Are brain scans useful for treating depression?
August 23, 2010 9:25 AM Subscribe
My mother wants me to try a psychiatrist who uses "brain scans" to figure out what drug would be most effective. Has this technique been proven to be useful by the medical community?
A lady at my mom's church wants to refer me to her friend's psychiatrist, who apparently uses "brain scans" (not sure if that means fMRI, MRI, CT scans, or brainwave monitoring) to determine what drug would be most helpful, sometimes including options like drugs designed for bipolar disorder.
Is this a legitimate science, or is the current approach of using trial and error with different pills more cost effective? I've been on many SSRIs and an SNRI, all of which have some unpleasant side effects that differ from pill to pill.
If it is legitimate, would I be better off taking a trip to see Dr. Amen, who Google seems to treat as the expert on this? Or are there different "brain scan" approaches, some more merited than others? What questions should I ask before scheduling an appointment?
I've also used cannabis therapeutically and recreationally (it relaxes me, raises my energy, and helps me do mundane tasks that would normally be impossible to do while depressed. I also am able to feel like I did before depression hit. A tiny dose makes me a more effective person, at least in terms of getting stuff done and not being depressed.). Will this show up or skew the brain scan? Should I detox before my first appointment? I know I should probably let the doctor know. And before anyone suggests it, I looked into getting the Marinol pill in my state. It's a non-starter without a physical condition. Same for the upcoming medicinal marijuana program.
A lady at my mom's church wants to refer me to her friend's psychiatrist, who apparently uses "brain scans" (not sure if that means fMRI, MRI, CT scans, or brainwave monitoring) to determine what drug would be most helpful, sometimes including options like drugs designed for bipolar disorder.
Is this a legitimate science, or is the current approach of using trial and error with different pills more cost effective? I've been on many SSRIs and an SNRI, all of which have some unpleasant side effects that differ from pill to pill.
If it is legitimate, would I be better off taking a trip to see Dr. Amen, who Google seems to treat as the expert on this? Or are there different "brain scan" approaches, some more merited than others? What questions should I ask before scheduling an appointment?
I've also used cannabis therapeutically and recreationally (it relaxes me, raises my energy, and helps me do mundane tasks that would normally be impossible to do while depressed. I also am able to feel like I did before depression hit. A tiny dose makes me a more effective person, at least in terms of getting stuff done and not being depressed.). Will this show up or skew the brain scan? Should I detox before my first appointment? I know I should probably let the doctor know. And before anyone suggests it, I looked into getting the Marinol pill in my state. It's a non-starter without a physical condition. Same for the upcoming medicinal marijuana program.
This article from 2006 sounds like it is still in its infancy. This paper sounds like it can be generally helpful, but definitely not in the way it was described to do you. Again, still in its research phase and definitely not being used clinically. Sounds like either snakeoil or misinformation.
Also: there is no single drug you take specifically for bipolar disorder. It's a cocktail, usually consisting of some combination of anti-psychotics, anti-depressants and mood stabilizers.
posted by griphus at 9:46 AM on August 23, 2010
Also: there is no single drug you take specifically for bipolar disorder. It's a cocktail, usually consisting of some combination of anti-psychotics, anti-depressants and mood stabilizers.
posted by griphus at 9:46 AM on August 23, 2010
Perhaps the problem with such a premise is that we still dont totally understand the relationship between statistically reconfigured images of the brain and the experience of being human that they purport to correspond to.
On a related, but perhaps not directly helpful, note, this book gives an interesting look at the cultural meaning of brain scans.
posted by refractal at 9:51 AM on August 23, 2010 [1 favorite]
On a related, but perhaps not directly helpful, note, this book gives an interesting look at the cultural meaning of brain scans.
posted by refractal at 9:51 AM on August 23, 2010 [1 favorite]
Interesting question--looking forward to the answers. I know functional scanning (MRI or PET) is not routinely used in diagnosis or prescribing but it sounds intriguing. As far as your mother's friend goes--who knows. Check out credentials, professional writings, professional memberships, number of scans completed etc. I would be a bit more skeptical if he has limited experience and a financial interest in a scanning service--This is very much on the edge of conventional Dx/Tx. As far as Dr Amen--he has quite impressive academic and professional credentials. He is obviously an entrepreneur but I do not see that as necessarily a drawback as long as he has infused the clinics with rigorous quality controls.
