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Carlat and Amen: Naysayers and the SPECT process have some fallout
Aphthous Ulcers/Canker Sores, Gluten Sensitivity and Unmanageable Behavior
May 12, 2008Amen, Carlat, SPECT and Psych Evidence for ADD/ADHD: Don’t look, don’t tell?
May 25, 2008SPECT in the news: Naysayers huddle together and build a straw man – so let's see what you think about terms like "mind reader" and "hype."
And do take a look at Carlat's brain [from his blog] and draw your own conclusions:
Then several other functional brain study modalities [e.g. qEEG] are all lumped in with a hyperbolic flourish with Amen and SPECT. Is Carlat saying that no functional neuroimaging works when the literature is filled with peer reviewed SPECT and PET reports, and much excellent progress with qEEG?
Come on…
Dr Daniel Carlat, author of The Carlat Report, recently visited Amen's office in Newport Beach to write a piece for Wired on SPECT brain scans and neuroimaging.
Carlat and Amen portray the meeting in different ways in their respective blogs. Take a look for yourself at Amen's blog account of the meeting, and then this blog piece by Carlat.
I am sending the links here for you to see, and to take a look at a comment I left over there as well, siding, for the most part, with Amen.
It is interesting to see how the naysayers grumble about statistics, including Rubin from UCLA, but have no clinical experience with *actually using the scans,* or even *learning how to use scans* clinically. It doesn't matter what your academic position is – if you don't know how to use the information, how to assess the findings, then why comment?
Carlat's Wired piece sounds a bit like People Magazine. Gossip, banter, – he said, she said – incredible.
Amen's response in his blog to this silly *statistical banter* [reported by Carlat in his blog] is perfect: We [Amen, Parker, and others who actually do this work] treat one person at a time. The complexity of the brain, the nuances of the brain function material, and evidence from the history and clinical exam… you just can't cookie cut it, and break out one piece, one comment.
Then dig into more of Carlat in his blog: his whole message, his appearance at the APA in DC – much massive hype and over the top showmanship. He could be the poster boy for public gossip about psych meds – implying that all docs are brain dead, just going for pens and trinkets. Glad we have some smart people like him to tell us what to do.
Yes, the public may think that docs are drooling over pens, but having myself "detailed" in offices for pharmaceutical companies for >12 years, I can tell you with considerable certainty from real experience, the medical population needs and wants more information. They are not stupid. All of this discussion about the validity of SPECT is a debate about more information – and the validity of that new information.
-And he and Rubin use old models: DSM-IV – "Depression" – phenotypic diagnosis to evaluate functional models. Apples and oranges… Phenotype is connected to endophenotype, but let's differentiate what we're talking about – they are not the same thing guys. Appearances often don't directly connect with brain function – that's the point!
Looks like he wants to be the "objective" gate keeper. Keep to your own limited gates, Dr Carlat, I won't be visiting your emotionally laden confusion.
Readers: Please review these matters in the discussion – see what you think about this "dialog" [read "copy" or "personal PR"] and drop a comment here so we can get on this subject!
7 Comments
I’m 65 years old and have struggled for years with what I had thought and been told was “classic” ADHD. Took Ritalin for a short time and hated it. Saw Dr.Daniel Hoffman here in Denver. Had a qEEG. From those findings, don’t have ADHD or at least not the kind that responds to stimulant drugs. Am on Neurontin now and it’s a whole new life! Brain imaging–whether spect, fMRI, or qEEG is the only way to go! For shame on Dr. Carlat.
MaryJo,
The swing is slowly happening to more evidence based assessments – the old days of superficial diagnosis with ADHD are fading fast. Think about this appalling idea : how many individuals are being treated in the world for the cloud of symptoms call hyperactive, how many for inattentive, and how many are specifying dosage based upon metabolism vs weight?
High time to get more into evidence – and after SPECT the next frontier is molecular and cellular physiology, much of which is downstream from immune dysfunction and nutritional deficits.
Stay tuned here for a free white paper soon to be out on this very subject – it’s an outline for my new book which will cover these issues in greater detail,
tnx
cp
MaryJo-
Sorry to be so late getting back, out of the office and am now picking up on some of these comments,
I know Dr Hoffman in Denver, and he is simply an outstanding doc, and has a very interesting way of assessing complicated cases from a brain function point of view.
Yeah, Carlat – poor guy is stuck in the dark ages, and disrespectful at that. Being stuck is one thing, being bombastic and excessive with no experience is quite another. He rails against innovation of any kind, except his esteemed pharmacologic insights – too bad he can’t listen to evidence – it might help him out.
