives of woo-scum), but today’s topic has given me pause, especially as I use my own name. But after some thought, here goes:

    I have a (now grown) child who suffers from a mental illness and started seeing child psychiatrists about age nine. As we were in small towns, there wasn’t a lot of choice and when the only psychiatrist left our town, I began commuting to a larger town where we came across a pediatrician who was recommended in Amen’s book–full of colorful brains that seemed to explain everything about children like mine. We got the SPECT scan (the state medical insurance plan paid for it!) and the pediatrician and a neurologist consultant friend of his “interpreted” it. They admitted that they had little experience with this endeavor and after all the fuss, they more or less shrugged and said the scan was “inconclusive”, but they proceeded to “diagnose” my son with no further testing (such as the evaluations he was later given by the evil mainstream docs).

    The (altie-inclined) pediatrician went on to prescribe anti-depressants for my child with disastrous consequences as my child has bi-polar illness. We also flirted with Amen’s “natural” remedies, which amounted to massive doses of amino acids. At this point, something in my innately skeptical brain said, “gee, if you take huge amounts of this stuff, isn’t it a drug?”

    I got my child to a real psychiatrist who informed me of the medical community’s doubts about Amen, the pediatrician gave up most of his practice for “health reasons” (that’s what the letter said), my son finally got some real treatment, and I became a full-time skeptic. It’s around this time that I first found Quackwatch–and began to lose friends at a rapid pace–friends who thought I shouldn’t be taking my child to ANY kind of shrink, but to some altie guru or other instead.

    So, I don’t know the “reasonable approach” MTR, or if the practice of medicine should be “strictly algorithmic”, windriven, but I do think something should be done about Amen getting his infomercials on PBS (and PBS not doing anything about asserting some kind of control over local stations), and I think his crappy books shouldn’t be in the “medical” section of libraries, right next to actual medical books, where concerned parents will pick them up and assume that they are valid.

    I have left out the details of the ramifications of the time I wasted getting real treatment for my son and the unnecessary havoc the wrong meds created, but they were not trivial. My son’s trust in me and in the medical establishment were seriously damaged and further treatment became very difficult to impose. THERE IS HARM. This can happen even with good psychiatry as much of the treatment is trial and error, but at least you have real support that will help when things go wrong. Where was Amen, or the altie-pediatrician when my son became psychotic?

    Thank you for the reminder about this quack, HH. It’s a painful lesson that I didn’t really want to re-visit, but one that bears repeating.

  7. Harriet Hall says:

    @Jeff,

    That published study by Dr. Amen reinforces my point. It studied the effects of a kitchen-sink mixture of diet supplements in athletes with brain injury; it was open-label rather than placebo-controlled. It used SPECT as an additional measure of outcome along with conventional outcome measures. It did not show that SPECT added anything useful to the assessment of outcomes.

    He has published a lot of things in peer-reviewed journals, but they are not good science and do not support what he is doing in his clinics.

  8. windriven says:

    @Janet,

    Three cheers to you for grabbing hold of your child’s care, especially in such difficult circumstances.

    “I don’t know the “reasonable approach” MTR, or if the practice of medicine should be “strictly algorithmic”, windriven,”

    I don’t either but it is something that, I think, needs to be addressed. Innovation happens in many ways and medicine is still a science defined largely by what isn’t well understood. But there are ethical constraints that apply to medicine that don’t apply to physics or metallurgy.

    Lowering the cost of care seems to advocate for generally algorithmic practice. Innovation seems to argue for a less restrictive approach.

    I don’t pretend to know the right balance. But I do know that much of the quackery discussed in these pages falls far outside what any rational person would consider appropriate.

  9. Richard says:

    I hate PBS. I used to love them for their educational programming. While they still have some good programs, I can’t support them anymore because of the quack infomercials they allow during their pledge drives. They claim to be an educational network and are supported by taxpayers, but their affiliates put out medical misinformation and they don’t do anything to curtail it. They are really just another part of the television wasteland they claim to be so far above. I think Big Bird should be roasted and served for Thanksgiving dinner. All ranting aside, I hope the SBM crew will write more articles highlighting how PBS has betrayed the public’s trust.

