Brain scans, the new snake oil

A reaction to an OpEd piece from the LA times

In an Op-Ed piece in the Dec. 5 L.A. Times, self-proclaimed "neuropsychiatrist and brain-imaging expert" Daniel G. Amen attempts to convince us that "three of the last four presidents have shown clear brain pathology." Starting with Ronald Reagan's Alzheimer's disease, which was never in dispute, he proceeds to Bill Clinton's moral lapses as indicating "problems in the prefrontal cortex" and Bush's emotional rigidity as a symptom of temporal lobe pathology.

Even the non-medical reader will have a sense of sweeping generalization in these pronouncements. If every moral lapse indicated "problems in the prefrontal cortex," most of mankind could be said to have disordered frontal lobes. And, if all the emotionally rigid people in this world were tallied, a large proportion of mankind would have disordered temporal lobes. Disconnects in Amen's logic include: first, there is no agreed-upon standard for evaluating moral lapses and emotional rigidity; second, brain imaging cannot detect attributes of individual personality; and third, there is no direct correspondence between obvious frontal or temporal lobe brain disease, including Alzheimer's, and the behavior Amen would attribute to these brain areas.

On his website, Amen lists "14 reasons to get your brain scanned at Amen clinics." One particularly outrageous claim is, "Even if you are not having trouble, SPECT scans can help check the health of your individual brain." Implicit in this claim is that Single Photon Emission Computed Tomography, which requires an intravenous injection of radioactive material and very expensive imaging equipment (and therefore high cost to the patient), will be correct every time. Nothing could be further from the truth.

This kind of hucksterism is not new to psychiatry. In 1964, psychiatrists responding to a poll attempted to "diagnose" presidential candidate Barry Goldwater by his political pronouncements as clinically paranoid. Charles Krauthammer, a psychiatrist himself, rightfully characterized this as a "shameful ... misuse of medical authority." Because of this episode, the American Psychiatric Assn. developed an ethical principle, the "Goldwater rule," which states that, "On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination [emphasis added] and has been granted proper authorization for such a statement." Clearly, violations of this ethical principle continue.

There are further instances. The medical profession, psychiatrists included, is coming under increasing scrutiny for excessive promotion of new drugs and medical devices. For example, in an August 2002 Stanford University news release, Dr. Alan Schatzberg, chair of Stanford's Psychiatry Department, stated that treatment of psychotically depressed patients with the abortion drug, RU-486, "may be the equivalent of shock treatments in a pill.…" Given that electroconvulsive therapy is the most effective treatment for such patients, this was a hugely exaggerated claim, particularly because there was no significant evidence for effectiveness of the drug at that time. (Indeed, later FDA-monitored clinical trials also have been uniformly negative.) The possible commercial connection? Schatzberg is a co-founder and major shareholder of the company established to market RU-486 as a treatment for psychotic depression, and in 2002 the company was preparing for an initial public stock offering.

A very recent example is the Nov. 11 New York Times Op-Ed, "This Is Your Brain on Politics," written by seven research scientists, including three from FKF Applied Research (on its website, the company calls itself "The Leader in NeuroMarketing"). The article describes the functional MRI brain scans of swing voters who were shown political pictures while in the scanner. Based on which areas of the brain were activated by particular pictures, the authors offered conclusions such as "Hillary Clinton and Rudy Giuliani are on opposite sides of the gender divide," "Mitt Romney shows potential," "Fred Thompson ... evokes more empathy (than Rudy Giuliani)" and "John Edwards has promise — and a problem." One presumes this is saleable information to political campaigns. In swift reaction, a Nov. 22 editorial in the scientific journal Nature harshly criticized this "questionable scientific research," calling it "a great disservice to science" and "a great deal for the company."

So, what to make of all this? The adage, caveat lector et emptor, applies well here — let the reader and buyer beware. Ask trusted professionals for their perspective and advice. Hype, if not outright hucksterism, unfortunately is all too frequent in medicine, whether it is the latest expensive drug, or technology such as brain scanning. But, considering the snake oil of old, hasn't it always been so?

Robert T. Rubin, a board-certified psychiatrist, is professor and vice chair of the Department of Psychiatry and Biobehavioral Sciences at the David Geffen School of Medicine at UCLA, and chief of psychiatry and mental health at the VA Greater Los Angeles Healthcare System.