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?