Has anyone had any experience with Dr. Daniel Amen or his work using SPECT brain imaging? Or even read his books?:

Change Your Brain, Change Your Life

Healing ADD: The Breakthrough Program That Allows you to See and Heal the 6 Types of ADD

His website is fascinating, as are his books.

Yes. it was his books that enabled me to diagnose myself and covince my doctors what was going on. My diagnosis was clear on historical /questionnaire grounds andIfollowed up with a SPECT that matchedit. Strictly speaking the SPECT was not necessary but I wanted it for my own research purposes.There has been great criticism of his use of SPECT - but I think it is so valuable in convincing people they have a biological problem and not a character defect. I think he is a gifted clinician. I find his assertion that peopple are not fundamentally bad-they all want to be liked and successful and a useful part of society- it is just that some have not been given the equipment to do so. THat little life affirming assertion drives me forwards every time Ilock horns with a patient who is hard to deal with.

I dont mean to stir up controversy but the guy is generally viewed as a kook. His methods are suspect at best.

Possibly so- but I do like his strong championing of the biological cause hypothesis and certainly found his books both motivating and stimulating.
I think there is a real danger of being too conservative here and he was certainly at the forefront of the push to look at the specifics of action of some medications in terms of localised action in the brain. I think he has helped push our ideas in the right direction- and we need people to push forwards into new territory.
Personally I think he reads too much into his SPECT scans - when most of his diagnoses really come from his clinical skills, and clearly compassionate approach to his patients. I would far rather have him as my personal doctor than most of the psychiatrists I have encountered.
I do agree though that he is a controversial area, and we should consider our judgements carefully.

Possibly so- but I do like his strong championing of the biological cause hypothesis and certainly found his books both motivating and stimulating.
I think there is a real danger of being too conservative here and he was certainly at the forefront of the push to look at the specifics of action of some medications in terms of localised action in the brain. I think he has helped push our ideas in the right direction- and we need people to push forwards into new territory.
Personally I think he reads too much into his SPECT scans - when most of his diagnoses really come from his clinical skills, and clearly compassionate approach to his patients. I would far rather have him as my personal doctor than most of the psychiatrists I have encountered.
I do agree though that he is a controversial area, and we should consider our judgements carefully.
As a footnote I think he lets his enthusiasm get ahead of him and fails to pursue enough data to back up his ideas.

I dont mean to stir up controversy but the guy is generally viewed as a kook. His methods are suspect at best.

He's definitely outside the mainstream view, and has a habit of championing his approach rather strongly and loudly . . .

I think the biggest controversy with him is the fact that he advocates SPECT scans for children. SPECT involves a certain amount of radiation, which most practitioners are loathe to expose children to unless there is a documented clinical reason (i.e. suspected seizures or brain injury; ADHD doesn't usually fit into this box).

That said, I do think that it's unfortunate that some of the leading experts have sort of thrown the baby out with the bathwater in dismissing his "research." If he really can, as he asserts, take some of the trial and error out of drug prescription for ADDer's, I think that's exciting and should be followed up.

I think the biggest problem is that you could look at his work from 2 perspectives. One is the one most of the researchers are looking at it from, which is that his results are not replicable, and aren't well controlled for. Basically, that the science isn't great and because the science isn't great, there are very valid concerns about subjecting children to unneeded radiological procedures.

But medicine is as much of an art as a science -- a very applied science at that -- and while anecdotal reports and categorization of clinical symptoms do not make good science, they can still inform us about treatments and treatment options. So, if one can, based on the framework that Dr. Amen proposes, somehow determine that a patient is most likely to respond positively to ritalin vs. adderall, or a combination of an SSRI and a stimulant vs. a stimulant alone, then we have a much better starting place.

That said, maybe it's possible to determine that from a well-researched patient history. I am sort of surprised that no one's thought to document drug response (or if the have, I'm assuming that no good correlations have emerged)>

He's definitely outside the mainstream view, and has a habit of championing his approach rather strongly and loudly . . .

I think the biggest controversy with him is the fact that he advocates SPECT scans for children. SPECT involves a certain amount of radiation, which most practitioners are loathe to expose children to unless there is a documented clinical reason (i.e. suspected seizures or brain injury; ADHD doesn't usually fit into this box).

That said, I do think that it's unfortunate that some of the leading experts have sort of thrown the baby out with the bathwater in dismissing his "research." If he really can, as he asserts, take some of the trial and error out of drug prescription for ADDer's, I think that's exciting and should be followed up.

I think the biggest problem is that you could look at his work from 2 perspectives. One is the one most of the researchers are looking at it from, which is that his results are not replicable, and aren't well controlled for. Basically, that the science isn't great and because the science isn't great, there are very valid concerns about subjecting children to unneeded radiological procedures.

But medicine is as much of an art as a science -- a very applied science at that -- and while anecdotal reports and categorization of clinical symptoms do not make good science, they can still inform us about treatments and treatment options. So, if one can, based on the framework that Dr. Amen proposes, somehow determine that a patient is most likely to respond positively to ritalin vs. adderall, or a combination of an SSRI and a stimulant vs. a stimulant alone, then we have a much better starting place.

That said, maybe it's possible to determine that from a well-researched patient history. I am sort of surprised that no one's thought to document drug response (or if the have, I'm assuming that no good correlations have emerged)>

It is not all that much radiation- certanly much much less than my son was exposed to when he had a nagging but severe knee problem at age 9- plain XRays, CTs bone scans, follow up films- it added up after a bit.