AND OF COURSE--you should always tell your physician any drugs you are taking and well as an accurate history of drug abuse. If you make an appointment with either the clinic or an individual physician I would ask them if you should stop using medicinal marijuana be fore your first appointment. It could mask symptoms or cause changes in a functional scan making accurate assessment more difficult. It is a good question--alcohol, absolutely detox--marijuana, I do not know.
posted by rmhsinc at 9:59 AM on August 23, 2010
AND OF COURSE--you should always tell your physician any drugs you are taking and well as an accurate history of drug abuse. If you make an appointment with either the clinic or an individual physician I would ask them if you should stop using medicinal marijuana be fore your first appointment. It could mask symptoms or cause changes in a functional scan making accurate assessment more difficult. It is a good question--alcohol, absolutely detox--marijuana, I do not know.
posted by rmhsinc at 9:59 AM on August 23, 2010
Freudian slip--that should be "drug use"not "drug abuse".
posted by rmhsinc at 10:01 AM on August 23, 2010
posted by rmhsinc at 10:01 AM on August 23, 2010
The consensus of the medical community is that Dr. Amen is a quack. Paying thousands of dollars to get scanned in one of his clinics (or those of any other doctor selling similar scans) would be a waste of money. Worse, it would put you at increased risk of cancer due to the radiation exposure.
Here are a few reference links quickly pulled from Google:
http://www.quackwatch.com/06ResearchProjects/amen.html
http://www.wired.com/medtech/health/magazine/16-06/mf_neurohacks?currentPage=all
http://www.salon.com/life/mind_reader/2008/05/12/daniel_amen
posted by zxcv at 10:39 AM on August 23, 2010 [3 favorites]
Here are a few reference links quickly pulled from Google:
http://www.quackwatch.com/06ResearchProjects/amen.html
http://www.wired.com/medtech/health/magazine/16-06/mf_neurohacks?currentPage=all
http://www.salon.com/life/mind_reader/2008/05/12/daniel_amen
posted by zxcv at 10:39 AM on August 23, 2010 [3 favorites]
One of the biggest controversies about pharmaceutical psychiatry is that it doesn't actually depend on physical diagnosis of brain structure or brain chemistry most of the time. Like others, I've heard rumors of attempts to use various MRI and PET applications to add some more empirical grounding to the use of SSRIs, etc., but I'm not aware of anyone who has developed an actual protocol for that.
So while it may be "legitimate," any physician who says he's going to use some sort of brain imager to diagnose your psychological/psychiatric condition is offering a highly experimental treatment at best. It seems more likely that he realized that insurance compensation rates for imaging studies are way, way better than compensation rates for regular, non-procedural diagnosis.
posted by valkyryn at 10:39 AM on August 23, 2010 [1 favorite]
So while it may be "legitimate," any physician who says he's going to use some sort of brain imager to diagnose your psychological/psychiatric condition is offering a highly experimental treatment at best. It seems more likely that he realized that insurance compensation rates for imaging studies are way, way better than compensation rates for regular, non-procedural diagnosis.
posted by valkyryn at 10:39 AM on August 23, 2010 [1 favorite]
Given the provenance ("A lady at my mom's church wants to refer me to her friend's psychiatrist") my first assumption is that said "psychiatrist" is some kind of freaky nutso snake oil quack, and that "brain scans" means anything from "engram testing" to "aura reading."
It's been my experience that the more people involved in a chain of suggestions, the more likely it is that what lies at the end is pure madness and woo-woo gibberish.
At the very least, I insist on putting this instance of the word "psychiatrist" in "scare quotes." I would bet... *checks pockets* twenty seven cents of my own hard-earned money that the person treating the friend of the woman who attends church with your mother does not have an actual medical degree.
posted by ErikaB at 10:40 AM on August 23, 2010 [1 favorite]
It's been my experience that the more people involved in a chain of suggestions, the more likely it is that what lies at the end is pure madness and woo-woo gibberish.