I do think he is well motivated, just short on information and clubby with the purported experts. Interesting how he rants about pharmaceutical companies distorting the logical thinking of us drooling incompetent docs who need pens in the office – so we automatically listen to the reps without thinking… and he does the same on his side, listens to his buddies in academia who sing the same tune, without thinking.
Please give my regards to Dr Hoffman, he is a great resource, and I hope to interview him on my new radio show – will be sending out a blog this weekend on all those doings,
tnx
cp
Gina,
Good question on the gold standard, and please permit me to answer it from another perspective:
To wit – the *gold standard* for the diagnosis of celiac:
“A small intestinal biopsy showing the typical celiac enteropathy is still considered the gold standard for proper diagnosis of celiac disease. However, several studies presented during DDW 2007 suggested that the histologic findings may not be the gold standard after all. A report from Argentina showed a high degree of discrepancy among experienced and nonexperienced celiac disease pathologists in interpreting the histologic damage.[11] Additionally, it was reported that the small intestinal recovery following a gluten-free diet and the resolution of symptoms is often incomplete,[12] making a follow-up biopsy potentially useless for monitoring diet compliance.”
All this is from this celiac discussion:
http://www.medscape.com/viewarticle/556299
Specialists know that even the *celiac gold standard* is at this moment undergoing revision because our technology is improving so quickly the real targets to identify the problems are changing.
This is the same situation with SPECT: My opinion here… some want the results to be 100% – reductionistically conclusive – but the real problem as I see it is an apples and oranges: Brain function does not typically apply to DSM4 diagnoses…
DSM4 diagnoses are simply too superficial to cover all the variables, and therefore will always only partially represent an aspect of the problem, not the whole brain problem.
Having said that – many using SPECT everyday do see very predictable patterns – and these patterns are decidedly present in the literature — e.g. the SPECT ADD findings with PFC hypoperfusion – as noted here:
*Gold standards* will continue to change as measuring devices continue to add more comprehensive information. With more information we simply have to deal with the complexity of all diagnosis, and can no longer find relief in simplistic labels.
Tnx
cp
Dr. Parker wrote:
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]
—-
Dr. Parker,
Sorry if I’ve missed your response on this issue, but what exactly would it take to conduct the “gold standard” study (double-blind, controlled) on SPECTS–and is it even feasible or practical?
Thanks,
Gina
Gina,
Many thanks for your thoughtful perspective – from a writer and ADD expert with her own accomplished editorial perspective:
http://ginapera.com/portfolio.html
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 editorial objectives. His unscientific, slanted views just don’t match with Wired’s sharp and clear edge on edge.
I personally love Wired’s work elsewhere, and having a shrink 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 the FDA
– do we accept information already approved by the FDA, but not appreciated as the standard of care
– 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?”
– 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 CorePsychBlog] 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 – it just makes practice a bit more difficult in the short run.
We professionals do have to know more to move ahead, but the real numbers are with the smiling faces of patients who do improve – the satisfaction of knowing you got it 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.
That is true satisfaction.
Thanks G,
cp
Thank you, Dr. Parker and Dr. Amen.
I know both of you to be fine physicians who care deeply about patient welfare.
As a volunteer in the mental-health community for many years, I’ve learned how to quickly spot the charlatans from the learned and compassionate professionals. So, for me, it is so easy to spot Carlat as a grandstanding egotist who cares more about building personal notereity than helping others to live happier, more fulfilled lives. Unfortunately, it’s not so easy for others to spot this.
This is where Wired has fallen down on its editorial duty, to vet the experts it showcases. Maybe Wired itself is just going for the stimulation, the shock value, and not the facts.
As for Dr. Amen, he is one of my personal heroes. Living in the Bay Area and knowing many people that he helped–after other psychiatrists had failed them miserably or even worsened their conditions–there is no doubt in my mind that he and his methods are light years ahead of most practitioners.
This whole ruckus reminds me of that film “Longitude,” wherein the 18th Century British Parliament established a prize for a way to establish longitude at sea.
Carpenter John Harrison came up with such a device, but it did not fit the Longitude Board’s biases. For 30 years, Harrison persevered, but meanwhile devastating shipwrecks continued. And all because this blind board could not accept a new paradigm.
“Shipwrecks” happen in human lives, too, when clinicians and pundits are more interested in outdated paradigms than in personal welfare–and especially when they shout their ignorance from the rooftops to an uninformed public. Grandstanders like Carlat are simply more heat than light.
Thank you, Dr. Parker, for shining clear light.
Gina Pera