It is not all that much radiation- certanly much much less than my son was exposed to when he had a nagging but severe knee problem at age 9- plain XRays, CTs bone scans, follow up films- it added up after a bit. <!-- / message --> <!-- controls -->

Very true. (though I though PET scans were fairly high-radiation, depending on isotope used; I know less about SPECT).


I wish I could remember where I read the consensus statement . . . might have been a pediatrics journal, but I think Castellanos and Barkley were on a brief communication or letter to the editor type thing, expressing concern over the SPECT scans.

Their major concern, aside from the lack of peer-reviewed research backing up the use of the SPECT, was the "unnecessary" exposure to radiation. I.e., because there was little scientific research that they considered "good research" supporting the use of SPECT scans in ADHD diagnosis, the exposure to radiation was unnecessary and therefore risky.

Not saying I necessarily agree, but if the SPECT scans are truly unnecessary for a differential diagnosis, I think I can understand the concern. I mean, ADDer's are more accident prone than average, so you're likely to have a kid who's having more X-rays and radiological procedures than your average kiddo. It's the total radiation exposure for the year that could hypothetically get ugly.

(as you obviously know from your experience with your son; hopefully he's on the mend now?)

I Read One Of His Books And I Found That I Have More Of The "inattentive Type" Affecting The "limbic System." I Don't Know If He's A Kook Or Not, But At Least He's Thinking Outside The Box Unlike Most Doctors I've Been To. I Really Want My Scans Done Because I Know For A Fact That It Will Show Something And Maybe Help My Doctor Treat Me More Effectively. I'm Resistant To Most Meds At This Point And Still Struggle Big Time With The "executive Function" Part. I Think Amen Is Worth Checking Out.

One of the contributions of Dr. Amen that I do like is that he expanded the subcategories of ADD from 3 (Inattentive, Hyperactive/Impulsive and combined) to 6 (Classic ADD, Inattentive ADD, Overfocused ADD, Temporal ADD, Limbic ADD, and "Ring-of-Fire" ADD). This is potentially one of the most controversial aspects of his diagnosis, because if this is true, it will probably lead to a number of "retro-analyses" of earlier studies which were limited to only 3 subtyes.

SPECT scans do show very different bloodflow patterns to very distinct brain regions for each subtype. Although I question whether a few of those are actual "subtypes" of ADD are actually ADD themselves and not merely other disorders which share a large overlap with ADD or ADHD, I do believe that having only 3 subtypes is a bit limiting. Anyone agree/disagree?

Also, just in case anyone was wondering, the radioactive "tracer" used in SPECT imaging for ADHD is the Technetium-99m or Tc-99m. A solution of this compound is injected into the patient's arm and makes its way quickly to the target region (in this case, the brain). The "99" refers to the total isotope mass (the mass of 43 protons and 56 neutrons), while the "m" refers to "metastable" or a less-stable form that "kicks off" a gamma particle (which can be used to detect and measure in medicine) and results in the more stable form Tc-99. Technetium is the smallest completely radioactive element (i.e. one with no stable isotope) and is used in a number of medical tests. It has a relatively short half-life and is very "potent", so only small amounts need to be used. Best of all, it clears from the system relatively quickly. For brain scans involving both relaxed and concentration states for ADHD with or without medication, Tc-99m SPECT is a good overall diagnostic option.

I just got the book. All I've done so far is glance through it. Oh! Pictures! That will make it more tolerable.

My first "look" at ADD was due to finding Amen's web site. I did his online diagnostics, which I printed and took to my initial appointments. Having that saved me probably hours of answering the same types of questions.

Drawing only on observations from this forum about people's own personal experience, I tend to agree that there aren't just 3 types. I have no science to back that up at all. It will be interesting to see how he delineates the types. As well as what works to resolve which types.

I just got the book. All I've done so far is glance through it. Oh! Pictures! That will make it more tolerable.

My first "look" at ADD was due to finding Amen's web site. I did his online diagnostics, which I printed and took to my initial appointments. Having that saved me probably hours of answering the same types of questions.

Drawing only on observations from this forum about people's own personal experience, I tend to agree that there aren't just 3 types. I have no science to back that up at all. It will be interesting to see how he delineates the types. As well as what works to resolve which types.

The book is very readable - even with untreated ADHD!
My biggest question is is he proposing that the other problem areas are actually subtypes of ADD or separate conditions that might muddy the diagnosis? The latter makes more sense to me.

The book is very readable - even with untreated ADHD!
My biggest question is is he proposing that the other problem areas are actually subtypes of ADD or separate conditions that might muddy the diagnosis? The latter makes more sense to me. <!-- / message --> <!-- controls -->

I don't really think he makes a strong distinction either way, though in the more "mainstream" paradigm, yes, they would be considered co-morbid conditions like bipolar disorder (ring of fire) or OCD (overfocused). In a way, he's less focussed on the labels, and more on the constellation of symptoms and how to treat them, which means he's wasting less time trying to fit a complex syndrome into tidy little boxes.

I think the bigge$t controversy ...

how much do these scans cost the patient ?

how much profit is made per scan by Amen's company ?

did he change his name to Amen to cash in on the parental need for faith that their child may be cured from an accursed mental disease ?

do people who assert some method of disease intervention in America need to undergo an FDA-type review to ensure that they're not radio-labelled snake-oil salesmen ?

there's nothing solid under the 'brainplace' link on http://www.brainplace.com/
- which (I think) is supposedly the section where he describes a little more of his science.

