Daniel Amen, Psychiatrist
Telegraph Magazine, Feb 2013
Dr Daniel Amen believes brain scans, not hours talking on the couch, can help cure depression, anxiety, and a host of mental problems. No wonder his peers think he’s out of his mind.
(Also at The Telegraph)
It’s no accident that the most controversial psychiatrist in America may also be the most commercially successful. For Daniel Amen, the two accolades go hand in hand.
At one extreme he has a booming business — six clinics, a packed speaking schedule and a new book on its way (his 33rd). But at the other pole, his critics – many representing major institutions such as the American Psychiatric Association — label him a snake oil huckster who preys on the afflicted. They liken him to a self-help guru rather than a scientist, on account of all the books, DVDs and nutritional supplements which he hawks so shamelessly on infomercials.
“One reason why they hate me is because I make money,” Amen says, with a shrug. “Well, excuse me, but I thought this was America! And by the way, our biggest referral sources are our patients. If I’m defrauding them how would I stay in business for decades, with a success rate that blows everyone else away?”
We’re sitting in his office at his clinic in Newport Beach, southern California, a modest low-ceilinged building of tube lights and grey walls. Amen is a slight man of 58, with an attentive manner. But he’s sprightly and keen to give as good as he gets. “The other reason they hate me,” he says, “is because no one likes to be told they’re wrong. And I’m going further. I’m saying 98 per cent of my colleagues are performing malpractice.” The heart of the controversy – and Amen’s success – is a form of brain imaging called SPECT (Single Photon Emission Computerised Tomography), which reveals the blood flow in an organ. Doctors use it to look for tumours and heart disease, as well as evidence of strokes, epilepsy and trauma.
Amen advocates SPECT as an aid to diagnosis in psychiatry – and it’s no secret that psychiatric diagnosis could use a little help.
The brain remains the least understood of all organs – a function of being the least accessible and the most complex. Plus, psychiatry is a relatively young science, whose most effective remedies were discovered by chance – the first antipsychotics were happened upon, rather than sought out. The most common conditions – bipolar disorder and depression – are diagnosed not by blood tests but by a conversation; that is, we diagnose mental illness by questioning the mentally ill. And in 2006, a study in the American Journal of Psychiatry, concluded that treatment outcomes were no better than they were 40 years previously.
As the infamous DSM — the Diagnostic and Statistical Manual of Mental Disorders — adds scores of new “illnesses” with every new edition, it adds to the suspicion that psychiatrists are either flailing in the dark, or, at worst, in cahoots with a pharmaceutical industry that, to paraphrase Gary Greenberg, author of Manufacturing Depression, would invent an illness in order to sell the cure.
For Amen, SPECT scans are a step towards scientific rigour, and ought to be mandatory. “We’re the only field of medicine that doesn’t look at the organ that we treat,” he says. But he doesn’t just believe that SPECT is a powerful tool – he sees it as a way to revolutionise psychiatry.
“My nephew Andrew was nine when he attacked a girl for no reason,” he says. “He would draw pictures where he was shooting other children. Now if you don’t look at his brain, you do what psychiatry has always done – blame the mother, or say that maybe someone’s molesting him.
“But it’s all just psychobabble. We looked at his brain and found a cyst the size of a golf ball in the left temporal lobe, which is often associated with violence. Once we removed the cyst, the behaviour stopped and Andrew and his family got their lives back. Modern psychiatry would have just thrown them on the trash.” This was 1995, and Amen had been a psychiatrist for almost a decade. He graduated from Oral Roberts University Medical School, in Tulsa, Oklahoma, and established his own practice in Fairfield, northern California, while writing books in his spare time. Business is in his blood. Amen’s father is a Lebanese immigrant who worked his way up from poverty to chairman of the board of Unified Grocers, a $4 billion company. “People need to understand,” Amen points out. “I don’t do this for the money. My family’s rich!”
He first became excited about the diagnostic power of SPECT in 1991 but when he gave a lecture on the topic, it caused such uproar that he shied away from talking about it. When Andrew came along, however, he became, in his own words, “a zealot”. He wrote a bestseller in 1999 entitled Change Your Brain, Change Your Life, which laid out his central thesis that many of our psychological problems are rooted in physical trauma, the kind that a SPECT scan can reveal. The title chimed with the burgeoning culture of self-help at that time, as did his sensible advice to take health supplements and to exercise. But above all, he advised getting a SPECT scan. And people listened. Today, he has a library of 74,000 scans and a website which claims that SPECT can help with “marital conflict”, “weight issues” and “anxiety and depression”. The argument is simple – these problems are sometimes caused by the kind of neurological damage that SPECT can reveal, such as head trauma, toxic damage or even the early onset of Alzheimer’s.
