Home > neurology, News > Blaming Amen: Nuclear Psychiatry or Unclear Medicine?

Blaming Amen: Nuclear Psychiatry or Unclear Medicine?

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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  1. September 20, 2010 at 8:00 am

    Mmm. Very dubious. But there is something fishy about the Am J Psych’s critique of Amen because the original critical review was written by Andrew Leuchter, who’s research interests are in a very similar topic, namely predicting treatment response with EEG.

    Leuchter is certainly a much more serious researcher than Amen. But he is not innocent of “highly commercialized use of scanning” that he criticizes because last year he authored a paper about using EEG to predict antidepressant response, funded by Aspect Medical Systems, who presumably intend to commercialize the technology…

    The paper described the technique in detail except that it left out 3 crucial parameters, without which no-one can try to replicate the findings. Hmm.

    • September 20, 2010 at 1:40 pm

      Great point. There definitely is the aroma of politics and bashing the competition here, and I don’t recognize the names in the field to really know who might line up with whom. So maybe Leuchter dislikes Amen because Amen has gone ahead and done what Leuchter would do but for lack of evidence? It also struck me as odd that Adinoff and Devous would write a second letter bashing Amen a year after the initial review. They must have some agenda besides a general regard for proper academic medicine. Perhaps someone will come up with a theory?

      Regardless, I do think Amen’s business is sketchy, even if he isn’t the leader in quackery.

      • September 20, 2010 at 2:34 pm

        I don’t know if Leuchter wrote the review because he wants to bash Amen; he may just have been who the journal asked to the review book – he is a fairly obvious choice given his interests – and when he sat down to review it, he was (rightly) critical.

        So I’m not questioning his motives, but I dislike the “Amen is bad, unlike the rest of us who are fine” angle. Pushing bad science for commercial gain is a “spectrum disorder”, not an either/or thing.

    • Enrique
      March 2, 2013 at 1:40 pm

      I took his treatment for nothing. Since I went for a treatment to “wake up the areas of the sleeping brain” my life is more miserable since I heard from the miracles of Dr. Amen.
      Thanks for nothing. I was happy before I accepted, by the force, to accept his revolutionary medicine. Only to know I kneeded vitamin D.
      (A blood test was enough).

      • Matthew
        March 16, 2013 at 12:32 am

        Personally, I think you would have been better off going to a regular doctor from the get go. Dr. Amen is more of a specialty, in my opinion. He’s not here to help those who have issues. He is here to help those who have issues and cannot get them resolved by the doctors in their area. I have been trying for a year and a half to have questions answered. Several doctors and they all scratch their head. I might be more of a candidate for Dr. Amen, but you? You went to the head honcho before you took the time to see if it was something simple.

  2. September 20, 2010 at 8:49 am

    Dr. Drew, whom you mention in passing here, is even more problematic than you might think. He doesn’t merely “sensationalize legitimate treatments” he uses addiction treatments like confrontation and humiliation that have repeatedly been shown to do harm. They may be “legitimate” in the sense that they are widely used– but they are not legitimate in the sense of being safe and effective. His position that 12-step programs are the only true way to recover is also not supported by data. But, of course, confrontation, humiliation and confession make much better TV than the empathetic, supportive treatments that research does support.

  3. September 20, 2010 at 1:45 pm

    I used to enjoy Dr. Drew many years ago on his Loveline radio show. I had many pleasant evenings listening to it while walking my dog, so I have good associations with him. He really did disappoint with the celebrity rehab tv shows, however. I must say that it is compelling television, but it just became a cringefest for me because the “patients” are people in extremis who should not have their every thrashing blunder recorded and memorialized for public consumption. It doesn’t matter if they are celebrities who have signed a dozen releases. I remember that Gary Busey, in one season, thought he was a staff member rather than a patient. It’s hard to imagine he could give a legitimate consent. I don’t doubt Dr. Drew’s (or anyone’s) intentions, but it’s something I couldn’t support.

