A recent story in the Washington Post about the infamous psychiatrist Daniel Amen reminded me why psychiatrists are poorly respected and have such a bad reputation. I am too young to remember lobotomies, or treatments for “hysteria”, but I have read about them. I also had a distant cousin who spent many years in an asylum for “retardation” when, it turned out, she was merely deaf. In recent years, as even the Post article pointed out, we have learned that a many studies of antidepressants were unpublished–specifically those that showed little benefit to of their use.
Despite knowing psychiatry’s sordid history, I have been offended at the many different ways my work has been scrutinized. I resent the insurance companies force me to seek permission to prescribe certain medications from pencil pushers without any medical degree who ask me “And, will the patient be medically monitored while taking this medicaiton?” [Isn't that a part of the practice of medicine?]
The profiteering and opportunism I believe Dr. Amen has engaged in are specific examples of why our field is so heavily distrusted –and why psychiatrists face so many barriers when trying to practice medicine with honesty and integrity.
I recall a number of years ago when a family of above average (but still middle class) means came to me for the first time. They presented to me a piece of paper from one of Dr. Amen’s clinics, where this child was diagnosed with “ADHD”. That’s fine. I do believe that ADHD exists. And that it usually responds well and robustly to appropriate treatment. HOWEVER, this paper also indicated that this child had a “variant” of ADHD that should NEVER be treated with stimulants, and advised that he be treated only with an SSRI (Selective Serotonin Reuptake Inhibitors are often used to treat depression and anxiety.) This was shocking and preposterous! Nowhere in any literature search in any peer reviewed journal could I find ANY information to support this claim. I worked hard to talk with the family about what exists in the literature about treatment of ADHD, how to treat it, and with what, and about how ADHD is diagnosed. I found myself in the uncomfortable situation of having to prescribe what Dr. Amen advised, or to be cast off as the child’s clinician.
Since then I have seen a handful of other youth with similar reports, whose parents have presented with similar instructions as to how their children should be treated for ADHD. These SPECT SCAN reports have cost families upwards of $3500 apiece, and have no scientific basis except the collections of scans that Dr. Amen himself has, but that have not been introduced to the scientific community for review or assessment. At that price, I could complete a tremendous number of very short medication trials of virtually every agent utilized to treat ADHD, and determine the best agent before even reaching that dollar value.
The Post Article indicates that Dr. Amen has an excellent bed side manner and presence. And that is important. It improves the likelihood that patients and their families will adhere to treatment recommendations, and it increases the likelihood, therefore of a success. But that same great presence and bed side manner can also be used to unduly influence patients and families to embark upon inappropriate treatments–and there are many examples of this: chelation therapy that is actually dangerous and without any positive evidence base, secretin therapy which was expensive and proven to be ineffective, homeopathic treatments which have repeatedly been debunked, and–once again going back to what should be the “dark ages” of psychiatry, “ice baths” to treat psychosis.
Even without intending to, we can become so convinced that something is effective for patients that we lose sight of what scientific evidence tells us. This is why it is important for physicians to continue to attend conferences, to consult with colleagues, and to submit their “data” to the scrutiny of the scientific community. Many people do not know this, but the psychiatrist, Walter Freeman, who performed many of the early lobotomies in the United States was so convinced of the effectiveness of his intervention, that he worked very hard to provide the procedure at minimal cost–simplifying it to an office procedure so that patients who would not otherwise be able to afford it could benefit. In contrast to what appears to be the case with Dr. Amen, who will serve only those capable of paying his exorbitant fees, Dr. Freeman was working hard to be mindful of the needs of even the most displaced and poor patients!
It is shocking to me, that in this era of increased awareness of the undue influence of drug company lunches and dinners on physician prescribing, that Dr. Amen’s multimillion dollar business has not been examined at all by any regulatory authorities. Certainly, even a well-meaning physician can become convinced that something so financially successful–due to patient/family “satisfaction” that his treatments are effective–even when they are not.
Unlike many physicians who are presented with documentation from Dr. Amen’s clinic, I have a fairly significant amount of experience with SPECT scans. They were used at a VA Hospital where I was a student, in an effort to research the progression of Hutington’s Disease in the brains of affected persons. SPECT scanning is complicated, and the subjects must be prepped in a dark room, lying still, and devoid of stimulus, because otherwise, the results are terribly inaccurate. During a SPECT scan, a patient is given an IV that contains certain binding agents that enter the brain and bind areas of high activity. The problem is, that if anything happens while a person is lying in the dark, waiting for the agents to bind, the study can be very misrepresentative about what is going on. Thus, it is impossible for me to fathom that SPECT scans have any capacity to be specific enough to provide useful information about SUBTYPES of ADHD. As the Post article pointed out, SPECT’s limitations have resulted in a number of other types of imaging studies being used more often–particularly PET Scans as they have become more readily accessible and as the technology has become more affordable.
Overall, I think the most important take home messages here are, that:
- Patients and parents of patients who struggle with dysfunction from emotional and behavioral disturbances can often be very very desperate. We often have few answers. We often can ameliorate but not cure symptoms. It is important that we be mindful of the vulnerability of the families that we work with.
- It is important to help maintain hope, but not to promise miracles.
- It is important to remain aware of current evidence-based practices. Physicians must maintain an awareness of the current scientific evidence, must consult with colleagues, and must submit their “data” to the scrutiny of the scientific community–which the Post article points out that Dr. Amen has not done.
- It is important for practicing psychiatrists to be have a current understanding of neurobiology and to relate this to clinical presentations and behaviors–so that people like Dr. Amen cannot go on saying that the rest of us do NOT understand the brain.
- It is our obligation to help families have as much data as they can to be able to make informed decisions.
- It is also our obligation to help them know when, perhaps, their vulnerability is being taken advantage of.
- It is REASONABLE to discuss with families interventions that have less evidence, or that are fringe or alternative. When doing so, we MUST help them weigh the risks and benefits, and help them consider a cost-benefit analysis: Is the cost of the treatment that is unlikely to produce harm with the dollars of investment? Or is the family better off to utilize those funds in other ways?