At the very least, I insist on putting this instance of the word "psychiatrist" in "scare quotes." I would bet... *checks pockets* twenty seven cents of my own hard-earned money that the person treating the friend of the woman who attends church with your mother does not have an actual medical degree.
posted by ErikaB at 10:40 AM on August 23, 2010 [1 favorite]
I do not think this is a particularly effective way to decide on a course of treatment. It probably won't hurt, and there isn't much chance of suffering any imaging-related side effect, but I really don't think that there is much of an upside at all to this (unless you consider the psychiatrist's pocketbook.)
In many imaging studies, there is a great deal of overlap between "depressed" individuals and "controls." To the point where the variation within groups is larger than between groups. Imagine the heights of men and women-- if you knew a person was 5'9, would you guess that they were male or female? If you guessed male, you would be more likely to be right, but 5'9 females are so common as to be almost unremarkable. You would be a lot better off guessing male/female based on some other measure (like "occasionally wears a skirt", "shaves legs," or the gold standard, "has ovaries.") I can look at an MRI scan of a brain, and make a decent guess as to whether the owner is male or female, but this would clearly be one of the most fantastically costly, inaccurate ways to arrive at determining gender.
My guess is that imaging is an attempt to construe "depression" as a disease in the sense of: "you have an illness that medical treatments can cure". This is good for people selling expensive treatments. Psychiatrists, encouraged by drug companies, used to tell patients that they have a "chemical imbalance in the brain that this drug will correct." This way of thinking also de-emphasizes many non-medical things that certainly improve depression, like the development of strong supportive social networks, talk-therapy, and physical activity. The more recent way to think about depression is as a disease in the sense of: "this is a pathological state that has multiple inter-related causes and risk-factors, as well as characteristic patterns of progression and deterioration." And the value of this metaphor is the attempt to carry over the ways of investigating biological factors into the realm of the social and cultural factors of depression as well.
The traditional technique to settle on a psychiatric medication is to try one thing, and keep changing it up until you find something that both works AND has manageable side-effects. What do MRIs tell you about potential side-effects? If the the answer is "nothing", well, you still have to use the guess-and-check method of settling on a treatment.
posted by Maxwell_Smart at 11:04 AM on August 23, 2010 [2 favorites]
In many imaging studies, there is a great deal of overlap between "depressed" individuals and "controls." To the point where the variation within groups is larger than between groups. Imagine the heights of men and women-- if you knew a person was 5'9, would you guess that they were male or female? If you guessed male, you would be more likely to be right, but 5'9 females are so common as to be almost unremarkable. You would be a lot better off guessing male/female based on some other measure (like "occasionally wears a skirt", "shaves legs," or the gold standard, "has ovaries.") I can look at an MRI scan of a brain, and make a decent guess as to whether the owner is male or female, but this would clearly be one of the most fantastically costly, inaccurate ways to arrive at determining gender.
My guess is that imaging is an attempt to construe "depression" as a disease in the sense of: "you have an illness that medical treatments can cure". This is good for people selling expensive treatments. Psychiatrists, encouraged by drug companies, used to tell patients that they have a "chemical imbalance in the brain that this drug will correct." This way of thinking also de-emphasizes many non-medical things that certainly improve depression, like the development of strong supportive social networks, talk-therapy, and physical activity. The more recent way to think about depression is as a disease in the sense of: "this is a pathological state that has multiple inter-related causes and risk-factors, as well as characteristic patterns of progression and deterioration." And the value of this metaphor is the attempt to carry over the ways of investigating biological factors into the realm of the social and cultural factors of depression as well.
The traditional technique to settle on a psychiatric medication is to try one thing, and keep changing it up until you find something that both works AND has manageable side-effects. What do MRIs tell you about potential side-effects? If the the answer is "nothing", well, you still have to use the guess-and-check method of settling on a treatment.
posted by Maxwell_Smart at 11:04 AM on August 23, 2010 [2 favorites]
Dr. Amen and his brain scans have a quackwatch page.
posted by The Michael The at 11:06 AM on August 23, 2010 [1 favorite]
posted by The Michael The at 11:06 AM on August 23, 2010 [1 favorite]
The only context in which a scan is central to diagnosis is a disease with and identifiable brain lesion or pattern of electrical activity like a seizure. Depression does not produce a brain lesion so scanning to find the depressed part of your brain makes no sense. There are sometimes differences on fMRI, EEG and other scans between depressed and non-depressed individuals, for example, but these have been found under conditions of tight experimental control and the findings are not nearly robust, replicable and consistent enough across individuals for a single scan on one person to be diagnostic.
