SPECT Brain Scans and Mental Health (Part 2) – Daniel Emina – HPP 123

SPEAKERS

Dr. Daniel Emina, Dr. Will Van Derveer

 

Dr. Will Van Derveer  00:07

Thank you for joining us for the higher practice Podcast. I’m Dr. Wil Van Derveer with Keith Kurllander and this is the Podcast where we explore what it takes to achieve optimal mental health. This is Episode Part Two of a two part conversation with Dr. Daniel Emina, who is a psychiatrist at the Daniel Amen clinics discussing with me a very different approach to assessing psychiatric problems. And if you haven’t listened to part one, then I’m just going to repeat the nerd alert here, Daniel and I, especially in the second part, go full nerd and functional medicine and neuroscience. So if any questions arise about these topics, feel free to ask me on Twitter. My Twitter handle is at will Vanderveer that’s all one word. wi ll VA n d e r v e r. Dr. Daniel Emina is a child and adolescent and adult psychiatrist who earned his medical degree from UCLA and completed his general residency and Child and Adolescent fellowship at the University of Hawaii. He is an Associate Medical Director of the Amen clinics, a nationwide network of pioneering brain health clinics founded by Dr. Daniel Amen. His leadership role there includes development of best practices, treatment strategies, quality control, mentorship, technology, implementation and outreach. He’s also the co author of the suicide solution by Salem books published by Salem books, which offers a unique holistic approach to treatment of suicidality through scientifically and theologically informed strategies. He serves his patients with psychotherapy, pharmacotherapy, pharmacogenomics, functional imaging, TMS, and alternative and integrative therapies to optimize brain health and function. Speaking of destigmatization, I kind of takes my mind to another topic that you and I have explored before is the issue of suicidality and just how much more intense things are for people since the pandemic and post pandemic, and particularly, so much going on for teenagers or young people. I’ve seen just a massive spike in suicide attempts and suicidal thinking, and brings up for me the question about, again, I’m coming from a place of almost total ignorance with regard to SPECT scan. So, I’m curious about, whether in people with a lot of suicidal ideation, do you actually see a pattern in the SPECT that is reflective of that or kind of consistently or typically present there?

 

Dr. Daniel Emina  03:01

Spectacular question again. Just as we discussed with depression and anxiety, ADHD, there are types, there’s almost subtypes of everything, right. And even with suicidality, they can be different subtypes. And we’ve published on this and others have published on this using other neuroimaging modalities. And from our perspective, the things that we will see in our studies, which actually mirrors and overlaps with other studies, externally, there’s the tendency to seem decreased prefrontal cortex activity, okay? Remember that attention planning follow through, but it’s also problem solving, right? And it’s also a downregulation that happens between that prefrontal cortex and its ability to regulate that limbic or emotional brain. Those that will see some level of dysfunction. When I talk to clients, I’ll label like the temporal lobes. But there’s actually quite a bit that’s occurring at the temporal lobes. There’s the insula, there’s the amygdala, and there’s even the interconnections and such there that come through there. But we’ll see some level of disruption, whether it’s injury to that area, decreased activity, or actually the opposite, sometimes increased activity. Whenever I see that pattern, I’m already going to be more concerned about more impulsive aggression, right. So if the frontal lobes are down, I’m seeing parts of the amygdala potentially being elevated or increasing activity. I’m worried about that amygdala overwhelming that frontal lobe, because we already know that happens when we get upset. As a tendency, our amygdala rises up in activity, our frontal lobes come down in activity and part of therapy is actually improving our ability to self-regulate it by boosting that prefrontal cortex activity so we can regulate that emotional brain, right?  We do that through different types of therapies, but even just naming the emotion actually starts that process of regulating it. So we’ll see patterns like that. And it doesn’t mean that we’ll use it in itself to just predict that you’re going to be suicidal, but it does tend to overlap with people who come in with a concern of suicidality. Here’s where it’s important as like a clinician, if I see that pattern, and let’s say I see a team, and as depression, anxiety, of course, part of my workup is that I always have to ask those questions, right after ask, Hey, you had those thoughts? Sure. It’s, it’s actually more important to have those questions have the discussion. But if I see that particular pattern, I’m in the back of my mind, even if they haven’t had the thoughts, I need to make sure that I’m creating a plan that would potentially manage those thoughts. What am I doing to regulate amygdala activity? What am I doing to support prefrontal cortex activity in the plan? To be even more specific, this will change how I sequence whether it’s supplement recommendation or medication recommendations. One of the things that has been noted is that, and this is not I mean, it’s controversial, but it was it’s something that’s out there. It’s in the data that sometimes when teens, especially young adults, they start taking an SSRI, there’s actually an increase in suicidal thoughts.