  4. autismavoca
    January 14, 2011 at 5:35 am

    If ever there was a case that could support Dr. Amen’s claims that SPECT could help someone, take a look at you tube videos that show “severe autism”. There’s a new video out called, “Autistic Patient in Crisis Goes Unnoticed”. The reason I find this video interesting is because the autistic patient had a long history of intraccable self injurious behavior that has failed to be controlled, despite a myraid of conventional treatments, including pharmacological, behavioral, educational, sensory, etc… what is most disturbing about this unique case is the fact that after 18 years of numerous neurologists and psychiatrists following this case and treating it, NONE have helped. What is the one thing they still haven’t done? None of the doctors, past or present, have ordered a SPECT scan to see how this autistic person’s brain is functioning. In fact, the parents are repeatedly told, SPECT won’t help. Well, if that’s case, then perhaps nobody should use SPECT, since it is apparently, in the case of helping autistic patients with intraccable, chronic self injurious behavior–an allegedly useless tool. See, what is fishy here is that SPECT is useful, and the people who say it isn’t only say it isn’t because they are usually burned out physicians who don’t want to invest time and energy into analyzing SPECT findings to better help treat patients. You see, that would entail doing more than the bare minimum, as in making the rounds, prescribing more pills, elevating doses of more pills and filling out computer charts. Dr. Amen and others who use SPECT are surely doing more than the average doctors are doing for severely autistic population suffering from chronic self injurious behavior. Too bad places like Kaiser Hospital still doesn’t understand this.

  5. January 16, 2011 at 11:05 pm

    The video mentioned above is footage shot by a parent of her son having a dystonic reaction after receiving an antipsychotic. This is apparently unnoticed by hospital staff for hours. Note that this drug reaction has nothing to do with autism, except that the nursing staff misses it because they assume his mute rigidity is his usual state. Certainly a moving piece of video for any parent who has felt things go out of control when their child is in hospital. It has no relevance at all, however, to the topic here, except that this is exactly the type of family who may turn to someone like Amen in a misguided hope that there is a cutting-edge test and treatment hiding somewhere which is unavailable only because of the disinterest of “regular” doctors.

  6. autismavoca
    January 29, 2011 at 6:55 pm

    While it’s true a good doctor will examine the signs and symptoms of a patient, and then precribe drugs, based on clinical presentation, the sad fact is, most doctors don’t do this. Instead, what we find is an increasingly carefree, let’s try this approach, that leaves families in crisis in crisis, with little relief. So, the assumption that Dr. Amen, or other doctors who are taking time to look at brain function, isn’t needed, is, in my opinion, rooted in fear that more people will insist on this close evaluation as patients, and as such, drive healthcare costs up. Indeed, cost cap fears are always the underlying pathology of naysayers, isn’t it? God forbid, anyone get higher levels of care outside the 15 minute drive by analysis year after year. What you’re saying then, is it’s just okay for healthcare professionals to “guess” what drugs will help, based on clinical signs and symptoms? Is it really logical to assume that if you’re prescribing drugs that target brain function, then it would be wise to know the brain function before prescribing drugs that may enhance or stabilize such functioning?

  7. January 29, 2011 at 8:52 pm

    You miss the point entirely. It’s not that Amen takes extra time or goes to extra effort, it’s that the PET scan is clinically USELESS. I’m all for using functional imaging in research, and I earnestly hope that PET, fMRI, etc. will be useful parts of psychiatric treatment in the near future. Basing treatment decisions on a PET scan is beyond a “guess” as you put it, it’s dishonest.

    The day I’m convinced that PET scans will improve the evaluation and treatment of my patients, I will demand it for every last one of them. This isn’t about being cheap, it’s about using our resources where they have benefit. The alternative to the “15 minute drive by analysis,” as you put it, isn’t the $5000 scan which adds NOTHING to diagnosis and treatment. Don’t be a sucker.

  8. Jack adams
    September 9, 2011 at 3:17 pm

    How does this compare to Brain State Technologies?
    Can you comment on their claims of success with their approach?
    Jack

  9. Xavier
    March 18, 2012 at 5:46 pm

    Let me understand this. If a PET scan shows someone has blunted choline wouldn’t that dictate that you would therefore consider pharmaceutical interventions that enhance choline in the brain? And if you didn’t do that test, you would never know, so you may be given drugs that further blunt choline and further damage the brain.

  10. Xavier
    March 18, 2012 at 5:49 pm

    I don’t understand why so many psychiatrists are against a PET scan. It’s obvious the dimissal of examing the brain through technology is rooted in costs. No other branch of medicine fails to examine the actual part of the body it’s treating, than does psychiatry.

  11. Miranda
    June 22, 2012 at 11:29 am

    “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.”

    Generally speaking, they haven’t had adequate treatment. You also say that most psychiatrists would come up with a similar treatment plan. After how many shots in the dark? People wouldn’t be willing to pay for the scans if they were getting quality treatment plans from their insurers where a treatment plan is nothing more than a paper prescription and a recommendation for some outdated form of talk therapy that is nothing more than a waste of time. It is sickening the way you refer to mentally ill people as such a vulnerable group as if any doctor who endorses non-pharmaceutical treatments is a predator upon a group you assume can’t think for themselves.