posted by slow graffiti at 11:16 AM on August 23, 2010
posted by slow graffiti at 11:16 AM on August 23, 2010
I'm thinking this would be kind of difficult to answer without knowing exactly what is meant by brain scans. If we're talking MRIs and whatnot then the answer would be very different than if, say, the doctor first scans your brain using Reiki or whatever.
posted by FAMOUS MONSTER at 11:19 AM on August 23, 2010 [1 favorite]
posted by FAMOUS MONSTER at 11:19 AM on August 23, 2010 [1 favorite]
My opinion on Doctor Amen: I read his book How to make a good brain great very closely. I also have seen the criticism. This gave me a new respect for the fellow that wrote that paper "Most published research is wrong". In this particular book, Doctor Amen has lengthy reference lists of scholarly backup for his regimens like ginko biloba. I am pretty sure the Neuro board that certifies Doctor Amen does not approve this, or any of the dozens of other nutritional supplements he recommends. I would bet anything he has a number of lawyers go over his books before he publishes them to make his statements as pussyfooted as they can possibly be, so that he can continue to run his lucrative business and keep his license.
Also I think he completely believes what he says. I do not. I think it is way too simple and the brain is more complicated than he can imagine. His book held my interest from the first page to the last. I may read another. If I had a problem with my brain, I would go to the person recommended by my local trusted Primary Care Physician. It would surprise me if I lived in Newport Beach and that person recommended that I go see Doctor Amen. But it is not impossible. I hope that he cannot have a license to do what he does and not have any patients referred to him by competent trusted Primary Care Physicians.
I enjoyed reading his book much more than the bulk of what is on quackwatch.
posted by bukvich at 1:03 PM on August 23, 2010
Also I think he completely believes what he says. I do not. I think it is way too simple and the brain is more complicated than he can imagine. His book held my interest from the first page to the last. I may read another. If I had a problem with my brain, I would go to the person recommended by my local trusted Primary Care Physician. It would surprise me if I lived in Newport Beach and that person recommended that I go see Doctor Amen. But it is not impossible. I hope that he cannot have a license to do what he does and not have any patients referred to him by competent trusted Primary Care Physicians.
I enjoyed reading his book much more than the bulk of what is on quackwatch.
posted by bukvich at 1:03 PM on August 23, 2010
FWIW--I have looked at the posts, links and other source material on Dr. Amen. After reflection it (he) would not be my first choice I would hope you take the time to locate psychiatrists in your community who may better meet your needs. There is nothing like a good history and the patience to work through various treatment strategies. You mentioned you have taken a number of drugs but discontinued because of unpleasant side effects. It makes me wonder if you stayed on the long enough and used other drugs to mitigate the initial side effects. Most side effects associated with the reuptake inhibitors are mitigated after 2-3 weeks.
posted by rmhsinc at 2:12 PM on August 23, 2010
posted by rmhsinc at 2:12 PM on August 23, 2010
I've seen a fair number of psych professionals and neurologists in my time, both in private practice and in giant teaching and research hospitals.
The only time brain scans have ever come up were in the cases of acute head trauma (two head CTs), ruling out seizures (two short sets of EEGs), and confirming migraine (an MRI, MRV, and MRA). At no point did anyone say "We need to get some brain scans to figure out a good medication for you."
The last guy to prescribe for me did the MRI sequence well after he prescribed an off-label migraine prophylaxis that also affects obsessive-compulsive conditions, and he was a Serious Brain Nerd at one of the best hospitals on the West Coast, doing Serious Brain Nerd Things out at the edge of what we currently know about migraine.
Anecdotes are not data-- and the folks who've cited Quackwatch have given you the tools to acquire more data-- but "brain scans" for psychiatric use isn't a standard procedure. Your insurance might or might not cover it, but I think the money you'd put towards this fishy practice would be better used finding a reputable teaching and research hospital and consulting someone there.
posted by fairytale of los angeles at 4:20 PM on August 23, 2010 [1 favorite]
The only time brain scans have ever come up were in the cases of acute head trauma (two head CTs), ruling out seizures (two short sets of EEGs), and confirming migraine (an MRI, MRV, and MRA). At no point did anyone say "We need to get some brain scans to figure out a good medication for you."
