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Brain Imaging and Psychotherapy: Why is it so controversial?

By Ryan Howes

Today’s highly informed, cutting-edge therapists take pride in their growing knowledge of brain science. Mountains of books and endless hours of seminars teach us about our left, right, male, female, and reptilian brains—all exciting knowledge we eagerly apply in our clinical work. We now know more than ever about the brain. Yet, according to California psychiatrist and eight-time New York Times bestselling author Daniel Amen, we’re still apprehensive about looking at it.

For nearly 20 years, Amen has led a controversial quest to make brain imaging common practice in the field. His prolific use of single-photon emission-computed tomography (SPECT) to detect various types of psychiatric disorders challenges the long-held belief that talk and observation are sufficient for diagnosis. Instead, he argues, we need to see the organ we treat.

Despite being admonished by prominent researchers for the unconventionality of his work, Amen continues to boldly advocate for the use of SPECT, train other clinicians to use it, and collect praise from clients who say his methodology has revolutionized their lives. Acknowledging both his detractors and extollers, he took a minute away from his work at the Amen Clinic to share his thoughts on imaging, diet, Adam Lanza, and the National Football League (NFL).

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RH: What first drew you to psychiatry?

Amen: I was drafted in 1972 and became an infantry medic, which is how I came to love medicine. But I realized I didn’t like sleeping in the mud or the idea of being shot at, so I got myself retrained as an x-ray technician—and that’s where I learned to love imaging. Then, when I was a second-year medical student, my wife at the time tried to kill herself, which horrified me. I brought her to the department of psychiatry at Oral Roberts University, where I was in medical school, and just fell in love with her psychiatrist because I realized if he helped her, which he did, psychiatry would save her life—and I’d be better, our children would be better, and even our grandchildren would be better for it. So I fell in love with psychiatry because I realized that it had the potential to change generations of people.

RH: How did this turn into an interest in brain imaging?

Amen: In 1991, I was the director of a dual diagnosis unit at a psychiatric hospital in northern California and heard a lecture on brain SPECT imaging, a computerized technology that looks at blood flow and activity in the brain. In that one lecture, my two professional loves—imagery and psychiatry—came together and revolutionized my life. Over the next 23 years, my colleagues and I built the world’s largest database of brain scans related to behavior, which is now about 87,000 scans. I mean, it was just so cool! Psychiatrists are the only medical doctors who never look at the organ they treat. Neurologists look, cardiologists look, your orthopedic doctor looks, gastroenterologists look. Every other medical specialty looks—but psychiatrists guess.

Before imaging, people would come in with six out of the nine DSM-IV criteria for depression, and I’d put them on Prozac. Some people would get better, and some would get worse, but there was no way to predict which way it’d go. Once I had imaging, I became much better at predicting who’d get better and who’d get worse. I’ve been pretty passionate about it, despite getting a fair amount of crap from my colleagues.

RH: Why is there so much controversy?

Amen: It’s easier for my critics to say that I’m a snake-oil salesman or a charlatan than to say, “Huh, I wonder what this really is all about?” In fact, the lecture I went to on brain SPECT imaging was at the American Psychiatric Association. So I actually learned the technique from the people who later criticized me for using it, which is sort of funny. The thing is, they’re basically complaining about what I’m doing because they haven’t blessed it. Of course, I’m not the only person who does it now. There are probably 30 people in the world who do it routinely, and it’s exciting! We have six clinics, and our biggest referrals are patients. Almost half our new patients come from our existing patients. We like that.

We do outcomes on every patient we see, and we’ve published an outcome study. On average, our patients have received 4.2 diagnoses, have previously seen 3.3 providers, and are on four to six medications—so most would be considered treatment resistant. We do sophisticated neuropsych assessments when people first come in; then six months later we repeat the testing. At the end of six months, 75 percent of patients are better across all measures, and for 85 percent, their quality of life goes up.

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