I think that DB (above) has it right

kook

how much do these scans cost the patient ?

how much profit is made per scan by Amen's company ?

did he change his name to Amen to cash in on the parental need for faith that their child may be cured from an accursed mental disease ?

do people who assert some method of disease intervention in America need to undergo an FDA-type review to ensure that they're not radio-labelled snake-oil salesmen ?

there's nothing solid under the 'brainplace' link on http://www.brainplace.com/
- which (I think) is supposedly the section where he describes a little more of his science.

I think that DB (above) has it right

Look a little closer there are papers on neuroimaging there- it is a bigger site than it seems.
As for the cost - I dont really know how it compares with the rest of US medicine - which is vastly overpriced imho. I have had patients travelling from Australia who have fallen in the street while travelling in the USA and been hauled off to an emergency department and had multiple investigations and come out with stitches to a cut arm and a bill for over $1000 US. If the had consulted me at home the cost for treating the same problem the cost would have been less than a tenth of that. So where $ 4000 for a full workup in afield that is well known for haphazard history taking and diagnosis is expensive in the light of that background I don't know. It is clearly beyond the means of most ordinary Americans- but that could just be a flaw in the system.

I also know for a fact that he runs a large organisation and there are whole layers of preparatory assessment before seeing the doctor. That kind of enterprise is expensive to run and cannot be done without a certain enrtepreneurial flair. I most ceratinly could not keep such a large organisation afloat myself. So while " I hear your concerns" I don't necessarily think they are the last word and I continue to watch him with great interest.

I understand the name is his own- though it might have been modified a little from his native Lebanese. He certainly is Christian and does deal with that in some books I have read- but his "Healing ADD" keeps that stuff at a professionally respectable arms length except to say that your spirituality can help you recover - or some other such non committal motherhood tpe statement.

-

Thanks for that -
I've copied all of his papers from the last 10 years (below).

First thoughts (in absence of reading his papers) -
- presumably we need evidence that there is a change in central perfusion patterns which may be detected using SPECT.

1.
a change in central perfusion

2.
which may be detected using SPECT

So - I'd start (noting that I'm trying to view this as an experiment to test the validity of Amen) - by asking the questions in dark red below.

1.
a change in central perfusion
what was the a priori evidence which lead you to examine and then develop a methodology for the use of cerebral perfusion patterns in diagnosis of a psychiatric condition?

2.
which may be detected using SPECT
what is the resolution of SPECT?

Q3.
Next -
I'd ask to look at control images drawn from extended families with people of different ages and from different races -
- of course -
all data prepared blind to phenotype,
Such a study might only consist of perhaps
4 (racial groups) x 2 sexes x 3 people from pre-school, pre-teen, 20, 30, 40 and 50 yrs
(plucking numbers semi-randomly out of the air)
which comes in at around only 140-150 scans.

I'd like to know how much variability is in the system.

Q4.
I'd then ask Amen to describe the difference between a psychiatric condition and a neurological condition.
(why?
- to be explained below)

Q5.
My first thought on examining the papers which I list below (all of his papers from the period 1998-2008 are listed) -
- from examining the titles alone -
- was set in motion by the words highlighted in red.

He appears to be using 'extremes' to validate a technique -
which he's then extrapolating to cases where less extreme variability may be seen.
This is a commonly used and potentially misleading technique which I have seen used in genetic research where it is suggested that a rare monogenic disorder (which the authors have solved) - will provide novel insight into understanding of a common disorder
(a common disorder which has only slight similarity to their successes).

I'm trying to suggest that if we've a technique which is very effective at weighing potatoes - that it might not be so effective at reporting back the weight of a sheet of tissue paper.

Disclaimer
- these are merely suggestions - it's impossible to make definitive comment unless I ?buy? his papers
- a luxury which the unemployed can ill afford.

We've an immediate problem here -
- because although the author may have peer-reviewed publications -
they may need to be taken 'off the table' in this current discussion
because we're trying (potentially) to weigh tissue paper
using evidence of the incredible skill of a researcher/utility of a technique
garnered measuring the weight of potatoes.
The devil (here) is in the detail.Science sells
- and by creating the impression to customers (patients) that the researcher knows how to use this technique, that he's a respected scientist and that he has proof of the technique in cases of central dysfunction -
he will succeed in gaining a larger customer base -
--- more money ---
(in other word$)

The point of Q4. to Amen
I'm pretty sure that we'll find that ADHD is a gradual psychiatric change which will be difficult to resolve by imaging unlike the gross changes which one might expect with neurological conditions including {glioma,Alzheimers,Parkinson's disease} for instance.
Sure - problems arise at the interface between neurological and psychiatric conditions
- such as in some of those cases listed below (highlighted in red) -
- though presumably the more extreme the psychiatric condition
- the greater the perfusion patterns will diverge from normality -
- the greater the likelihood of picking up some kinda' difference -
- though of course without explaining away that difference
(although that latter point is unfair to raise here - because Amen is claiming a tooll for diagnosis alone)
- the more easily it will prove to define a classifier to separate case from control.

So

- a potential criticism -

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------
- it's possible that we have a world renowned potato assessor (who has realised that the world no longer needs his services (due to automation no doubt)) trying to hoodwink the population into believing that he can turn his world renowned (though no longer required) skill in weighing potatoes
to
the desperately sought after (top dollar paid) service of weighing tissue paper for a fawning public.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Disclaimer
I am more than prepared to be proven wrong
- these are simply first thoughts based on reading the titles of his papers.