    If there are psychiatrists and clinics threatened by these professionals then maybe it should be a wake up call. Patients are tired of lazy treatments that are nothing more than a checklist out of the DSM and the best interpreter wins.

    How about taking your focus off of these alternative clinics and start offering some body based therapies, some EMDR, and therapies that actually work.

    I do agree that it is annoying the way some of your mentioned doctors have had to turn themselves into pseudo-celebrities in order to attract patients, however, would they not have been blackballed by the AMA otherwise. It looks like the APJ is following suit. How sad.

  12. 9nnoetic
    August 4, 2012 at 2:46 am

    The brain scan you are talking about is a SPECT scan, not PET scan. SPECT is the acronym for Single Photon Emission Computer Tomography. It evaluates cerebral blood flow. A CAT and PET scans evaluate the construction of the brain itself –which is good for blunt force trauma resulting from a car accident, etc.

  13. August 18, 2012 at 11:14 pm

    I have been referred to the Amen Clinic for treatment of my daughter. She is 13 years old and has had severe depression, generalized anxiety disorder and the worst case of trichotillomania anyone has ever seen, for 3 years. No doctor or therapist has been able to help her in any meaningful way. I would not wish this on my worst enemy (if I had one.)

    Her father is against having her evaluated/treated at the Amen Clinic. He believes it’s a scam and potentially harmful (radiation.) I have read some of the negative comments and warnings, and I have to say, this is an absolute nightmare. I can not afford to spend $4,000 on anything, much less another ineffective waste of time, but if a SPECT scan would give her life back, there’s no question. I have no idea what to do.

  14. Andrew Kercher
    September 2, 2012 at 8:31 pm

    I had my brain scanned by Dr. Amen’s office in Oct/Nov 2011. There is no evidence whatsoever that the treatment prescribed by his doctor assigned to my case would differ significantly from what I had already convinced my own doctor to prescribe me based on reading Amen’s books. When I met with Amen’s doctor, a significantly overweight psychiatrist, I had already been on Lamictal prior to the scan, and this doctor basically recommended I continue this treatment, also prescribing Theanine Serine, an herbal remedy, with exercise and meditation. If these did not improve my condition, which they did not, I was prescribed Prestiq a very expensive drug I cannot afford because I do not have medical insurance. Eventually I moved away from the sythetic drugs and am working with amino acid supplements with common sense diet and exercise. I may struggle with depression, anxiety and other symptoms of my Traumatic Brain Injury (TBI) for as long as I live.

    Most of these treatment options were recommended by counselors and doctors prior to my visit to the Amen Clinics, as I had requested the meds based on the information I read in Amen’s books I’d obtained from my local library for free. I would have to say now that I spent close to $5k for peace of mind that I was already doing what I could to heal from my 2008 TBI. I could have that $5k for other purposes now since I am still seeking gainful employment and my funds have depleted. Thanks for posting this article for others who may be considering the claims of the Amen Clinic without verifiable scientific evidence to back up the claim that SPECT significantly improves treatment.

    I now have a $5k work of art of my brain to frame for my wall thanks to Dr. Amen’s Clinic.

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  16. Rosalina Birmingham
    August 16, 2013 at 3:58 pm

    I also had a SPECT scan at the Amen Clinic in New York on March, 2013. I have been depressed for over 35 years and have tried many of the antidepressant meds on the market without success. When I received my results from the scan,the doctor said I was depressed and suffered from anxiety disorder. DUH!!!!!!!!! I received a pretty folder with colorful pictures of my depressed and anxious brain. I call it “my $3500. folder”! The follow up care I was to execute was to take Lamictal. I was also told to get bloodwork done for my sex hormones,thyroid and adrenals, which I did. The doctor said I could go to LabCorp (he said they have a contract with them for discounted prices for Amen patients) in my hometown and get the bloodwork done for about $300. Surprise ….cost was over $5700.!!!!
    Needless to say, I am contesting this charge with LabCorp and the Amen Clinic.
    My advice to any one that is depressed is to find a local psychiatrist that can tell you what kind of medicine you should take. If you have insurance your co-pay would be $60. instead of the thousands I’ve spent on bogus,money grubbing doctors. Shame on you Amen and LabCorp for taking advantage of people who are looking for hope.

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