Posted by manowar on January 12, 2002, at 1:40:35
In reply to Re: Old School nailed it » manowar, posted by bob on January 10, 2002, at 23:14:22
Thank you for your post and I'm glad you raised these concerns.
> I'm not so convinced about SPECT imaging, or any other imaging to help in out *treatment* of our diseases. For example, say a person consults a psychiatrist complaining of classic OCD behavior and depression. Then the patient is referred for a SPECT scan and it is confirmed that, indeed, the specific areas of the brain involved in those aberrations are indeed not functioning properly. How would that change the treatment?
First of all, imaging doesn’t treat depression, it’s a tool that helps diagnose why severe treatment resistant depression along with other psychiatric ailments are NOT responding to conventional treatment.
My point is that in 'treatment resistant' cases, functional brain imaging can be very beneficial. Instead of a doctor solely relying on what a patient tells him – which-let’s face it- can be erroneous, misleading and downright confusing-- not only to the doctor but for the patient, also-- he now has another tool to help diagnose and pinpoint the problems so that he can devise a better and more aggressive plan towards treatment.
BTW: Can you imagine a person with chronic chest pains talking to his doctor, and his doctor deciding on what medications, operations, or other treatments are needed for his patient, based solely on what the guy tells him—COME ON PEOPLE!!! Unless the poor guy is in Siberia, the doctor is going to order up a whole battery of tests, scans, blood work, etc…
Clinical Depression is very complex disease and many areas of the brain can be involved which may necessitate a complex approach to therapy. I’ve yet to see two people with the exact same symptoms.
In my case, the doctors found that not only did I have the normal malfunctioning areas of the brain for depression, but there were some other areas of the brain such as the Temporal Lobes and the ENTIRE Cortex that were under functioning + my Basil Ganglia was a bit over-active. I could go on and on, but to get to the point—AFTER the scans and the consultation, my home pdocs FINALLY took me off the SSRI merry-go-round and began to work with polypharmacy and use more aggressive meds, since my problem wasn’t so simple.
For instance: pstims or Provigil was NEVER a consideration, until the doctors saw the scans. A person with above average intelligence (I guess I would be a good example) can limp around with cognitive impairment without a doctor EVER suspecting abnormal pre-frontal cortex under functioning.
My local pdoc also refused to use a benzo to help me with my Cyclothymia. THANK-GOD his attitude changed! And it changed because, in part, THE RESULTS OF THE SCANS.
My attitude also changed. I wasted fifteen years of my life thinking I just needed to go to church more, listen to Tony Robbins, and meet some new people, yada, yada, yada. Don’t get me wrong, good psychology and a balanced lifestyle are necessary to a healthy life. The problem was, I was just lukewarm about psychiatry for many years.
The last three years of my life were a living hell. Thank God, last summer, I took the GIANT STEP and decided that I would spare no expense towards getting better. Now, because I’m a better informed consumer, I’m a hell of a lot more vigilant about psychiatric treatment than I EVER was before. I take complete responsibility for my condition. I don’t just rely on a doctor’s opinion anymore. The way I look at it—I pay my doctor as a consultant, just like I pay consultants in my business. Some consultants I’ve hired in business are more expensive than doctors. I DEMAND cooperation and respect from consultants I HIRE in business, so why should this be any different with my doctors? Because he has a PHD? I don’t think so. If I feel that my doctor is not working for me, and treating me like he thinks I’m a lowlife, I won’t hesitate going somewhere else (which I did recently).
And when I gave the new doctor the 10-page report with scans from the Amen clinic, he knew I meant business, and he listened.
I used to be one of those poor saps that bumbled into my pdocs office without a clue, completely and utterly dependant on his experience, compassion and grace to help me with my DISEASE. Not anymore. I come prepared- and because of places like Psychobabble- I’m armed, not with lame propaganda that we get from television commercials, but good, rock solid data (My pdoc just eats it up!) And I refuse to listen to the propaganda that drug reps feed to so called doctors (e.g. That Effexor is “Prozac with a punch”-BS)
>What if the person was refractory to the meds, then what would the scan bring to the table? I agree that mapping out the specific areas associated with behavioral/psychological problems is a necessary part of the evolution of our treatment of these conditions, but it doesn't change what tools are currently at our disposal.
Refractory to the meds? There are literally hundreds of medications and therapies available for depression. There is NO WAY that a person is refractory to all the meds and treatments for depression.
Again, a doctor would be more vigilant in trying new and novel drugs to treat his patient (e.g. Amisulpride, Adrafinil, ECT, Microcurrent Stimulation)
Contrary to popular belief, this is a VERY debilitating, deadly, complex disorder with many subtypes.
Examples of subtypes of depression:
This is from Dr. Amen’s web page www.brainplace.com:
Decreased prefrontal cortex activity at rest, especially on the left side is a consistent SPECT finding in depression. The severity of depression is often related to the degree of frontal hypometabolism. Several studies have indicated that the hypometabolism normalizes after treatment if the patient's mood improved. Researchers have also seen increased limbic system activity as well in depression (thalamus, amygdala, cingulate gyrus and deep temporal lobes). When depressed patients perform a concentration task the left prefrontal cortex often activates to normal levels, differentiating depression from attention deficit disorder which often shows normal activity at rest and decreased prefrontal cortex activity with concentration.
SPECT can be helpful in the diagnosis and treatment in complex or resistant depressive disorders by differentiating it from other disorders, enhancing compliance by the patient being able to "see the changes in the brain," and by subtyping depression. Here are three subtypes that one of the authors has identified.
· Decreased prefrontal cortex activity with increased deep limbic system (thalamus) activity. This subtype is often associated with moodiness, negativity, low energy, sleep and appetite problems and poor concentration. It often responds best to dopaminergic or noradrenergic interventions such as buprion, imipramine or desipramine.
· Increased anterior cingulate (this part of the brain is heavily innervated with serotonergic nerve fibers), thalamus and basal ganglia activity. This subtype is often associated with sadness, negativity, irritability, worrying, cognitive inflexibility, worrying and getting stuck or locked into negative thought patterns. It often responds best to the serotonergic antidepressants such as fluoxetine, sertraline, paroxetine and venlafaxine.
· Decreased prefrontal cortex activity with increased or decreased temporal lobe activity. This is often the most serious subtype and it is often associated with sadness, irritability, rage (toward others or self in suicidal behavior), mild paranoia, atypical pain (atypical headaches or abdominal pain) and insomnia. We have seen this subtype often made significantly worse by serotonergic medications and it is often helped by anticonvulsants, such as gabapentin or divalproate.