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San Jose Mercury-News, 5/4/04 UNTESTED TOOL BELONGS IN LAB ONLY, EXPERTS SAY Some question value of brain scans by Lisa M. Krieger "Brain scans'' are being marketed in San Jose and a growing number of other US cities, worrying doctors who say that the test is unproven and does not belong in a place as private as the human mind. The brain-imaging tool called SPECT (single photon emission computed tomography), whose use has long been confined to research studies, is beginning to be used by some doctors as a way to help diagnose patients with conditions ranging from anxiety to schizophrenia. Dr. William Klindt uses Technicolor snapshots of scans of brain activity to illustrate the dangers of alcohol or drug abuse in presentations to students at Los Gatos High School, Lynbrook High School in San Jose and other local schools. A healthy brain glows bright red in the scans, while the brain of a user is a blotchy green and blue, he said. "You can see what is going on in the brain,'' said psychiatrist Klindt, who runs Silicon Valley Brain SPECT Imaging in San Jose and has performed more than 1,000 scans on local residents. "It takes it out of the abstract and makes it real.'' Unconventional as that view may be, Klindt is not alone in his beliefs. He is a member of a small but vocal group of iconoclasts across the country. These doctors, along with their patients and their families, praise the tool. Unlike other magnetic resonance imaging (MRI) scans or X-rays, SPECT gives a picture of organ function, not strictly anatomy. It does this by measuring blood flow patterns, which these doctors believe is a measure of mental health or illness. They say that they do not rely on SPECT alone for a diagnosis. Other factors are also taken into consideration, they said, such as a patient's clinical history, a personal interview and other tests. Diagnostic danger But many doctors warn about using the SPECT imaging as a diagnostic tool, saying it is unethical -- and potentially dangerous -- for doctors to use SPECT to identify emotional, behavioral and psychiatric problems in a patient. The $2,500 evaluation offers no useful or accurate information, they say. An incorrect psychiatric disorder could be fatal, they say. They worry about its routine use in youngsters, whose parents seek an explanation for normal things that go wrong, such as absent-mindedness, unfinished projects or moody outbursts. Healthy children could be inaccurately labeled as emotionally or mentally disabled, they fear. "There is no scientific basis for these claims,'' said M. Douglas Mar, a San Jose psychiatrist who is working to stop the practice. "At a minimum, patients should be told that SPECT is highly controversial.'' Bioethicists fear that exaggerated claims about the tool will lead to its use by unskilled people in places like courtrooms, airports, schools and corporations. Someday, they fear, it will be used to screen job applicants, select jurors or determine who qualifies for disability benefits. "We're not talking about a tumor in a bone. The brain is where information resides about ourselves, our individuality,'' said Judy Illes of the Stanford Center for Biomedical Ethics. The scanning industry flourishes because the shifting, shadowy world of the human mind is so tough to decipher, doctors say. Most psychiatrists must rely on intuition, based on years of experience with symptoms and patient histories, to diagnose what is wrong. "But patients get frustrated. They look for certainty,'' said Dr. Mark Graff of the California Psychiatric Association. "They want short, simple, unequivocal answers.'' Practitioners of SPECT diagnostic imaging say psychiatry is long overdue for a change. One of its biggest proponents is Dr. Daniel Amen, who has done more than 20,000 scans in the past 13 years at two California clinics and promotes his practice in lectures across the United States. "Psychiatrists are the only medical specialists who don't look at the organ they treat,'' Amen said. "That's because, for the average psychiatrist, it's not part of their education, their training or their experience. "If you have a chest pain, a cardiologist looks at the function of your heart. If you have a back pain, orthopedists look at your back. Why aren't we looking at the brain, if we have the tools available to do it?'' Amen said. There is widespread agreement that refinements in imaging technologies such as SPECT are allowing new measurement of brain function. At Stanford University, for instance, scientists are scanning the brain not just for defects and injury but patterns of thought, emotion and learning. Cautious use Experts in psychiatry and radiology say the tool is most appropriate when used in research, where analysis of large patient populations has found, on average, a difference in patterns of brain activity between sick and healthy people -- and where interpretations are cautious and nuanced. They say that nothing has been published in reputable peer-reviewed journals that suggests a role for SPECT in the diagnosis of behavioral, psychiatric or learning problems. Conclusions from research studies