Content uploaded by Daniel G. Amen
Author content
All content in this area was uploaded by Daniel G. Amen on Jun 25, 2014
Content may be subject to copyright.
FORMAL RESPONSE TO:
January 2005 American Psychiatric Association Council on Children, Adolescents and
Their Families Resource Document
“Brain Imaging and Child and Adolescent Psychiatry with Special Emphasis on SPECT”
PREPARED BY:
Daniel G. Amen, MD, John Holttum, MD, Arthur Prezbinda, MD, and Chris Hanks, PhD
WITH SUPPORT FROM THE FOLLOWING
PSYCHIATRISTS AND NEUROSCIENTISTS
!"#!
$%&!'(%))!
*($+! &$)
"#!!',')$
+ %,)$,
% !*##$%)*$
-.!.$%).*'!,."
$,*!$+ %$ ,!/
!'$'
, ,&&%"&'%
!"%"."&
"*!-$&*'
.##"
Summary
'#)#$
$#$$-$#)'
)#),
$" (--'0
$)1# $
2#)'###$
'#" (-#)$$)
$$/-3"'$4
$$'
$'$'$#)$
" (-$$$$,"
'$)'%)#$#
)''$,$#$
'$$)$$5$
6
'7889$ '
-+$$:$
''"($" (-;)'+'-$
))$# $$))#
4<<'<'=<=<<<" (-#
-#+')'##$
6>'#0#)" (-$'
-)'$'#''
)) #'
)))#'$
$$
)#$$4
The findings, opinions, and conclusions of the report do not necessarily represent the
views of the officers, trustees, or all members of the APA. The views expressed are those
of the authors of the individual sections of this document.
?)#$ #'-
##" ($
$-$'@" (-A$''#
'
'###$
$'$#$$-
)#$'#$##)$2
'$*$$#$)
#$)#)$)
#0)###
$#)$''
"$#$3$))'#'
##$))#
01#0#$'
-' )<###
'#')###)$
@"A0$'@%"A#%
" (-
#" (-#
#')$"$#$$
$'-$
#$" (-$#"0
'))#'##)
$'
-$#)')#
7
),$" (-
'$'$"#'
0$0,34
#'#)" (-
#" (-
$$#$
#
)#
')" (-##
#)#" (-#+'
)##
#$
Safety of SPECT in Children
#$'" (-#'#0
'-,
Particular caveats are indicated with regard to brain imaging involving radioactive
nucleotides for children and adolescents because of children’s known greater sensitivity
to radiation and risk of radiation induced-cancer. The long term risks of initial and
repeated exposure to intravenous radio nucleotides are unknown.
$')#
$$
#)
#$''
''$$#2'!'$
788B3*#$C8D6$#
3*# #$D9BE3
*#$>FC8),##$'$
')$#)#0)$,
$1$$-
'''$$#$)0
/
-0#" (-8F$-$)
)-)$0G'4'#$$
$-#0
$#0
,#'#+''
)$0#'#$
0),)$@7A#"'#
#H$I4
B
The purpose of this section is to briefly describe the data regarding low-level radiation
and risk and to clarify that in fact SPECT and PET procedures have no more risk
than MRI-based procedures… Indeed, there are no data that have ever demonstrated
any harm to humans by radiation exposure at diagnostic imaging levels. In fact, current
data support the presence of radiation hormesis: that low levels of radiation exposure
induce beneficial effects of cellular repair and immune system enhancement…
Therefore it should be concluded that neither SPECT nor PET brain imaging
procedures are associated with any particular risk over activities of daily living and
certainly should not be considered to be any more “risky” than MRI or any of its
associated functional imaging derivatives.