The last guy to prescribe for me did the MRI sequence well after he prescribed an off-label migraine prophylaxis that also affects obsessive-compulsive conditions, and he was a Serious Brain Nerd at one of the best hospitals on the West Coast, doing Serious Brain Nerd Things out at the edge of what we currently know about migraine.
Anecdotes are not data-- and the folks who've cited Quackwatch have given you the tools to acquire more data-- but "brain scans" for psychiatric use isn't a standard procedure. Your insurance might or might not cover it, but I think the money you'd put towards this fishy practice would be better used finding a reputable teaching and research hospital and consulting someone there.
posted by fairytale of los angeles at 4:20 PM on August 23, 2010 [1 favorite]
Has this technique been proven to be useful by the medical community?
I can tell you unequivocally: no. (I'm a primary care physician who has been practicing for 15 years. I diagnose and treat depression and anxiety disorders every day. And this opinion is being
posted by neuron at 4:51 PM on August 23, 2010
I can tell you unequivocally: no. (I'm a primary care physician who has been practicing for 15 years. I diagnose and treat depression and anxiety disorders every day. And this opinion is being
posted by neuron at 4:51 PM on August 23, 2010
I can tell you unequivocally: no.
I second this as a physician and academic research scientist trained in internal medicine and clinical research. There is nowhere near anything amounting to strong evidence to support this.
posted by drpynchon at 6:25 PM on August 23, 2010
I second this as a physician and academic research scientist trained in internal medicine and clinical research. There is nowhere near anything amounting to strong evidence to support this.
posted by drpynchon at 6:25 PM on August 23, 2010
At the psych hospital where I used to work, we would do Complex EEGs (patient was awake and was given various stimuli to monitor how the brain reacted) to determine if a patient's "rage episodes" were connected to some seizure activity. However, that was done mainly in children and adolescents...not adults. More often than not, the kids with out of control rage issues (and you could tell they were truly out of control and not just acting out) also showed signs of seizures, and we treated them with Tegretol and other anti seizure meds, along with everything else. It also wasn't always just the seizures...they usually had other things going on so it's hard to definitively say that everything was based on the EEG.
I am not aware of any brain scans that can detect bipolar or depression, unless those issues are caused by traumatic brain injury. However, a brain injury doesn't always lead to psych issues, so it's not a direct cause and effect.
I'd be extremely wary of any sort of brain scan to diagnose psychiatric issues unless there's a history of brain injury that is primary and needs treatment.
posted by MultiFaceted at 7:37 PM on August 23, 2010
I am not aware of any brain scans that can detect bipolar or depression, unless those issues are caused by traumatic brain injury. However, a brain injury doesn't always lead to psych issues, so it's not a direct cause and effect.
I'd be extremely wary of any sort of brain scan to diagnose psychiatric issues unless there's a history of brain injury that is primary and needs treatment.
posted by MultiFaceted at 7:37 PM on August 23, 2010
I can tell you unequivocally: no.
I'll third this, as a radiology resident also doing a phd in neuroradiology. There has been research done on imaging and depression, e.g., DTI, fMRI - but that's research and isn't a part of standard clinical practice. Using imaging to see what drugs you need? That's just complete nonsense. Seriously.
posted by sero_venientibus_ossa at 12:37 PM on August 25, 2010
I'll third this, as a radiology resident also doing a phd in neuroradiology. There has been research done on imaging and depression, e.g., DTI, fMRI - but that's research and isn't a part of standard clinical practice. Using imaging to see what drugs you need? That's just complete nonsense. Seriously.
posted by sero_venientibus_ossa at 12:37 PM on August 25, 2010
This thread is closed to new comments.
Short version: There is some promising research on detecting bipolar disorder using fMRI. It is extremely early, and by no means ready for clinical use. Of course, there are already clinics springing up where they stick you in an MRI and then prescribe drugs based on your results. Do not trust them.
posted by Oktober at 9:37 AM on August 23, 2010