cannot be applied to a lone individual who arrives at a doctor's office seeking help, said Dr. Michael D. Devous of the Nuclear Medicine Center at the University of Texas Southwestern Medical Center, an expert in the field. "At this moment in time, SPECT scans are not useful for routine clinical management of cases -- to identify a specific abnormality that is subtle, in a single subject,'' he said. This is because large studies show that brain-flow patterns of many troubled people fall within the range of what's normal -- and many healthy people fall within the range of what might be considered troublesome. An accurate diagnosis based on a scan is simply not possible, he said. "I wish it were.'' The Society of Nuclear Medicine accepts only four reasons to do brain SPECT imaging: the evaluation of suspected brain trauma, suspected dementia or cerebral vascular disease and the pre-surgical identification of epileptic-prone regions. But Klindt, Amen and others claim to use the test to identify mood disorders, anxiety disorders, substance abuse disorders, autism, psychotic disorders, attention deficit disorder, behavioral disorders and certain learning disabilities. They also use it to measure what they called "ongoing trauma'' in hockey players, boxers, NASCAR drivers and other professional athletes. It also measures whether a medicine works, they say -- for instance, whether depression is increasing or decreasing as a result of treatment. "I don't mean to say that we use brain imaging to make a definitive diagnosis,'' Klindt said. "What it does is give us crucial physiological information about the underlying function of the brain -- and when taken along with other lab tests, symptoms and exams, can guide us toward a diagnosis in a more medically informed way.'' SPECT was life-saving, said an Alamo patient named Stephanie, who asked that her last name not be used. "I went to Dr. Amen's clinic because I was having difficulty concentrating, as well as memory problems and focusing problems. He did SPECT imaging for me,'' she said. It led to further testing by her usual doctor, and the eventual detection of a benign tumor the size of a lemon, called meningioma. Since surgery, her symptoms have improved. Mainstream help Critics say patients or their parents, lured by the promise and apparent precision of the tests, fail to seek more mainstream evaluations. In addition to wasted time and money, patients are needlessly exposed to radioactive agents, they say. "Patients are diverted from mainstream medical practice. They come in, clutching their results, invested in this whole other belief system,'' Graff said. A misdiagnosed psychiatric patient, wrongly treated, is in danger, Mar said. "A patient could kill themselves, or others.'' "The history of medicine is littered with lovely procedures that end up not working at all,'' Graff said. "We wish there was a test that is so easy and definitive,'' he said. "But first we want independent confirmation that it works.'' Contact Lisa M. Krieger at lkrieger@mercurynews.com or (408) 920-5565 Copyright 2003 Knight Ridder ---------------------------------- USING SPECT IMAGING The Society of Nuclear Medicine accepts only four reasons to do brain SPECT imaging: -- Evaluation of suspected brain trauma -- Suspected dementia -- Cerebral vascular disease -- Pre-surgical identification of epileptic-prone regions But some doctors use the test to help diagnose: -- Mood disorders -- Anxiety disorders -- Substance abuse disorders -- Autism -- Psychotic disorders -- Attention deficit disorder -- Behavioral disorders -- Ongoing trauma due to sports -- Certain learning disabilities ----------------------------------------------------------------------------------------- San Jose Mercury-News, 5/15/04 DOCTOR CLARIFIES COMMENTS ON BRAIN-IMAGING TOOL I am not "working to stop the practice'' of SPECT, or single photon emission computed tomography (Page 1E, May 4). This is the purview of appropriate regulatory agencies. However, it is the responsibility of physicians to raise patient and public awareness regarding unnecessarily costly, misleading or potentially detrimental procedures. My statement that "there is no scientific basis for these claims'' is based on communications from respected authorities at Harvard University, the National Institutes of Mental Health, Stanford University, University of California-San Diego, University of California-San Francisco, University of California-Davis and others. Their unanimous input: SPECT imaging is currently a research tool without clinical utility in the evaluation and treatment of behavioral and psychiatric conditions (except as indicated in your article). As to my statement that "a patient could kill themselves, or others'': I have treated hundreds of bipolar patients, many previously misdiagnosed as Attention Deficit Hyperactivity Disorder or depression. A number reported being ADHD based on SPECT scans. Misdiagnosed bipolar patients treated with medications for depression and ADHD can have their condition deteriorate into life-threatening depression or mania. M. Douglas Mar, MD San Jose

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