$0#'
'$#'0$,GG)#-)##
#$#$" (-$),
-)#')##$
##+'&)$,#
#1'$,,#
##''J,###$0
'#'$,##$" (-
The Appropriate Use of SPECT in Psychiatric Practice
-####" (-#
'+4
Brain imaging does have important clinical uses….The usefulness of SPECT to study
perfusion abnormalities in the brain as well as elsewhere (e.g., the myocardium, carotid
arteries) is well established. SPECT has a role in the diagnosis of cerebral trauma,
certain kinds of dementia, strokes, seizure disorders, and brain tumors, in which
characteristic patterns of perfusion abnormalities are detectible. In addition, brain
SPECT with neuroreceptor imaging radiopharmaceuticals is used in cerebrovascular
diseases, dementias, epilepsy, head injury, malignant brain tumors, movement
disorders, and Gilles de la Tourette's syndrome (Camargo, 2001). This imaging
modality has been used in diagnosis, prognosis assessment, evaluation of response to
therapy, risk stratification, detection of benign or malignant viable tissue, and choice of
medical or surgical therapy…The primary clinical use of SPECT in psychiatry has been
to rule out the neurological conditions listed above.
'$'#))#'$
-3'$$$#"G&'
$/$$#')#
.
#" (-##'#''J"
'##$J-
'*$'')$J#,
>
,J#$$#$)
$,)#)2#
$$/-'$'#$'
$,)',#
'
-$$$,)$4
Imaging research cannot yet be used to diagnose psychiatric illness. Specifically, no
published investigation in the field has determined that any structural or functional
brain abnormality is specific to a single psychiatric disorder. Additionally, imaging
studies examine groups of patients and groups of healthy controls; therefore, findings
may not apply to all individuals with a given disorder. Even when significant
differences are identified between groups, there is a substantial overlap among
individuals in both groups. We conclude that, at the present time, the available evidence
does not support the use of brain imaging for clinical diagnosis or treatment of
psychiatric disorders in children and adolescents.
#" (-#$'$#
$,#0'#
#" (-$,'##
',,#'#$
" (-$$$$$" (-'
#)$#$4
" (-$')0##'
)'0)#)$
'')$
+)$:0;))'#
$,$
" (-$$##$'
#)'#$#$
'#)$“yet be used to diagnose
psychiatric illness,”))'
'###'
##')'making psychiatric diagnoses is not the goal of imaging
research.)#K6888$'#$
'$$J
0)0$'
"G&''$-3
$)$#)#
#$"G&#
#$#))#$$'
-)#$#'
'"G&)//)'
"G&##$-$)
#'#")'#$
9
$#" (-#)'
'"G&)2#
'$,'"G&
#$+'',#"G&
)" (-$#$)
#$wereG#))$
$''$'$'##
$2'/,#
1$'
$'##,$#$
)4#$
'2$
*$$
$G)$-
%#$#
'/'##
$@BGEA
$$##)$
#$#''/)'###
@)2'))A#
$)####
$$#)'')#'
')'
" (-,'$#$
)'$'###'###$
" (-#'"-$)
#$/#$-#'$$
##"G&'
" (-,#$#
'$,###
#$$0$)'+'
:Imaging studies examine groups of patients and groups of healthy controls; therefore, findings
may not apply to all individuals with a given disorder.”#'''
$$
'$''#)$
2$-##)#
,#$,$
+'$$/#4
We conclude that, at the present time, the available evidence does not support the use
brain imaging for clinical diagnosis or treatment of psychiatric disorders in children
and adolescents.
D
-$#$0#)$
'E#)" (-
6 (/'@)' A
7 ()@)' A
B ($@)' A
> (###$@)' A
9 "#')/')
))$00#
D (')
F $0#)$$)')
C (''
E ")'$0#0'
+',##" (-#'##
#" (-L?'" (-#'
$'$'-0##$
))00##'2
'##$"$$$$)
$$"G&$,0#)$
)6888#)" (-
'-)))$
)'#,
''$$$')#
''
##)$
))#69'$$
##')$
#"G<%<&'$)'$$
)',#$#)''
'$$'')'
#$#"
*#,)''#
)''30
+$$##
2'0$$
#$#$,)$#
Missing Studies
-:a brief summary of the research studies of psychiatric disorders in which
brain imaging tools, including SPECT, have proven fruitful.” -,#$
$)#?#'$
$'
Attention Deficit/Hyperactivity Disorder
F
#<*'')$
#)# )#$$'-'@7888A4
Findings in Attention Deficit/Hyperactivity Disorders are still provisional, but suggest
minor structural changes in frontal and caudate areas, especially on the right side.
