A Skeptical View of SPECT Scans
and Dr. Daniel Amen
Harriet Hall, M.D.
Daniel G. Amen, M.D., runs the Amen Clinics, writes books, gives lectures, maintains a Web site, and makes other media appearances. He recommends single photon emission computed tomography (SPECT) to help diagnose and manage cases of brain trauma, underachievement, school failure, depression, obsessive compulsive disorders, anxiety, aggressiveness, cognitive decline, and brain toxicity from drugs or alcohol. He claims to use SPECT to "re-balance a brain whose activity patterns are clearly abnormal.” He describes SPECT as a "window into the hardware of the soul." He claims that SPECT scanting provides “guidance in the application of specific medications or other treatments such as supplements, neurofeedback, transcranial magnetic stimulation, and hyperbaric oxygen therapy.”
For about four years (2002 to 2006), the The Amen Clinic's home page stated:
Everything starts and ends in your Brain-Soul connection.
How your brain and soul work together determines how happy you feel, how successful you become, and how well you connect with others. The brain-soul connection is vastly more powerful than your conscious will. Will power falters when the physical functioning of the brain and the health of your soul fail to support your desires, as seen by illogical behaviors like overeating, smoking, drug and alcohol abuse, and compulsive spending.
It is the aim of The Amen Clinics to provide instructional programs and materials, evaluations and medical treatment where necessary to help you to understand and direct your mind to enhance your relationships, your work, and your health!
The site currently (2007) states:
SPECT . . . . basically tells us three things: areas of the brain that work well, areas of the brain that work too hard and areas of the brain that do not work hard enough. Once we know how the brain works, the goal of treatment is to balance brain function, such as calm the overactive areas and enhance the underactive ones.
SPECT creates a colored picture representing blood flow or chemical reactions in different areas of the brain. It requires the injection of a radioactive material. Areas of low blood flow show up as apparent “holes” on colored pictures of the brain, giving a moth-eaten appearance. Amen says that when patients improve clinically, the appearance of their follow-up scan typically improves. For example, patients using marijuana had areas of low activity in the temporal lobes compared to patients not using the drug. Dr. Amen says he can literally show his patients “this is what your brain looks like on drugs.” In one case he reported, a patient with attention deficit disorder, obsessive thinking, anger outbursts, and depression had demonstrable defects on the initial scan which were visibly improved after three years of clomipramine therapy. Dr. Amen says that this kind of graphic demonstration can help persuade patients that their problem is physical or physiological and might be helped with medication or other treatments.
The Amen Clinics charge $3,250 for a "comprehensive evaluation," which included the patient's history, two SPECT scans (concentration scan and baseline scan), a physician consultation, and a 30-minute treatment follow-up appointment. Follow-up scans after treatment are $795 each.
The key question in evaluating a diagnostic test is whether or not its findings are useful in determining what treatment the patient should have. SPECT is a research tool useful for exploring how the brain functions, but the findings are nonspecific, and uses related to treatment of emotional or behavioral problems should be considered experimental. Dr. Amen has vast clinical experience and says he has performed and interpreted more than 35,000 scans. However, I do not believe he has demonstrated that specific scan patterns reliably reflect specific clinical problems and how they should be treated. Even when he is able to show a correlation between a diagnosis and an area of low perfusion (blood flow), he has not shown what this really means and how it could aid clinical treatment. Is low perfusion an indication of the primary pathology or perhaps just a secondary brain response to the symptoms? His published research comprises “preliminary studies,” and most psychiatrists believe it is premature to use SPECT clinically. In fact, the American Psychiatric Association (APA) has issued two skeptical reports, one pertaining to children and adolescents and the other pertaining to adults.
In 2005, the APA Council on Children, Adolescents and Their Families concluded:
Although knowledge is increasing regarding specific pathways and specific brain areas involved in mental disease states, at present the use of brain imaging to study psychiatric disorders is still considered a research tool. . . . . Particular caveats are indicated with regard to brain imaging involving radioactive nucleotides for children and adolescents because of children’s known greater sensitivity to radiation and risk of radiation induced-cancer. At the present time, the available evidence does not support the use brain imaging for clinical diagnosis or treatment of psychiatric disorders in children and adolescents.
The APA's Psychiatric Evaluation of Adults Guideline (2006) states:
In patients with schizophrenia and mood and anxiety disorders, structural and functional neuroimaging studies have reported differences between patients and healthy control persons as well as differences in some patient subgroups and in responders and nonresponders to some treatments. Nevertheless, the clinical utility of neuroimaging techniques for planning of individualized treatment has not yet been shown. Further research is needed to demonstrate a clinical role for structural and functional neuroimaging in establishing psychiatric diagnoses, monitoring illness progression, and predicting prognoses.
Dr. Amen claims to be able to choose the best therapy based mainly on scan results, but this claim is supported only by anecdotal evidence and testimonials.
The following questions might be useful for evaluating Dr. Amen's claims:
- Do patients treated at the Amen Clinics do better than patients treated by competent professionals who do not use SPECT?
- Are the SPECT findings consistent enough that blinded observers could agree on the diagnosis from the scan alone?
- What are the rates of false positives and false negatives?
- Have the effects of different treatments on the scans actually been compared?
- What is "brain balance," and how is it measured?
- What does the scan tell us that would change how we treat a patient?
- Does Dr. Amen claim that SPECT can help evaluate the patient's "soul"? If so, what gets measured?
- Why did Dr. Amen leap into clinical applications, writing for the public, appearing on television, and lecturing about findings that most doctors would consider preliminary?
I believe it is improper to charge thousands of dollars for a test that has not been validated and may not be safe. I don't think any of Amen's research has provided clear evidence that patients who have had SPECT scans have superior clinical outcomes to adequately treated patients who have not been scanned. That's really the bottom line—especially with an expensive test that involves significant radiation. At the very least, he should be describing the test as experimental.
Some of Dr. Amen's treatment suggestions also worry me. For example, he recommends: (a) uses for dietary supplements that are not supported by good evidence, (b) EMDR (a highly questionable approach), and (c) hyperbaric oxygen therapy for conditions not generally considered to warrant such therapy.
I don't doubt that many patients who visit the Amen Clinics are helped. The key question, however, is whether or not SPECT scanning is justifiable for most of them. I, personally, would not undergo the test at Dr. Amen's clinic even if it were free. In my opinion, based on current knowledge, the possibility of harm outweighs any potential benefit. Pictures showing that "this is your brain on drugs" may impress some people, but I am far more impressed by quantifiable data (such as tests of mental performance) and clinical consequences (such as improved behavior) than by nonspecific pictures of "holes" in the brain.
This article was originally posted in 2005. In 2007, attorneys representing Amen complained to Dr. Stephen Barrett that it was unfairly negative. Our response included questions similar to those above. To read the answers we received and my comments on these answers, click here.
For Additional Information
- Aetna Clinical Policy Bulletin on SPECT
- Aetna Clinical Policy Bulletin on Hyperbaric Oxygen Therapy
- APA Report on Brain Imaging and Child and Adolescent Psychiatry
- CIGNA HealthCare Coverage Position on SPECT
- Eye Movement Desensitization and Reprocessing (EMDR)
- Amen's Response to Criticism on Quackwatch
This article was revised on November 15, 2007.