  10. WilliamLawrenceUtridge says:

    @Richard

    I hate PBS. I used to love them for their educational programming. While they still have some good programs, I can’t support them anymore because of the quack infomercials they allow during their pledge drives. They claim to be an educational network and are supported by taxpayers, but their affiliates put out medical misinformation and they don’t do anything to curtail it. They are really just another part of the television wasteland they claim to be so far above. I think Big Bird should be roasted and served for Thanksgiving dinner. All ranting aside, I hope the SBM crew will write more articles highlighting how PBS has betrayed the public’s trust.

    You might enjoy Science Left Behind by Alex Berezow and Hank Campbell, who divide the political spectrum into four rather than two groups. On the right are Republicans and Libertarians. On the left are Democrats and Progressives (I’m not positive on the terms, read the book!). Progressives are the left’s answer to creationists, ignoring or selectively quoting science when it suits them and advocating for strong social controls. It is here that the sins of the left, like PBS, are most apparent, adopting similar rhetoric and strategies about science as creationists, but with different goals.

    It’s a very good, very eye-opening book, and you might even be able to read the ideas for free (Berezow and Campbell apparently based the book on a blog, which is quite apparent).

  11. danielafalcon says:

    I have seen this guy on PBS, and wondered about it. This is at least tacit endorsment by PBS. His plaintive countenance and manner of speech are so irritating. PBS needs to get this scammer off the air!

  12. Richard says:

    I’ve heard of it, and it does sound interesting.

  13. MTDoc says:

    @windriven

    Amen, windriven (pun intended). This isn’t exactly innovation, more like experimentation, and perhaps self delusion. If studies are being performed in a hospital setting, a competent audit committee should be constraining his enthusiasm, as we have well defined standards of care, as well as utilization criteria. But then medical staffs now days are largely hospital employees, and hospitals want increased utilization of their expensive technology. I also expect he is well lawyered up.

    @richard

    I prefer turkey,never tried ostrich. For what its worth, I agree with you.

  14. mousethatroared says:

    @Janet – Thanks so much for telling your story. My older brother has schizophrenia. In his younger years, he had intense paranoia, violent and suicidal episodes. You are absolutely right. Folks with psychiatric disorders need real responsible science based medical treatment as quickly as possible. Representing speculative diagnoses and therapy as effective or helpful is not only terribly unethical, but also dangerous and can easily do lasting harm.

    To be clear, when I said “a reasonable approach”, I had in my mind the need for the use of plausible therapies (with a well understood risk profile) in conditions with real (rather than speculative) health consequences that may not have a well documented or well researched successful treatment. This would be more in the line of responsible off-label prescribing for things like migraines or rare under researched conditions – NOT speculative trial and error with any random therapy that strikes someones imagination for random findings that have no evidence of accuracy of anything.

    And by the way – shame on those “friends” of yours. I get so fed up with people’s romanticized idea of mental illness as something that can be cured with a different diet, a lot of love, a spiritual epiphany or more self-discipline. Some people really do not get it and I have no idea how to deal with those folks.

  15. Jacob V says:

    I wonder if a SPECT scan can evaluate a patients credit card limit.

  16. Narad says:

    I do think something should be done about Amen getting his infomercials on PBS (and PBS not doing anything about asserting some kind of control over local stations)

    They can’t. The affiliates aren’t O&O’s (“owned and operated,” in the jargon). PBS distributes (i.e., sells) a portion of the affilates’ programming. Let’s take an example from radio: NPR got WBEZ to produce “Wait, Wait Don’t Tell Me” explicitly in order to compete with Michael Feldman’s “Whad’ya Know,” which is (currently) distributed by PRI. Would you want NPR to be telling affiliates that they had to pick one or the other or couldn’t air “Whad’ya Know” live?

  17. windriven says:

    @WLU

    “who divide the political spectrum into four rather than two groups.”

    I am reminded of the only bumper sticker I would have ever agreed to put on my car (other than a Darwin fish). It read in large letters DEMOCRAT on the left half and REPUBLICAN on the right. In smaller lettering underneath it said “same sh|t, different piles”.

    Those who identify strongly with a particular political ideology are often no different than those who embrace a particular confessional; they have outsourced their judgment. And who can blame them? Thinking is just too much work and besides American Idol will be on in twenty minutes.

