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rEEG System Helps Guide Prescribing

Posted by johnj on February 10, 2005, at 8:41:54

rEEG System Helps Guide Prescribing

Sharon Worcester
Tallahassee Bureau

Brain waves may be the wave of the future when it comes to prescribing medications for the treatment of psychiatric disorders.

Using a normative EEG database and an extensive and growing outcomes database of more than 12,000 patient electroencephalograms, researchers have developed the referenced electroencephalogram (rEEG), which involves performing an EEG on a patient and then selecting a drug or drug combination based on how other patients with similar patterns have responded to those treatments.

Early evidence suggests that the system is useful for reducing trial and error and drug stacking in psychiatric patients and for improving outcomes.

Several small studies and numerous case series suggest that the patented system, which is owned by CNS Response Inc. of Santa Ana, Calif., and is set to be studied in larger randomized controlled trials at Stanford University and the University of Texas, could bring a scientific and rational approach to prescribing that is rarely seen in psychiatry, John Milner, M.D., told CLINICAL PSYCHIATRY NEWS.

Medical treatment in psychiatry is symptom-based and largely a process of trial and error. But the rEEG provides a biomarker of sorts—a physiological basis for prescribing.

That's because resting EEGs are stable over time, and research is showing that rEEG abnormalities respond predictably to specific treatments, explained Dr. Milner, medical director at Rancho L'Abri, a dual-diagnosis residential treatment facility in San Diego. The system has been used at Rancho L'Abri for 18 months as part of standard care for eligible patients.

He likened the use of rEEGs to the use of electrocardiograms for guiding therapy in cardiac patients. Using rEEGs, a clinician can individualize therapy and select a drug that affects neurophysiology in known ways.

“This is not a ‘doc in a box’—the clinician makes the ultimate decision,” Dr. Milner said. And the results are astonishing, he added.

He primarily uses the rEEG system for dual-diagnosis patients in addiction treatment, who are among the most challenging patients to treat.

Patients who have been treated in the best hospitals, with the best medications, and who still failed to respond, are responding to the medications recommended by rEEGs, he said.

Max Schneider, M.D., who is another proponent of the rEEG system, described the case of a 47-year-old man with opiate and other dependencies, and severe chronic pain from injuries, surgeries, and professional athletics. The DSM-IV diagnosis was polysubstance dependency, Tourette's syndrome, and dyssomnia disorder not otherwise specified. The patient had been treated with varying combinations of narcotic analgesics, tricyclic antidepressants, and selective serotonin reuptake inhibitors without adequate improvement. On the basis of his rEEG correlation, the patient was treated with carbamazepine, and fluoxetine was then added. He experienced rapid improvements in his tics, sleep disorder, dysphoria, and cravings.

A repeat rEEG at 3 weeks' follow-up showed marked improvement. However, 3 months after discharge, the patient saw a new psychologist and medical doctor, who together questioned—and changed—the treatment regimen.

The patient “called in a panic with recurrent tics, dyssomnia, and anxiety,” said Dr. Schneider of the University of California, Irvine.

The patient is now on 800 mg of carbamazepine and 20 mg of fluoxetine daily and was doing well at 7 months follow-up.

During a talk on the subject at a conference jointly sponsored by the National Association of Addiction Treatment Professionals and the Medical College of Georgia, Dr. Schneider said he is “enthralled” with rEEG.

The rEEG concept began more than 17 years ago with the work of Stephen Suffin, M.D., and Hamlin Emory, M.D., who have been developing and studying the rEEG system since that time.

In one study of 39 patients who had 17 different DSM-based Axis I diagnoses but had a similar rEEG-defined abnormality, all of the patients responded well to the same agent.

And in a small controlled study of treatment-refractory patients with major depressive disorder and an average of 16 years of unresponsiveness to various treatments, researchers at the University of California, Los Angeles, found that six of seven patients with rEEG-guided treatment had significant improvement based on Hamilton Depression Index scores and Beck Depression Index values, compared with only one of six patients in the active control group who were receiving medications based on their physicians' best judgment.

One physician who uses rEEG developed the Helpfulness Index to evaluate the role of rEEG in treating refractory patients. In his experience, rEEG was helpful for finding the right treatment in 25 of 28 patients, and in 14 of those it was “essential.” In other words, without rEEG, it would have been impossible or would have taken years of trial and error to find the right combinations.

In numerous other studies, rEEG has predicted patient response in 70%-97% of patients.

Albert Davis, M.D., medical director at the Florence McDonnell Center in Atlanta, uses the system with outpatients and has seen similar outcomes. In one series of 18 patients who had been previously resistant to traditional treatments, 16 had an almost immediate response, he said.

“It was just amazing to me,” Dr. Davis said, noting that one of the patients who did not improve was claustrophobic and could not complete the EEG, and another had an EEG that didn't fit with any known pattern. Often the drug or drug combinations recommended by the system seem counterintuitive, he said.

“In most cases, I never would have thought of the medications or combinations that came back as recommended, but I'd already tried everything that I thought would work best, based on symptom criteria,” he said.

And at Rancho L'Abri, Dr. Milner found that rEEG was helpful or very helpful for finding the appropriate therapy in 56 of 58 patients and that 54 of the 58 had Clinical Global Impressions-Improvement scores showing they were much or very much improved. The greatest benefits appeared to occur in the most severely ill patients.

“This is an opportunity for us to successfully treat the sickest of the sick,” Dr. Milner said, who predicts that rEEG will never replace psychotherapy or recovery programs but that the system will enhance them. He added that he hopes the system, which is relatively low in cost (about $500-$600 per rEEG) and accessible (requiring only access to EEG equipment) will expand to other areas of medicine—and will not be labeled an addiction treatment tool.

For example, Dr. Milner envisions rEEG as a useful tool in the treatment of children who are diagnosed with attention deficit disorder. Studies show that successful early treatment helps prevent later substance abuse. “If we could use rEEG to pick the right medication early in these children, we could prevent some of (the future substance abuse),” he said.

At press time, Dr. Milner, Dr. Schneider, and Dr. Davis, had no financial interest in CNS Response.




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