Papers

An Analysis of Regional Cerebral Blood Flow in Impulsive Murderers Using Single Photon Emission Computed Tomography, accepted for publication by J Neuropsychiatry Clin Neurosci 2006
Brain Imaging In Clinical Practice: Pro/Con: Pro written by Daniel Amen, Clinical Psychiatry News September 2006
High Resolution Brain SPECT Imaging and EMDR in Police Officers with PTSD, written with Lansing, K, Hanks, C and Rudy, L, J Neuropsychiatry Clin Neurosci. 2005 Fall;17(4):526-32.
The Clinical Use of Brain SPECT Imaging in Neuropsychiatry. With Joseph C. WU, MD. and Blake, Carmichael, PhD. Alasbimn Journal 5(19): January 2003.
Why Don’t Psychiatrists Look At The Brain: The Case for the Greater Use of SPECT Imaging in Neuropsychiatry. Neuropsychiatry Reviews. February 2001, Vol. 2, No. 1. Pages 1, 19-21.
Attention Doctors: Newsweek. 2001 Feb 26;137(9):72-3 on Subtyping ADD.
Brain SPECT imaging in the assessment and treatment of aggressive behavior: A putative “Reward Deficiency Syndrome (RDS)” behavioral subtype. Abstract of presentation at the First Conference on “Reward Deficiency Syndrome:” Genetic Antecedents and Clinical Pathways, San Francisco, November 12-13, 2000, in Molecular Psychiatry, Volume 6 Supplement 1, February 2001, page S7
Criminal recidivism as a neurobehavioral syndrome. J Am Acad Child Adolesc Psychiatry. 1999 Sep;38(9):1070-1. With Al French.
Regional Cerebral Blood Flow In Alcohol Induced Violence: A Case Study: Journal of Psychoactive Drugs, Volume 31:4, October-December 1999.
Brain SPECT Imaging in Psychiatry. Primary Psychiatry, Vol. 5, No. 8, pgs 83-90, August 1998.
Attention Deficit Disorder: A Guide for Primary Care Physicians. Primary Psychiatry, Vol 5, No. 7, pgs 76-85, July 1998.
High Resolution Brain SPECT Imaging in Marijuana Smokers with AD/HD, Journal of Psychoactive Drugs, Volume 30, No. 2 April-June 1998. Pgs 1-13.

I still have an account some place with the Amen forum -
his site appears to have changed quite radically since last I remember posting -

if it's any help I'll re-post this exact same post over on his site -

maybe I'll be proven wrong with proper answers -

--- or ---

maybe the post will be ignored, deleted and my membership rescinded -

- but who'd want to be part of a community forum which exercises unfair censorship ?

$ 4000

please can I ask what $4000 buys ?

- that amount exceeds by several factors the costs which I have incurred over the last 5 or so years in gaining diagnosis and drug for ADHD -
though if the truth were told - the act of finding an ADHD specialist in the UK is enough to justify diagnosis -

it really is that hard -

- only ADDers who really need the meds would work that hard

and then there's the cost of the medication -

dexedrine is real cheap -
- can't help but feel that the NOT real cheap ADHD meds represent a real cheap trick by pharmaceutical company to make a whole lotta' money.

I took myself off Strattera when I discovered the amount that Eli Lilly was charging for their drug.

Dexedrine works great after all; my brain signalled when the 3 hours and 45 minutes were approaching 'up' .

http://brighamrad.harvard.edu/education/online/BrainSPECT/Contents.html

the potato argument is holding -
either we need tissue-light potatoes or potato-heavy tissues.

amen.

My 3 cents...

The 2nd therapist we went to (LFMT) brought out this book to help convince my wife that ADD was indeed something tangible, and there were measurable results while an ADD brain was off and on medication. The therapist also recommended that we go for the scan. At that time (over a year ago) it was $5k (according to the therapist). We never pursued because it was prohibitively expensive for us at the time. In hindsight, I should have robbed a bank that day.

The book I am referring to above is Images of Human Behavior - A Brain SPECT Atlas by Dr. Amen.

please can I ask what $4000 buys ?

- that amount exceeds by several factors the costs which I have incurred over the last 5 or so years in gaining diagnosis and drug for ADHD -
though if the truth were told - the act of finding an ADHD specialist in the UK is enough to justify diagnosis -

it really is that hard -

- only ADDers who really need the meds would work that hard

and then there's the cost of the medication -

dexedrine is real cheap -
- can't help but feel that the NOT real cheap ADHD meds represent a real cheap trick by pharmaceutical company to make a whole lotta' money.

I took myself off Strattera when I discovered the amount that Eli Lilly was charging for their drug.

Dexedrine works great after all; my brain signalled when the 3 hours and 45 minutes were approaching 'up' .

Check the site to be sure- but off the top of my head I believe that it includes Resting and Concentrating SPECT, diagnostic workup by practice assistants folllowed by consultation with psychiatrist - initiation and stabilisation of meds- and I think ( but could be wrong) a follow up Spect.

Compare with the Australian situation- $800 for 2 Spects _ resting + concentrating ($500 back from Medicare)- $ 280 per hour AMA recommended fee for a psychiatrist- about 1/2 refunded on insurance.
Or $450 an hour for a good contract lawyer in the big city.

His fees are not cheap- but not out of the ball park for a skilled prefessional. Incidentally our dreaded socailised Medicine in Australia does tend to restrain total fees charged even if not completely. Its a system that works pretty well for the majority. The US system tends to encourage very high fee charging- and the UK system works by strangling availability of doctors and preventing them from working in a patient friendly manner. Knowing people who have worked as doctors in the UK they are always unimpressed with the disincentives and rigidity of the system- and lack of patient focus. Brittania Hospital (the movie) was not far from the truth-- but lets not get too far off the track :)

To be fair it has also taken me years to get to the bottom of my issues in Australia- despite my relative affection for "the system".