 

Dr. Will Van Derveer  06:14

Sure. Blackbox warning, sure.

 

Dr. Daniel Emina  06:16

It’s a blackbox warning, it’s right there. And it makes sense when you start to understand how these meds work, and which receptors they may be hitting, especially when they increase serotonin. And initially, what’s what it’s actually doing, you get that over activation at this or it’s on a to a receptor, and sometimes that can lead to a regression. So that will influence my plan. Right? I will say, Okay, I see this on the scan, we like to do genomics, maybe I see that they have a sort of 20 to a receptor variants, though, to put me to like watch out a bit more. So I may be more likely to start with something that’s mood stabilizing, even if it’s just a supplement, whether it’s a GABA, lithium orotate or even a Gabapentin or Lamictal if we do go use a med, obviously, then combination omega threes changes and up to diet, avoiding sugar, getting a bunch of healthy fats there, because that’s supposed to have a part of the brain before I bring an SSRI, or SNRI, or some other med option, because I know those can destabilize that area. So I need to make sure that I’ve done enough to stabilize that error before I do that next step of maybe the antidepressant.

 

Dr. Will Van Derveer  07:24

That’s a great example. Yeah, I like that. Makes sense. Laying down a foundation before you potentially, you know outside the context of the foundation, you lay it it might it could overstimulate and further exacerbate frontal disinhibition that may be there, relative to the activation in the limbic system. Excellent. Yeah. Well, I want to ask you a weird question. And maybe it’s not weird, but I’m wondering if you now, hopefully, you will never need to do this. But let’s say, you know, SPECT Scans went down, you couldn’t do specs for a year or two. It sounds like your experience over eight years, has set up a way of thinking about what is being presented in front of you. That’s not going away. You know, even if you let’s say there was a blackout or something, and you couldn’t get a scan for a couple years. Now you see patterns right in the presentation of the patient, that the pattern recognition doesn’t go away, even if you’re flying blind for a while, so to speak, without the scan, would you? Well, I see you answered the question already nodding. But it sounds like the way you would treat patients would not change because you you have this formulation. And the way the lens of seeing what’s in front of you is just what it is after this experience.

 

Dr. Daniel Emina  08:53

Yeah. So again, another great question, because this is literally one of the reasons why I’ve stayed at the clinic. And I continue to enjoy being here. And I want to be a champion for this type of way of working with our patients and just the patients in general. First, I always like to focus on the fact that we want brain health, right? It’s not just about mental health, it’s about brain health. Right? Can we own that, that I think that’s one of the foundational changes doing this type of work and being so focused on the brain. Now, the truth is, I know we’re talking about so purely on biology, biology, the truth is not just purely about that, too. That’s the other thing and doing this work has taught me I’ve learned that people drive their brains differently. And I’ll give an example here imagine if you gave everybody an identical car, and as they race around the track or in they do this in racing, right? Relatively identical cars, they will drive their cars differently, right? We all drive our brains differently and we relate this to maybe we are experienced is the skills of gaining the road time there’s some elements of personality that impacts how we drive our brain. So, yes to individuals may come in with, now, let’s say similar diagnosis and similar brain scans. So it’s not that they completely different similar diagnosis, similar brain scans, okay. But one individual might have more challenges with their particular diagnosis. Why, in the context of their environment, in the context of their skills in the context of how they perceive themselves, their interior narrative, how they are perceiving whatever they illness and such as it will impact even how they do on a treatment plan. For example,

 

Dr. Will Van Derveer  10:36

what your father said to you about your limitations, or, you know, what the teacher said to you about what it means to be, let’s say, dyslexic, or whatever the situation is, yeah, got it.

