Perhaps nothing mirrors our cultural obsessions more than how we deal with our “issues.” In early-Victorian times, phrenology was all the rage, as crowds flocked to have their skulls probed for depression-causing bumps and hysteria-inducing ridges—fitting for a generation that loved circuses and magic shows, and for a time when biology was just emerging as a mainstream explanation for behavior. At the turn of the 20th century, Sigmund Freud introduced psychoanalysis, and his notion that we could talk away our problems was in lockstep with the inward-looking literary (see Virginia Woolf and James Joyce) and cultural tendencies of the day. The idea of settling into a plush couch and talking about ourselves proved irresistible well into the narcissistic ’80s. But by the mid-’90s, with the decade’s burgeoning 24-hour-business-day mind-set, who had time? Instead, we came to prize the speed and efficiency of pills, for everything from a flagging sex drive to insomnia to the inability to say no to that third serving of ice cream. Now, however, for a growing and vocal group of doctors and patients, the idea of writing a prescription based solely on a conversation seems woefully old-fashioned. With nearly every aspect of existence being digitized, the next big fix may very well be the brain scan.
Within a decade, it may “be malpractice not to scan the brain,” contends the psychiatrist Daniel Amen, who, thanks to his considerable media presence, has emerged as a scan guru of sorts. “This is the future of psychiatry.” If Amen’s business is any indication, he’s on to something—though whether that something is a medical breakthrough or simply a brilliant entrepreneurial venture depends on whom you ask. In the past 24 years, Amen’s empire has grown from a single clinic in Northern California to six around the country. He also has written eight New York Times best-sellers (his latest, Unleash the Power of the Female Brain, came out earlier this year), often including SPECT (single photon emission computed tomography) scan imagery of the brain to illustrate, and ultimately explain, mood disorders and behaviors such as binge drinking, shopping oneself into debt, or eating oneself sick.
A SPECT scan uses a radioactive tracer to measure the flow of blood in the brain: Areas with higher-than-average flow suggest too much activity; areas with lower than average, not enough. The price of a scan starts at about $1,200 and is not usually covered by insurance. Amen charges $3,575 for a complete evaluation, which includes two scans (one done at rest and one while the brain is active); a pre-scan session, during which a personal history is taken and a neuropsychological test is performed; a post-scan meeting, to review results and prescribe a treatment; and a follow-up appointment to assess how the treatment is working.
Paying thousands to be shot up with a radioactive substance (which, not incidentally, delivers the equivalent of about three years’ worth of everyday radiation exposure) might sound extreme—but Amen doesn’t see it that way. “Cardiologists look, gastroenterologists look, but psychiatrists guess,” he says. And that, he believes, is one factor holding his profession back.
Anne (not her real name), a tech executive in her early 50s who lives near San Francisco, agrees. Three years ago, she found herself perpetually bummed out, overcome with anxiety, and almost too distracted to function at work. “I didn’t know if it was burnout or something else,” she recalls. After tiring of talk therapy, she started reading Amen’s books and became intrigued. “I didn’t want to just treat the symptoms,” she said. “I wanted to get to the root of the problem.” So she made an appointment for a scan.
The results surprised her. There were areas of “scalloping”—indicating low activity—along the surface of her brain; the result, perhaps, of the drugs she took during her club-kid phase or of a long-ago bike accident. That is probably what made her anxious, says Bradley Johnson, her prescribing psychiatrist, who works with Amen. The scan also illuminated decreased blood flow along the front sides of her brain, which explained her short attention span and disorganization; and near the temples and middle front, which, according to Johnson, likely accounted for her irritability and contributed to the depression.
A standard dose of antidepressants would have ramped up Anne’s anxiety, says Johnson. Instead, he advised her to cut her workload and take brain-nourishing vitamin D, omega-3 fatty acids, and green-tea-extract supplements. Later he added prescriptions for low-dose antidepressants, mood stabilizers, and attention-focusing pills.
Anne’s response to learning she had, well, brain damage? Believe it or not: relief. “It made my issues feel tangible and authentic in that they had a physical cause,” she says. And after being shown an image of what her brain could look like if she took the proper drugs and made some lifestyle changes, she also felt hopeful. “I walked out of there motivated and empowered,” she says.