“A famous neuroscientist once said that all truth goes through three stages,” he says, misattributing a quote by the 19th-century philosopher Arthur Schopenhauer. “First it is ridiculed. Second it is vehemently denied. And third it is accepted as self-evident. Right now we’re between two and three.” Amen’s critics find it all either outrageous or amusing. I spoke to several – from the American Psychiatric Association, the Society of Nuclear Medicine and Molecular Imaging and others – and their view is that SPECT is a limited diagnostic tool. Depression, for instance, has many causes outside of clear physical damage – in particular, low levels of serotonin (the notorious “chemical imbalance”). SPECT doesn’t reveal any of that, so the impression that Amen gives his patients – that SPECT is key to recovery – is misleading. In fact, say his detractors, there’s no evidence that common psychiatric disorders can be diagnosed with a SPECT scan at all, and Amen hasn’t published any research that might persuade them.
“SPECT is valuable for diagnosing neurological disorders like epilepsy, dementia and brain tumours,” says John Seibyl of the Society of Nuclear Medicine and Molecular Imaging. “But not for psychiatric disorders like depression. There’s no debate here.” Amen’s response is similarly robust. “I’ve never said that you can make a blind diagnosis using SPECT scans alone. You have to talk to people. But scans add an important part of the evaluation puzzle.”
Another charge is that, as scanning techniques go, SPECT is old news. According to Elizabeth Oates of the American College of Radiology, “PET (Positron Emission Technology) is a much better way to image the brain. The images have better resolution, and they map brain function, rather than just where the blood’s flowing.” Again, Amen is dismissive: “PET is just as old as SPECT. The fact is SPECT is the least expensive and most widely available scan – every major hospital has a machine. But PET researchers are biased to PET. The reason they say SPECT is a crude technology is because they don’t know how to use it – they can’t make 3D renderings. Let me show you.” He opens a file on his computer and a series of brains appear on his screen, each one a vivid patchwork of red, pink, yellow and blue (“hot” colours correspond to high blood flow and “cold” to less).
“These are healthy brains,” he says. Then he shows me images of a brain that has experienced toxicity damage, and the colour distribution is darker, with noticeable holes. It’s a startling contrast.
But what these images reveal is unclear. There’s no telling if the damaged brain is depressed or schizophrenic or none of the above. And as Amen admits, a slight adjustment of the settings on the software can transform a “healthy” image to one that has suffered severe trauma. “You can make it look like anything if you want,” he says. “But why would I do that if I’m trying to help a patient?”
Then there’s the placebo effect to complicate things further. In psychiatry it’s been shown that, for depression, sugar pills work almost as well as standard SSRIs (selective serotonin reuptake inhibitors). Similarly, SPECT images may have a palliative benefit irrespective of their diagnostic power. “All those pretty colours make it look scientific,” says Oates. “So when the doctor tells the patient, ‘this yellow part should be red’, there’s comfort in that.”
For Amen, this comfort is not trivial. “When patients see their own brains, they feel for the first time that there’s not something wrong with them, but with their brains,” he says. “I’ve had patients burst into tears, they feel such relief.” Could it be, as the Washington Post posited, that the placebo effect of a SPECT scan is enhanced by the fact that the scans are much more expensive than a bottle of pills? An initial session of two scans comes in at $3,500 (£2,225).
“Sure!” Amen looks delighted. “I don’t care! If it’s helping the patient, I’m all for it.” In some ways, Amen isn’t quite the wild card within psychiatry that he might appear. For instance, his belief that neuroimaging is the future is something his critics agree with – they just don’t believe SPECT will be the technique of choice. Jeffrey Lieberman, of the American Psychiatric Association, believes that “nuclear imaging will be a cornerstone of diagnosis.” For Oates, the potential of scanning is already in evidence – “we already have tracer chemicals that we use in PET scans, which can target the protein that causes Alzheimer’s.” Neuroimaging is also part of a larger shift in psychiatry – a shift towards biology, the province of organs and neurons, as opposed to one’s relationship with one’s mother.
For now, diagnoses are based largely on behavioural, not biological, criteria (although most treatments are biological, especially pharmaceuticals). But this is changing. Thanks to neuroimaging, we understand better how neurology can guide behaviour – how tumours, for instance, can drive people to violence. It’s even possible that, by giving psychiatry a biological foundation, brain scans may rehabilitate its chequered reputation.
As for SPECT, Amen isn’t entirely alone in his advocacy. No specialists practise his techniques in Britain, but his publicist encourages me to call Ted Henderson, a psychiatrist in Colorado, who finds it a useful tool in diagnosing treatment-resistant depression. Often, those patients who don’t respond to traditional antidepressants have an underlying brain injury or condition. SPECT scans can reveal this root cause. Henderson views the whole ruckus over SPECT as a symptom of American arrogance. SPECT, he tells me, is used in several countries like the Netherlands and France. “But American institutions don’t pay attention to what’s being done abroad,” he says.
In the meantime, Amen remains undeterred – his commitment to his colourful scans undimmed. “I scanned my wife within two and a half weeks of dating,” he says. “And the rule in my family is that if you date my daughters for more than four months, I want to see your brain.” Evidently one of the boyfriends had a brain that was “overactive”, while the other exhibited signs of toxicity which Amen attributed to growing up on a farm. Neither case was a deal-breaker – both boyfriends became husbands.
“These people who accuse me of selling snake oil need to explain: when your outcomes haven’t improved in 40 years, what’s the argument against more information?” He grins. “And anyway, snake oil is 23 per cent Omega 3 fatty acids.”