Dexedrine/ dextroamphetamine is remarkably cheap, and effective, thankfully.

I don't think SPECTs are necessary for diagnosis- nor does the majority of doctors- most have not even heard of the idea. They can be helpful though- especially if you have a patient or family who want something concrete to help them understand the diagnosis - or a doctor who feels the need of some concrete evidence to support his prescribing pattern- which may well attract the unwelcome attention of the dangerous drugs authorities.They do pay attention if one individual doctor has a very skewed prescribing pattern- questions will be asked and if you cannot answer them well your medical registration may be on the line.

family who want something concrete to help them understand the diagnosis
or
a doctor who feels the need of some concrete evidence to support his prescribing pattern

thanks -
- just one question -
- all I'm after is a best guess (it's an unfair question to anyone other than a member of SPECTre (so no worries if you'd prefer not to bite))

if I have 10 of the most 'extreme' ADD-Inattentives. ADHD-hyperactives, and perfectly matched controls at different ages -
if I were to give these patients to Amen in a classical 'blind' study -
what should I expect?

Will SPECT always separate ADDer from nonADDer ?
Will SPECT identify sub-groups of ADHD and ADD-I which will then be handled differently ?

My problem is that his technique (if it works) - is of tremendous utility to us ADDers (if it works) -
- especially since there is much controversy over whether ADHD even exists -
(McTavish23 is an ADDer psych ADDforum member who has a stickie above many of the fora here - justifying ADD as a disorder/condition -
as a counter to the dissenters)
- since there is much controversy over whether ADHD even exists, if I were Amen -
I'd produce a definitive study on the subject and publish it in a high impact factor neuroscience journal -
and then champion the introduction of 'my technique' world-wide.

He'd make a large number of ADDers real happy
(- if that is his goal)
and he'd also make a great deal of money -
- which presumably he'd like also

- and all of this with only one classical empirical study which is conducted along the lines of a proper case-control/scientific/empirical study.

We're blessed :-) with a massive population of ADDers who'd bend over backwards to help Amen (especially if they were permitted access to their SPECTs after the experiment had been analyzed and published) -

- Amen isn't limited by


access to methodology

(he has the expertise and equipment),


access to patients

(there are plenty of ADDers about),


access to money

(a blind study on a couple of hundred patients would only cost him the wholesale price of a couple of hundred SPECTs and I'm sure that an organization like the Stanley Foundation would pay
if he was down on the USD and if he asked them nicely)

The American Stanley Foundation is powerful in the UK -
and the last study which I observed reported results which discriminated
- between post-mortem degradation in schizophrenic brains versus normal controls -
and not as was suggested in the paper
- of between the schizophrenic and normal brain.

(re-inforcing the need for appropriately matched controls and 'blind' methodology during experimentation and analysis)

I'm trying to suggest that the empirical approach which I seem to spend most of my time attacking here -
can work
if it is applied properly
- though that there needs to be a willingness amongst researchers to report inconclusive studies.

(re-inforcing the need for appropriately matched controls and 'blind' methodology during experimentation and analysis)
If an inappropriate experimental design is applied
- it is simple for the unscrupulous researcher to twist results to meet his a priori desires
(in this latter case by inappropriate choice of controls - the researcher exaggerates the difference between case and control - exaggerating the size of difference which they then go onto define (a successful study through the eyes of the researcher because the many significances which result - fuel the likelihood of acceptance of the paper for publication (publication bias)))

- the subterfuge which is at play here may be unintentional - regardless though - it is certainly poor science which benefits only the scientist
- it is difficult for poor scientific methodology to be assessed by member of the general public
- even scientists who have no time to assess methodology may be fooled into believing the hype.

As long as a scientist has a speciality -
there will be no motivation for a scientist to do anything but 'sell' that speciality for (essentially) - his own personal gains.

A couple of my best friends work in the research sections of Psychiatry within Oxford and Cambridge Universities -
both scientific data analysts -
and both have described the pressure which they are under to deliver significant findings to their supervisors -
- at least if continued employment is desired.

Who pays for your mortgage if you're unemployed?

good old money -
eh?

- it fuels lies.

-*-

We really are spoilt by the number of ADDers who are available as study subjects, and the non-invasive nature of SPECT -
the experiment is almost trivial to conduct over classical lines -

and if it were conducted and was successful, then it would one of the greatest contributions which one could imagine -

- it would herald the beginning of usage of imaging from gross neurological through gross psychiatric into subtle psychiatric conditions.

Once again (apologies for repeating this point) -
but the two points which I'd really drill down on (if I had the opportunity to review his methodology) -
would be

what is the evidence that there are meaningful central perfusion changes in subtle psychiatric conditions

what is the limit of resolution of SPECT?