Not everyone, however, is so enthusiastic. Although many mainstream physicians believe that brain scanning will someday be widely used to determine the course of psychiatric treatment, that day may still be far off. Amen has published several encouraging small-scale studies, and other scientists have investigated psychiatric applications of technologies like PET and MRI. But Anissa Abi-Dargham, M.D., chief of the division of translational imaging at New York State Psychiatric Institute, points out that a large randomized, double-blind study is still needed to determine which of these small findings are actually valid. Other doctors contend that the drug regimens prescribed to scanned patients aren’t all that different from those of non-scanned patients. If one prescription isn’t doing the trick, they reason, there is little risk, financially or in terms of side effects, in tweaking the cocktail until it works.
But Shelby, a 20-something who lives outside Washington, D.C., disagrees. She’d been plagued by headaches, panic attacks, and depression for 13 years, during which time she tried “every prescription medication under the sun” and countless hours of talk therapy, to no avail. So last fall, when a new primary care physician suggested a brain scan at Amen’s clinic, she didn’t hesitate. “It was a drop in the bucket,” she says.
The resulting picture was not pretty—but she was thrilled to have some answers. “I can’t tell you how wonderful it felt to be able to point to what’s wrong with me and know that it wasn’t all in my imagination,” she says. The problem, according to Joseph Annibali, her psychiatrist at the Amen Clinic, was that the Lyme disease she suffered as a teen may have reduced blood flow to key areas. She also had the sort of depression that is triggered by overactivity in the limbic portion of the brain (which controls emotion) and an overactive basal ganglia, a hallmark of anxiety. The prescription? Meditation, light yoga, and walking—along with prescription meds, not for depression but for anxiety, concentration, and migraine-prevention, a combination that ultimately improved the depression, too. She began to feel better in a matter of weeks.
This sort of immediate gratification is not surprising to scan proponents. Andrew Newberg, M.D., a neuroscientist and director of research in integrative medicine at Thomas Jefferson University Hospital and Medical College in Philadelphia, believes that psychiatry “needs to be imaging more frequently.” He has used scans to study patients who binge-eat at night, finding that, compared with the rest of the population, they have greater activity in the midbrain. “A patient with cognitive impairment, such as memory loss, would get an MRI, so it seems odd that we don’t do the same with mood disorders,” he says. And though he wishes for more data, he believes “it doesn’t make sense not to use [scans] at all.”
Clearly, there’s a hungry market for the technology. Amen has conducted more than 80,000 scans, and he says his practice has never been busier. The International Society for Neuroimaging in Psychiatry, founded in 1988, now has more than 500 members all over the world. And although Amen offers extensive assessment tests that can predict, to some degree, information gleaned from a scan without actually scanning, he says the vast majority of his patients get into the machine anyway—cost, radiation, and controversy be damned. The temptation to look inside one’s brain—the very core, in many ways, of identity—is pretty irresistible. This has made some scan-savvy psychiatrists quite rich.
These entrepreneurial psychiatrists, it’s worth noting, aren’t the only ones profiting from this practice. A wide variety of mind-revealing tools—including MRIs, EEGs, PET scans, and CT scans—are being used by neuroforensic experts to build brain-scanning lie-detector machines, by sleep scientists to interpret dreams, and by neuromarketers to get pictures of exactly how excited (or bored) consumers are by what brands are trying to sell them.
And when it comes to mental health, while the data to support the widespread use of scans hasn’t yet caught up with the trend, stemming the scan boom is no more realistic than shutting down hot yoga studios or cellulite-treatment centers. There are simply too many patients convinced that seeing is believing—and the key to curing whatever ails them. It’s not hard to imagine a future in which the technology could be used to help those of us who simply want to sleep better or lose those extra 20 pounds—though Amen points out that issues of cost and radiation exposure would need to be resolved before scanning becomes routine. For Anne, however, the test was well worth it. Three years after her initial appointment, she’s off antidepressants, and she just signed up for another scan. Thanks to her post-scan regimen, her brain, she believes, has undergone a total makeover. This will be the after shot.
Top: © Lillian Bassman; courtesy of The Amen Solution