In 1991 I was a psychiatrist for nearly a decade before I ever ordered a brain scan to help with diagnosis. I had made diagnoses on patients solely based on symptom clusters. Then I attended a lecture on brain SPECT (single photon emission computed tomography) imaging, a nuclear medicine study that looks at brain blood flow and activity patterns. It revolutionized how I treated patients. Twenty-three years later, my colleagues and I have built the world's largest database of brain SPECT scans related to behavior, numbering nearly 100,000 scans on patients from 111 countries.
SPECT came into clinical use in the late 1980s to help evaluate seizures, strokes, dementia, and brain injuries. When I first started to use it, I was thrilled with the results. In my practice, SPECT aids in breaking denial, decreasing stigma, and increasing compliance with my patients. For example,
- When Sandy, 40, saw her scans, she stopped feeling ashamed about ADHD, took her medication and was dramatically improved.
- Ken, 44, was in denial about his alcohol and cocaine abuse. After seeing the “toxic” pattern on his scan, he completely stopped the substances.
- Nikki, 16, was depressed, aggressive, and impulsive. She had seen multiple psychiatrists before getting a scan, which clearly showed a brain injury pattern. On further questioning she remembered a bad fall from her bike a month before her symptoms began. On appropriate treatment she did much better.
In some complex cases, scans can provide valuable information and improve outcomes, particularly when kids or adults either do not get well with traditional treatments, or the traditional treatments make them worse. For example, if your ADHD, anxiety or depression are clear and responsive to treatment, you don't likely need a scan. However, if your case is complex and you are your loved one is not getting better, more information may be warranted.
Despite research showing that scans can be useful in complex cases, traditional psychiatry remains resistant to using them in clinical practice. In a recent debate, Jair Soares, Department of Psychiatry Head at the University of Texas, Houston, reflected a common belief that scans are not ready for clinical use until more research is done. As a result, psychiatry remains the only medical specialty that rarely looks at the organ it treats. Cardiologists, orthopedists, gastroenterologists -- in fact all other medical specialists -- look at the organs they treat. Psychiatrists guess.
SPECT scans can add important information that physicians do not get from talking to patients. My colleagues and I think that getting biological data on patients can make an enormous difference in their outcomes. For example, at one of the annual meetings of the American Psychiatric Association, physicians from Nebraska reported on a study that found having a SPECT scan on admission cut hospital stays for bipolar teenagers by more than half.
What's the Fight About?
So, what's the fight about? Why shouldn't more doctors use SPECT, or other imaging tools, in clinical practice with complex cases? Here are my responses to the most common objections to using scans in clinical practice:
Scans will not give an accurate “psychiatric” diagnosis. This is true. Psychiatric diagnoses are symptom-based, not brain-based. ADHD, major depression, panic disorder, obsessive-compulsive disorder, etc. are based on symptoms, not brain function. But scans help clinicians see the underlying biology of these disorders to better target treatment. Clearly, scans do not help everyone get better, but in our experience, when psychiatrists use clinical histories plus scans in the right circumstances, success rates increase. In a published outcome study of more than 500 complex patients (those who had failed 3.3 providers and 6 medications), 77% reported high levels of improvement at 6 months.
There is not enough research. Since there are no patents to be obtained on established neuroimaging tools, there is little financial incentive for independent research. However, on our website (www.amenclinics.com) there are over 3,000 scientific abstracts that underlie our use of functional imaging in psychiatry. In a recent study published in the Journal of Psychoactive Drugs, getting a SPECT scan changed the diagnosis or treatment plan 79% of the time.
Scans are expensive. They are about the same cost as MRI brain scans. Ineffectively treating complex brain problems is more expensive than the cost of the scans, not to mention the costs of a lost job or failed marriage.
There is radiation with the scans. This is true, but the radiation exposure is less than most CT scans, which are routinely ordered when needed.
SPECT is not ready for clinical use and should be left in the hands of researchers. Withholding a useful medical procedure from patients until a group of researchers decides to focus on it is disturbing.
If you are thinking of getting a getting a SPECT scan to aid in diagnosis I suggest you think of it like radar. If the day is sunny, pilots don't need radar to land the plan, they can see the runway. However, if the day is stormy and the pilot cannot see the runway, radar can be lifesaving. For complex cases, when you or your family is not responding to traditional treatments, it may be time to take a non-traditional approach.
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Amen, D, Highum, D, Licata, R, Annibali, J, Somner, L, Pigott, HE, Taylor, DV, Trujillo, M, Newberg, A, Henderson, T, Willeumier, K: Specific Ways Brain SPECT Imaging Enhances Clinical Psychiatric Practice, (2012): Specific Ways Brain SPECT Imaging Enhances Clinical Psychiatric Practice, Journal of Psychoactive Drugs, 44:2, 96-106