Absolutely without doubt - SPECT will work in any condition where there is a visible change in the structure of the brain -
because this will result in a change in the vasculature required to sustain the absence or growth in neural tissue -

but

I'm unaware of gross anatomical changes occurring with ADHD -
- unlike Alzheimers, Parkinson's disease and glioma (the three diseases which I mention above) -

and which (says he quickly checking)

- are also prominent within the Brigham SPECT Atlas of Brain Perfusion
(http://brighamrad.harvard.edu/education/online/BrainSPECT/Contents.html)
Dementias

Alzheimer's Type (http://brighamrad.harvard.edu/education/online/BrainSPECT/Alzheimers/Alzheimers.html)
Alzheimer's Type (http://brighamrad.harvard.edu/education/online/BrainSPECT/Alzheimers2/Alz2.html)
AIDS Dementia Complex (http://brighamrad.harvard.edu/education/online/BrainSPECT/AIDS/AIDS.html)
Parkinson's Disease Dementia (http://brighamrad.harvard.edu/education/online/BrainSPECT/PDD/PDD.html)
Multi-Infarct (Vascular) Dementia (http://brighamrad.harvard.edu/education/online/BrainSPECT/MID/MID.html)
Pick's Disease (http://brighamrad.harvard.edu/education/online/BrainSPECT/Picks/Picks2/Picks2.html)

Brain Tumors

Astrocytoma (http://brighamrad.harvard.edu/education/online/BrainSPECT/Tumors/Astrocytoma/Astro.html)
Recurrent Metastatic Melanoma (http://brighamrad.harvard.edu/education/online/BrainSPECT/Tumors/Melanoma/Melanoma.html)
Recurrent Metastatic Melanoma (http://brighamrad.harvard.edu/education/online/BrainSPECT/Tumors/Melanoma2/Melanoma2.html)
Glioblastoma Multiformé (http://brighamrad.harvard.edu/education/online/BrainSPECT/Tumors/GBM/GBM.html)

I think that astrocytoma is also traditionally classified as glioma by pathologist.

- ps -

thanks for supporting Amen/SPECT -

it's often difficult to find well-educated individuals who're willing to support controversial methodology.

My personal view is that although it's a plausible technique -
whether it could work requires that we understand the nature of the mind.

The mind isn't the brain -
and the distributed nature of the mind
---for instance---
the stats which're often quoted of the great extent to which the brain may degrade and yet the experiential perspective of man (mind) retained -

- leads me to believe that the changes which accompany psychiatric condition will not bear simple relationship with gross anatomical deformation.

thanks -
- just one question -
Will SPECT always separate ADDer from nonADDer ?
Will SPECT identify sub-groups of ADHD and ADD-I which will then be handled differently ?

My problem is that his technique (if it works) - is of tremendous utility to us ADDers (if it works) -
- especially since there is much controversy over whether ADHD even exists -
.

My answer is that I don't know and I would like to know. His detractors principally attack him for his patchy research. All I can really say is I have found his work published in Healing ADD and on his website immensely helpful in dealing with my own ADD and that of my daughter. Our lives literally have been turned around.His clinical descriptions of his cases are very accurate and vivid and cearainly gave me the tools to pursue my own issues to a very satisfactory resolution.
(To be honest I have only been on medication for less than a month. There is so much that I have thought over the years but never had the organisation or persistence to pursue to a conclusion- and all of a sudden I can think again. It will take me a time to get my thoughts into a more mature perspective- but you can expect to see me making a nuisanceof myself round here for some time yet.)
Digression over, I think Amen is a first class clinician and I do think he genuinely cares about the results he gets, and the lives of his patients. I would like to see if his SPECT approach works well in the hands of a less passionate individual or whether he is more using it as a tool to carry his clinical skills and lend them authority. He is obviously costly- but I am certain my own personal wealth would be much greater had I got this monkey off my back 20 years ago- so the cost would have been returned many times over ( for what that is worth- money is not everything).

However both the family physician and the psychatrist I see are keen converts of his work on SPECT and use it daily in their practice, working closely with their local radiologist in reviewing films and cases to advance their own skills. This is not being done lightly or carelessly.

Medicine is a funny thing- people tend to be either researchers or clinicians- and many dedicated doctors simply find the grind of ongoing resaerch work too much of a drag compared with the real pleasure of directly helping an individual. Never mind that research is a good way to a very poor income and a more difficult personal existence. The balance is hard to find- but the older I get the more I understand the need for research and the fear of having one's own experience follow one to the grave.

Thankyou for McTavish's link. I have already found it and acquired it as one of my armaments! It is so important for us all to be strong and clear as to the science behind ADHD. There is so much misinformation about- much of it inspired by people whose ideological/ religious position blinds them to reason. It is important that those of us who have experienced the reality be able to advocate for others in the same position by explaining the reality in a clear and learned manner. After all we have only got where we are by the kindness of other individuals in doing exactly the same.

ps - Thankyou very much for the Brigham SPECT atlas link. That will need some careful attention. My own images MUCH higher resolution ( though quite different from the 3d projections that AMEN favours) are the fine detail part of the scan differentiates the basal ganglia into about 8 or so different zones. The atlas dates from 1995. If I can find a way to deidentify them I might send them on.

PPS as for supporting controversial techniques- it is all very well being prudent and conservative- but you can be conservative to a fault. At some point it is essential to trust one's own judgement- subject to revision with experience of course. To my mind what passes as conservatism is often simply a mask for stubbornness and laziness.

I just spoke with someone from the AMEN clinic and the complete testing which consists of: History; Concentration Scan; Resting Scan; Final Consultation...all for a mere $3,250!! PLUS, you have to travel to their center, stay for 4 days and pay for your hotel. Yeah right. Doesn't look like I'll be able to swing it. :(

hi -
- thanks again -

I've tried a couple of other searches for information and found this on an unlikely site (I generally would not cite from places like these
http://en.wikipedia.org/wiki/Aetna)

I'm restricted to freely available information only and am on a slow connection and so am only looking for info in straight html.