Functional studies suggest reduced activation in these and other areas. A 2000 review
of studies in children and adults concluded, “The techniques do not yet contribute to
individual diagnosis” (Overmeyer & Taylor,2000).
#$#'
!,'')$#),#
#''#6E
" (-*@6B#$7888A$$#
#0$$@68G7CA
" (-)'!))'$@78A$*
$$G$)*!))'$
" (-$$'##
$$$
#'''
!+'4
As of this writing, no studies have been published in journals indexed by the National
Library of Medicine examining the predictive ability of neuroimaging for psychiatric
disorders in either adults or children
'$',#'0$$$
#$#)0$
#####*'$
,#$##0
,#$$
*@6C7B7CA')$'/
##@BGEA
(" (-3)*
)#$0$
Autism
M$:To date we do not have definitive answers
to questions of how the brain functions differently in this disorder (Eigsti & Shapiro, 2003;
Rumsey & Ernst, 2000).”
-)'("'$)'#
/)')#'$$$
,'$)-'
$$0,)
)'$#
C
$
Depression
-#$3" (-@7EA"
$$)'
$0$
Errors in the APA Council Report on SPECT
"#3###
)##)$
6 -“SPECTwas originally introduced in the 1980s (Goetz, 2003).”
-#" (-'6ED86ED7.
$$'-$)$)#
" (-@6EF8A# (-0'$NG
',-@B8A
7 -“SPECT makes use of radioactive tracers tagged to a molecule, which
can indicate glucose metabolism, oxygen consumption, or blood flow.”-#
" (-$)$%')
@NA)#$)
)
B $$1#)#$$
4“In addition, brain SPECT with * neuroreceptor imaging radiopharmaceuticals is
used in cerebrovascular diseases, dementias, epilepsy, head injury, malignant brain
tumors, movement disorders, and Gilles de la Tourette's syndrome (Camargo, 2001).”
O:#;$#$1
-#)$#'$#
$$)" (-)
#$#$$
" (-'*#
* ($'$'#$#
$$3$#)" (-
),'''#)
$#$
> -“Some have advocated for its use in clinical diagnosis of
psychiatric disorders (Amen, 2001).”-##" (-
$#$)'#
9 -“There is one case report of SPECT and an adolescent with OCD who
showed changes after being treated with clomipramine (Amen & Waugh, 1997).”-
'#>9'$)
E
$'
D -“There are few normative data sets on children (Hinton, 2002).
Without normative data, interpretation of findings on individual patients is meaningless.;
-$'-##"
+0$#
" (-##$$'
+0$)#
$#@00
2'A',#
Biased Representation of the Issues
#$#
$$#$#" (-##-)
,#scientific rigor and would not pass the test of any peer reviewed publication. This seems
also to indicate a level of a priori bias difficult to imagine, coming from any kind of select
Council appointed by a professional organization. It may also suggest an ulterior motive.
#," (-#
'#$'#'#
" (-"$##)$$%'
#')$) ##
''
#,,'#,#
$'$'$
)###)$$0'
-#$##
$" (-,'$'
#" (- ''''$$)
" (-)'$$#$$$
##" (-," (- 3
6EEB6EED6EEE788>
Four Clinical Examples
" (-')'#)'*
)#0$" (-#'
-0$" (-)')$
6 E,))##+
'0)$')
0$)$*" (-'
###$)#$)
)'0#$)
68
'$3)$
7 ?6B#<''$2
?'$$$#'
#$'#)
/*" (-'$,##
$)##)#*
)$/@'#$))#1'
/'A$'$))
B D$###$*#
P#D7# "1&'*
#$ 3" (-'#
00-' $)0
-#$'$# #0
$$' #
$,$$P68B)'*
/22G# ''!$*M'
$788>" (-''
',)1
> ..,69'$#
-*""#''6D6EEC
),$$$$
.$#$$)'#
-'$0$#$'
-*",'#.