  18. mousethatroared says:

    Bumper stickers? I can’t decide between a “If you can read this, thank a teacher.” and “What do we want? Time travel! When do we want it? It’s irrelevant.” (tardis graphic)

  19. WilliamLawrenceUtridge says:

    Those who identify strongly with a particular political ideology are often no different than those who embrace a particular confessional; they have outsourced their judgment. And who can blame them? Thinking is just too much work and besides American Idol will be on in twenty minutes.

    I listened to a lecture series by Peter Navarro, an economist at University of California, Irving. Very interesting, for a lot of reasons – makes the news a lot more sensible when they talk about monetary and fiscal policy. He had an economic reason for the political parties being essentially the same – every time they move in one direction, they gain some voters and lose others. To get the kinds of numbers they need, both need to become similar. It’s a sad truth about democracy – it’s the least bad system. Enlightened dictatorship is the best, but the “enlightenment” part is too dependent on who the dictator is, and there’s zero guarantee they’ll be good for the majority. Look at China – currently they tremendous central planning (really one could almost argue the Communist Party is essentially a new incarnation of the Emperors of old) and fantastic economic success because of it. The economy and development can be strongly directed, vaccines can be rigorously promoted (probably mandatory in some cases) and you can make things like acupuncture illegal if you wanted to. So in this case, Deng Xiaoping and his successors did a fantastic job – benevolent dictatorship. However, Chairman Mao – terrible dictatorship; the Great Leap Forward starved millions to zero benefit and the Cultural Revolution gutted the country of scholars, knowledge and civil discourse.

    That’s why I want an interim rule by technocratic decree through committees of scientists, until benevolent robots and artificial intelligence can take over. The only sensible solution.

  20. windriven says:

    @WLU

    ” until benevolent robots and artificial intelligence can take over.”

    I’m just back from Washington, DC. I didn’t find any benevolent robots but plenty of artificial intelligence. ;-)

  21. Hyperion says:

    The really sad part about this is that SPECT, PET, etc have been very useful in research into these conditions. They’re obviously not yet at the point of being able to make individual diagnostic distinctions, but numerous studies have found aggregate specific differences in neurological activity and structure in some of these conditions. With ADHD, I’m thinking specifically of Zametkin’s 1990 PET study and numerous followups, and Krause et al’s SPECT studies, among others. See, for example, this 2005 review: http://www.ncbi.nlm.nih.gov/pubmed/15949999

    I guess my concern is that the general public take-home message is (incorrectly) going to be that there is no evidence from these scans supporting a neurological basis for these conditions, rather than the more specific fact that the evidence does not support using these scans for individual diagnostic purposes. And to be honest, given the cost and risk involved, I still think the basic DSM diagnosis would be preferable even if these scans were diagnostically relevant. At best, these scans might be useful for research purposes to get a better idea of which diagnostic criteria are the most relevant. To that extent, I think that Dr. Amen is doing far more harm than good, both by peddling invalid diagnostic testing and by the way that his quackery gets far more publicity than real functional neuroimaging research (really cool functional neuroimaging research, too).

  22. BillyJoe says:

    Michelle,

    “Doing something can have health and safety consequences, doing nothing can have health and safety consequences. What is a reasonable approach to balancing the possibilities between risks/consequences of the two”

    I tend to think along the lines of….
    Do nothing unless doing something is science-based.
    But I see you agree:

    “To be clear, when I said “a reasonable approach”, I had in my mind the need for the use of plausible therapies (with a well understood risk profile) in conditions with real (rather than speculative) health consequences that may not have a well documented or well researched successful treatment”

  23. mousethatroared says:

    BillyJoe – Yes, it’s an idea that’s hard to summarize in a comment box. But my main concern, as windriven mentions up thread, is balancing the benefits of standarization without unduly stiffling innovations and treatment plans based on individual needs.

  24. Lemons says:

    Thanks for commenting, Dr. Hall. Amen, Brain Balance, and the “chiropractic neurologists,” seem to gaining ground amongst the post-TBI community, which is dominated by non-MD allied professionals who are easily fooled by the promise of sciency high tech breakthroughs.

  25. Lemons says:

    “In this country we allow physicians very wide latitude in diagnosing and treating patients. Should the practice of medicine instead be purely algorithmic? Should no new approach be tried until a dozen RCTs have demonstrated safety and efficacy to high statistical probability?”

    There’s flailing around a bit to help a unique patient, and then there’s opening a string of franchises across the US.

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