- To Change Your Mind - Details Matter
Amen, Carlat, SPECT and Psych Evidence for ADD/ADHD: Don’t look, don’t tell?
Carlat and Amen: Naysayers and the SPECT process have some fallout
May 22, 2008ADD/ADHD: Real People Discuss Real Improvement
May 27, 2008Carlat Derides SPECT – Is He Just Trying To Be Cool?
Carlat Stays Firmly in The Box
We shouldn't use SPECT tools that we know work to help discover the many missed diagnoses often found under the large umbrella of ADD/ADHD? This question regarding the use of SPECT is more than it's use as simple, high-end-price-point-tool for ADD diagnosis.
These comments, taken from a previous CorePsych Blog post highlight changes present in psychiatry today… challenges for how we begin to rethink matters.
As we review the issues with Carlat and Amen the broader issue of *what evidence counts* arises for all of us, from the editors of Wired magazine, to the man on the street, – boxed in by all this limited thinking.
The Debate Links:
The article by Dr Carlat in Wired, and comments following.
– The blog post in The Carlat Psychiatry Blog with interesting comments.
– The blog post by Dr Amen in Dr Amen's Brain Blog with more comments
– My previous post on this debate at CorePsych Blog with further comments
The comments:
Carlat is remarkably obvious in his hysterical hyperbole… and I couldn't agree more that his position with Wired raises the question of Wired's questionable editorial objectives. His unscientific, slanted views just don't match with Wired's sharp and clear edge on edge matters.
I personally love Wired's work elsewhere, and having a shrink on Wired's staff with good credentials [“writes a pharma Report”] – makes editorial good sense on the front end. Indeed we should be talking about all of this psych stuff with more transparently. But…
Carlat is an example of several problems currently facing psychiatry nationally: The larger question is…
– do we simply wait for the approval of stats from some external group?
– do we continue to ignore what works in the office because people like Carlat don't get it?
– do we accept information already approved by the FDA, but not appreciated as the standard of care by the academic community?
– do we presume *the edge* is only present in highly controlled numbers which take out any commonly seen complex variables?
– do we expect the *only answers* are somewhere buried in the psychoeconomics of pharmaceutical companies and connections with academia?
– do we hope to find real truth in minimalist stats: small n numbers of 200-300, and meta-analytic reviews that take the numbers up to 5000 [but cut our all the variables we see in the office everyday] when thousands go unheard?
– do we know who actually sets the *standard of care* – and in the meantime accept *less than standard of care* work as standard?
– do we sit on our hands and ignore everything else going on with brain science, until someone in academia is paid for the research to anoint the numbers – when the research has been on the books for more than 20 years [SPECT]?
or….
– do we stride forward, searching for new evidence that might help those who aren't helped by the “standard of care?”
– do we ask the basic, more challenging question, of our colleagues who have some experience with new data – for example: “Can you teach me how to understand that new neuroscience for my office work?”
– do we take a hard look at these “anecdotal” laboratory findings from
functional imaging to findings in molecular and cellular brain physiology that effect thousands of people every day?
– do we actually start to examine the complexity of the drugs, and their metabolism [a remarkably hot topic, addressed many times here at CorePsych Blog] in relation to the many somatic variables and immune challenges that effect somatic/brain function?
With new laboratory and medical measurement tools we are rapidly, even in just the last 5 years, finding many new answers that are surprisingly transferable to everyday office practice – Just because you don't understand it doesn't make it snake oil – however, it does makes practice a bit more difficult in the short run.
-And these remarks do shift the responsibility for teaching SPECT tools to those who have the SPECT experience. Professionals do have to know more to move ahead…
And we must consider these other revealing real numbers:
– the smiling faces of patients who do improve following new biologically based evidence
– the satisfaction of knowing you got it right after years of difficulties when others didn't, long after all
the previous timid placebo hopes have been repeatedly dashed, and everyone is running on cold, frozen reality, with no hint of hope fueling the tank. Those real numbers of patient improvement provide true satisfaction – for both the practitioner and the patient.
The abundant other numbers from peer reviewed research are not invalid – this note is not a condemnation of science, as some have indicated in reductionistic straw man representations. Actually I am so conservative regarding the need for the regular use of brain and biologic evidence, that I appear, oddly enough, surprisingly liberal!