- however I really need to commend these guys (I think that they're a sorta' health insurance company (I don't think we have them in the UK - certainly I don't know anybody in the public sector with an association to a company such as Aetna) - which pays for treatment and medication) on their synopsis (they're very rich apparently and so probably have the funds to hire a cheapo scientist or two (we earn $15 dollars an hour and so are only considered 1/30th of a lawyer - calculated from the figures you quote) -

here it is

source (http://www.aetna.com/cpb/medical/data/300_399/0376.html)

07/18/2008

Noncardiac Indications: Aetna considers single photon emission computed tomography (SPECT) medically necessary for any of the following indications:


hemangioma
epilepsy
osteomyelitis
abscess
necrotic tissue in brain
lymphoma
neuroendocrine tumors
spondylolysis
parathyroid disease.


-> where no psychiatric conditions are listed

Aetna considers SPECT experimental and investigational for all other noncardiac indications, including any of the following, because its diagnostic value has not been established in the peer reviewed medical literature in these situations:



Initial or differential diagnosis dementia
Diagnosis or assessment of stroke
Scanning of internal carotid artery during temporary balloon occlusion
Diagnosis or assessment of members with attention deficit/hyperactivity disorder
Diagnosis or assessment of members with autism
Diagnosis or assessment of members with personality disorders (e.g., borderline personality disorder, anti-social personality disorder including psychopathy, schizotypal personality disorder, as well as aggressive and violent behaviors)
Diagnosis or assessment of members with schizophrenia
Differential diagnosis of Parkinson's disease from other Parkinsonian syndromes
Prosthetic graft infection
Vasculitis.


-> where psychiatric disorders are listed heavily.

and the conclusion would be

I was expecting to see more neurological diseases in the first section than in the second
- which did not happen
and more psychiatric disorders in the second section than in the first
- which did happen.


What does a healthcare insurance company care about -
in an ideal world it would be about paying for the best treatment in those who need it.

Why might we be seeing a major healthcare company rejecting SPECT?

- reason 1 -
SPECT is too expensive to fund or would cost the company too much money in subsequent payments if the patient could be unequivocally diagnosed.
- reason 2 -
SPECT does not work

The $ argument might be true - that SPECT is too expensive and the potential number of patients with mental disease too great for them to afford
- that they'd like to spend as little as possible to maximize their profits and dividends to bloated share-holders -
whereas all of this might be true -
- I think though that a definitive diagnosis through neuro-imaging would probably save these companies money in the long term -
it would allow them to set tight criteria below which they would not support the patient and above which they would.

Shareholder value could be retained whilst help afforded to only the most urgently deserving -
sure that'd be tough on the rest -
- but I think that most of us realise that capitalism cares little for people.

All things considered and guessing (pretty much) - I'd probably tend then towards believing that Aetna actually does not believe SPECT to be of clinical diagnostic value in either the majority of neurological conditions or all psychiatric conditions.

I'd probably need to probe a little further to determine whether the company
prefers PET over SPECT
as opposed to
SPECT over {nothing}

why?
Because of it turns out that PET is preferred - since it is several times more expensive than SPECT - this circumstance would push me towards rejecting my suggestion that their reticence to use SPECT was for maximizing shareholder value, profits, high position in the fortune 100 -
- and instead made because insufficient evidence exists to justify a switch in methodologicla acceptance.

Since I generally consider insurance companies to be in it for the money -
- any evidence that they're taking a more expensive route towards going about their business

- is generally (I think) - a statement that there is no cheaper way.

I have no faith in money -
I'm pretty sure that :-) this idea comes through 'loud and clear' in most of my posts.

I would agree that the current scientific consensus is that SPECT is not clinically proven in these conditions - but it is also not clinically disproven. There is no doubt that the SPECT approach is out on a limb compared to the proven evidence, or the current evaluation of that research.
This is where personal judgement on the part of the patient and an honest disclosure and consent process on the part of the doctor is vital. For most of us a trip to the Amen clinic is out of the question for one reson or the other in any case. My own suggestion to anyone seeking assessment elsewhere is that if the subject of SPECT is brought up you dscuss it with a doctor and come to a mutual agreement about what way you both want to go. Very few doctors will dictate something that the patient is uncomfortable with and any caring doctor will go out of his way to make management affordable when it is within his power.
As I said above I feel that one of Amen's failings is that he is not working hard enough to get his ideas across to the profession in a format that they are prepared to deal with. It does not mean that his ideas are incorrect or his clinic is not producing helpful treatment. From what I have seen of the rest of his approach he is very careful and exacting in his history taking- and this is probably more important than anything.

Insurance companies are highly conservative though and ruthlessly aim to maximise profits. What they will fund is only evidence of the areas that they cannot avoid liability no matter how they twist and turn. They are not averse to simply opting out of areas that they find too costly or offering them only on special expensive tables, or by insuring such a small percentage of the total claim that the out of pocket is prohibitive. You are right that they are only in it for the money. but for the rest of it.... well those other factors complicate your well reasoned inferences.

In Australia it is common to offer insurance that does not cover private psychiatric hospital admission- and believe me if you are that sick a public ward is a very frightening place to be.

I do hear you on the subject of relative incomes though. ( As for the lawyer's fee I have just paid the bill so that figure is correct and up to date- and they were only a "second string" firm). A good friend of mine earns more for a days casual work stocktaking in Bunnings Hardwarehouse than she does in a day and a half as a registered nurse on a rehabilitation ward dealing with very distressed patients with multiple injuries, all made worse by systematic understaffing and deskilling of the workforce). Go figure. That however is a whole 'nother argument ad if you dare raise it you will be howled down as a communist! ( I've just been watching the last stages of the Obama- McaCain campaign and the treatment dished out to Obama over his very modest suggestions re wealth redistribution, so I am in a particularly cynical mood today).