,##96-77
2#." (-*
"M'-'##
$)#0
0#.')$'
)1'#0)#-#
)/#$)*'#
$)''$),)'3)#$
$'#$,)
APA Council Report Will Inhibit Further Research in the Clinical Application of SPECT
-)###$
'''#" (-6ECE$
$$'$)#4:+$
'#;-6D'L*$)#
0$##J
')" (-$$#$#M"
./-,'
66
#$)
#$
Conclusion
)#''$)'
#?#$
##''J
-##$###'
$$+D8'$)
#*')$,##
$-'$',BGD##'
$$,)#)##$
-'$$'#'''#2
)'#,
$))###0#
3)''),
'#)0'
$$$'
References
1. #4! %%%788>
4<<#<<$<%<#
7 @7887A" (-+$4-"
$ : 96BG9BB
B N"#//%&! &*, &),
)#+)+'@EE$A-G"
(0+#- -$$G
7887QBF@>A4B>FGB9>
> )$"-"2#.(*/
.'(+*. #(###"
)')%& #
0$ ''6EEEQ69D@CA466>EG9C
9 '% (*$)
* *"')+$"!%))
#%-$'+2
788BQEE@DA46868GF
D %"!'%$(* *)
')*"!,+$)$)
67
#$'#)$
''78866Q98@EA4D9EGDF
F "$/')*"%..'""R%#G-
"!$)G#'$24$$'$
788>'Q77@6A4>8EG6C
C ')*"".-,!"%."),
%$)####0$24
''788869Q>C@CA4CB8G>B
E ')*"".%.), ,$"-,!"
"-+0 -#4
#$6EEFBQC@>A4689FGD6
68 $$*G)" (-$*
''6EEFQE@7A4C6GD
66 $*)" (-$#$2$,
<* '6EECGQB8@7A478EG6>
67 # -%'(%)))
)G#$)'$$$'@" (-AG
$@((A)'$$#
G#''@*A 7888
QCE@FA4CB8G9
6B .' ,,%("($,*-$GEE$
* )" (-#''
7887Q6D@CA497FGB6
6> .$!""""!"%)#)$
#<''"$$'(
''7887Q797@9A476EG79
69 .$!""!"'))#
)2#<''?7886+)Q>7@6A46EG
7E
6D !) ($.,% '
%)*"*(###$'))
#))'#''
6F !).,%)*!"*
$'$$'#))#))'
#''$$7886Q77@67A46BBBG>8
6C !".$.(!".$?..!"%)
)##''4$)#
6B
#$'$*$7889Q7>@BA469FGD>
6E !))'$$),!$G"--$EE$
''$G$$$'@" (-A
$)G#
''@*A788>+)Q6E@7A4E6GD
78 !**,! *"'#
#',6ECEQ>D@6A4>CG97
76 !**,! +)'#'
<#6EC>Q>6@CA4C79GE
77 !**,! +)'#$
)!6EE8DQBB9@CDC8A4CG66
7B ", ,%))-
',$$')'$#)
$)788869Q78@DA4%D9
7> '.,)(%))#
*47889Q7F@>A47FEG7C9
79 %!%$-"/)%*/*$$
$'))#G#<''
4'"'788B'Q>C@7A4CFGE
7D ".##'% +*" (-)$)$
#''6EE9Q78@6A499GD8
7F " +! #)#
'*)$
-$7886Q68C@68A4678BG6D
7C "/)./% !) ./,+
%!-###$'))#)'
G#<''($788BQB8@BA4>7BG
D()788B66
7E +-*"*-" '.)*'%
)##$2
7886Q>7@FA4689EGD6
B8 4<<$<0#$J S668FT% S68
6>
This Response Was Prepared by:
$
$
*$-$
# '$
*,
%$
/)
$$
In Consultation with:
## ''*$
M'##"#
#$
#$# ''*$
M'##"#
%'
#$# ''*$
M'##"#
##%'
M'#!
,!/
+$ '
#M'$# ''
"-#!
U
'%" ## ''M'!
2 ##"M'
69