I'm standing with Amen on this one – been there done that. Carlat, my friend, you don't know what your are talking about.
cp
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6 Comments
[…] at human brains through functional SPECT brain images starting in 2003 – 10 years ago – with Dr Amen in DC. Many of those patients looked like TBI – brain injury – but never experienced brain […]
[…] at human brains through functional SPECT brain images starting in 2003 – 10 years ago – with Dr Amen in DC. Many of those patients looked like TBI – brain injury – but never experienced brain […]
Tom,
Great hearing from you and thanks for weighing in on this tough subject!
Yes, I do think that Carlat is a good guy, a bright guy, and right on track with challenging some of the marshmallows being thrown around by big pharma as truth.
As a speaker for just a few pharma companies, I do see sales pressures arise at times, but don’t for a minute feel guilty about teaching my fellow docs about the best practices with psych meds, even if the dinner was paid for by pharma.
I think docs are smarter than that, and the docs I see at the hundreds of meetings I have presented leave no stone of inquiry unturned. And, for me to do it, I always turn a few potential negatives over myself.
I personally have a very high suspicion index for anything stated categorically, either positive or negative [thus applied the heat to Carlat].
My several favorite books that address these issues are here:
http://astore.amazon.com/cpbks-20/104-4113148-0403906?%5Fencoding=UTF8&node=15
And Tom – do stay tuned as I will be offering specific webinar training this fall on the use of SPECT in office practice… details from the inside, including the most overlooked point: How to use them.
Thanks for your note!
Hope all is well,
Chuck
thanks for pointing out the Wired article , Chuck. The sad thing about it is that Dr. Carlat is actually also a very good psychiatrist as well. He publishes a useful newsletter and has published an honest apology for being used by big pharma to deliver canned talks on their behalf which he now regrets. i’d be curious from an analytic perspective as to how he came to some of his own “scientific ” conclusions about Amen’s work. Remember Heisenberg’s uncertainty principle- the observer affects that which is observed. It would be instructive for Dr. Carlat to divulge his own biases- cos they aint all scientifically based.
Sarah,
Yes, you do make the point “a bit” more emphatically! Thanks for your kind remarks-
The biggest problem for all of us with SPECT imaging is the process of trying to explain *SPECT/PET imaging results, functional results,* in the context of *DSM-4 superficial, descriptive, non-functional diagnostic slices.*
That conundrum results in apples and oranges arguments every time… and the naysayers keep pointing out problems from SPECT diagnostic assessments that only partially correlate clinically.
To wit –
Said another way, and this happens all the time: A limbic hot spot often doesn’t correlate with “depression,” because raters are still looking, if you can believe this, only for *affective* depression, and have almost no appreciation, for *cognitive* depression. So scans don’t work…?
Yes, Dorothy, this is no longer Kansas, those aren’t cows over there. Depression is more than simple affect.
But, then, perhaps some don’t count cognition.
Thanks again, – love your style!
-Readers should get over to your blog and sign up right away – Sarah minces no words:
http://thesexaddictedbrain.com/
Chuck
Hats off to you Chuck! The debate, if I can take the liberty for a nanosecond of actually raising it to that level of discourse, between Carlat, Amen, and the scientific community at large, seems to be less that of the scientific merit of SPECT scanning for psychiatric diagnosis then it is one of separating the message from the messenger. We have a rather peculiar habit, us humans, and in light of our otherwise stellar feats of logic and reason, of shoving large square objects into teeny weeny round holes and then with hubris in hand, roaring at amazement as to why they don’t fit. I don’t get it – will someone please beam me back home. I for one, said with considerable restraint, do not think that Dr. Amen is a particularly able candidate – as self-proclaimed as he may be, concerning something as serious as the diagnostic utility of SPECT scan analysis which holds such promise and possibility for ALL of us. He has become our SPECT scan guru and herein lies the proverbial rub – I have significant trouble taking him seriously (read: scientifically) and certainly as the spear head for something as incredibly important as say, the new wave of psychiatric diagnosis. I am grateful to Chuck Parker for presenting this troubling issue, front and center, as it so deserves. Smacks of the Bush-Stem Cell “debate”, but let’s not digress… The second order of business must be to restore the sanctity of the science behind SPECT scan analysis, which in my occasionally humble opinion speaks for itself, by taking it out of the hands of those that exploit the science behind it which said another way, is to give it scientific merit sans the commercialism that smacks of astrology. The first order of business is keeping the issue front and center where more reasonable minds can prevail – like yours…