Dr Amen is a prolific researcher, for which he deserves recognition & respect.

However, he is not widely respected ( and that's being polite) within the clinical, as well as the research communties.

His research has only been replicated by his grad students and no one else.

The "gold standard" for all scientific research is "longitudinal validity & reliability ( i.e., can complete strangers ( if you will) come along and replicate your reseach and get the exact same results time & time again")?

Without that, no researcher develops credibility.

In Dr. Amen's case, some of the other main criticisms are :

1) he has created his own nomenclature that no one else ( in any discipline uses or even recognizes)

2) the use of radioactive dye with human subjects,especially with children, violates Ethical Principles designed to protect the human subject

( even though the dye is urinated out within 24 hrs).

3)charging thousands of dollars for a method that is not condoned, nor backed by research, cuts more ethical corners and raises more concerns.

Overall, he is viewed as someone who wants to draw attention to himself; over and above the advance of science.

He will either be remembered as a "cutting edge visionary," or an off the wall wing nut.

I've read some of his works and find (some) of them compelling.

However, when you play "loose & fast" with the scientific method, for what appears to reasons of drawing attention to yourself, it looks less like science and more like self absorbed.

This always makes for interesting dialogue.

In closing, SPECT scans are clearly designed for research.

One of the most well respected researchers in this area is Jay Giedd, MD.

He's done fascinating work on the Adolescent Brain, as well as some earlier ADHD work.

Please check him out when you can.


tc

mctavish23

(Robert)

Dr Amen is a prolific researcher, for which he deserves recognition & respect.

However, he is not widely respected ( and that's being polite) within the clinical, as well as the research communties.

His research has only been replicated by his grad students and no one else.

The "gold standard" for all scientific research is "longitudinal validity & reliability ( i.e., can complete strangers ( if you will) come along and replicate your reseach and get the exact same results time & time again")?

Without that, no researcher develops credibility.

In Dr. Amen's case, some of the other main criticisms are :

1) he has created his own nomenclature that no one else ( in any discipline uses or even recognizes)

2) the use of radioactive dye with human subjects,especially with children, violates Ethical Principles designed to protect the human subject

( even though the dye is urinated out within 24 hrs).

3)charging thousands of dollars for a method that is not condoned, nor backed by research, cuts more ethical corners and raises more concerns.

Overall, he is viewed as someone who wants to draw attention to himself; over and above the advance of science.

He will either be remembered as a "cutting edge visionary," or an off the wall wing nut.

I've read some of his works and find (some) of them compelling.

However, when you play "loose & fast" with the scientific method, for what appears to reasons of drawing attention to yourself, it looks less like science and more like self absorbed.

This always makes for interesting dialogue.

In closing, SPECT scans are clearly designed for research.

One of the most well respected researchers in this area is Jay Giedd, MD.

He's done fascinating work on the Adolescent Brain, as well as some earlier ADHD work.

Please check him out when you can.


tc

mctavish23

(Robert)

I agree with your analysis of Dr. Amen's work. It is very interesting and thought provoking but many of his conclusions are based on his theory and not on scientific facts. There is definitely a place for the SPECT imaging but it has not reached the point of being a diagnostic tool for ADHD. And considering the tremendous cost of the scans for "unproven" methods, I think we have more effective tools for a lot less money. Perhaps one day we will have learned enough about how the brain works to be able to use the scans in a more productive way, but more research needs to be done.

I do have his book on the six types of ADHD and two of his other books and he does have some good points but not everything he says is valid or proven. It also appears to me that some of his types resemble ADHD with a comorbid disorder. Limbic ADHD resembling the additional diagnosis of depression, Overfocused ADHD may include OCD or GAD, the "Ring of Fire" sounds a lot like a description of bipolar disorder, and lastly, the temporal lobe type is a perfect description of my husband, who in addition to the combined type of ADHD, has a diagnosis of Borderline Personality Disorder, although he would be considered the "high-functioning" type who acts out (extreme anger fits) rather than self-injures.

I agree with your analysis of Dr. Amen's work. It is very interesting and thought provoking but many of his conclusions are based on his theory and not on scientific facts. There is definitely a place for the SPECT imaging but it has not reached the point of being a diagnostic tool for ADHD. And considering the tremendous cost of the scans for "unproven" methods, I think we have more effective tools for a lot less money. Perhaps one day we will have learned enough about how the brain works to be able to use the scans in a more productive way, but more research needs to be done.

I do have his book on the six types of ADHD and two of his other books and he does have some good points but not everything he says is valid or proven. It also appears to me that some of his types resemble ADHD with a comorbid disorder. Limbic ADHD resembling the additional diagnosis of depression, Overfocused ADHD may include OCD or GAD, the "Ring of Fire" sounds a lot like a description of bipolar disorder, and lastly, the temporal lobe type is a perfect description of my husband, who in addition to the combined type of ADHD, has a diagnosis of Borderline Personality Disorder, although he would be considered the "high-functioning" type who acts out (extreme anger fits) rather than self-injures.


To a certain extent that is true- but I have that most "co-morbidities" may acutually be complictions of untreated ADHD, and the struggle of the untreated mind to fit in to a world in which it is subtly disadvantaged. Intersestingly I am reading Brown's book-( ADD the Unfocused Mind in Adults and Children) and I find analogies to Amen's system in the 6 groups of symptoms that Brown discusses.