 

Dr. Daniel Emina  10:48

Exactly, exactly. Right. So that piece becomes important. So I’m thinking, Alright, brain health, I want you to love the brain you have. Work through it as continuously taking care of it and refining its health wants you to have a good understanding of what your brain is good at. That’s actually again, one of the things about doing this, it’s not all about saying, Oh, well, you got too much activity or too little here. It’s like, oh, having that extra activity actually allows you to be better at analytical thinking and creativity. And your level of empathy is through the roof. But it also means you got to take care of yourself, you got to be careful about who you’re interacting with, and the relationships you’re building, because you’re going to carry some of that emotion. Right. So we try to speak in that balance. And then what you were getting at earlier was that because of doing this work long enough, based on presentation based on the way they describe things, I do tend to get an idea of what I believe is going on actually pride myself in trying to almost imagine what the brain scan will look like before I looked at it, I still do get surprised at times. That’s why we do it still. I even add another level. We haven’t talked about this, but there’s some genetics and genomics can kind of impact how their scans look a bit too. So I add that little bit of a level I’ll be trying to like, Okay, I think I know what may be going on here. We’ll test it to be sure. So yes, even if we didn’t have if I didn’t have it, we didn’t have it. There’ll be other ways of practicing. But I would be definitely missing this tool. Yeah, and let me take it even a step further. I think, you know, neuro imaging was such a controversial thing in psychiatry. But even the biggest centers now are using neuro imaging. They’re doing studies done, as they call it, they’re related in their precision psychiatry departments. They’ll combine your imaging genomics, they’ll combine it with big data and analysis and creating subtypes of depression, things that were you know, in clinics was left to death for even considering in the past. And now we’re recognizing that hey, oh, that really is a thing.

 

Dr. Will Van Derveer  12:53

Yeah. They say in medicine, you know, First they ignore you, and then they ostracize you and then they accept and reify you or something like that, that three steps of advancement of medical knowledge. And, well, I’m curious about this piece you were talking about? You’ve alluded to, that we wanted to get to today, is this piece about correlating different databases, and especially around the genomics piece, and I wonder if you could tell us a little bit about, you know, what you’ve learned from running genomics and SPECTs on, you know, sounds like quite a few people over the years. And those of us who have used a lot of genomic testing, you know, it’s, it’s fun to think about and predict, like, you were saying, What do you think is going on with this person and their comp status? Or, you know, how are they processing dopamine, the frontal lobes, et cetera? And then get the test and, and get surprised or not surprised. But I’m wondering what, what you’re seeing around that? And are there once again, patterns that confirm or don’t confirm these genetic variations that, you know, a lot of people are running pharmacogenomics in their, in their clinics, but most people that I know are not, you’re the only person I know who’s running specs in your work. So tell us about that. Tell us about those correlations.

 

Dr. Daniel Emina  14:16

Yeah, genomics is myself, another colleague at the clinic, we’re like big proponents. And we just actually had a, an Amen clinic doctor’s conference, and we did a presentation on genomics and you know, what we’re seeing and, you know, continue to encourage more and more people to use it and become more comfortable with it, because it is the future. It’s the present, but it’s also there’s the future in it too. I don’t think we know everything. Obviously, in relation to it. It just continues to evolve. I remember when I first started using some genetic testing and training, I think we’re looking at just CYP 450 genes. So we’re just looking maybe like six genes or something and then we’ve added and added and added some of the tests have 24 Gene genes we’re looking at some have more Depending on how you got the test done, but it’s really, really an exciting field, and especially when you’re able to correlate it with scan data. This is actually something we’re attempting to do internally to, and maybe partner in the future. But we have an our research team. And we have a very skilled data Localytics researcher, who’s going to be helping us make some further correlations. But I mean, I’ll give you an idea of what that ends up looking like. Right. So HUMAX mentioned catecholamine, methyl transferase, so cu MT, and the snip status there if they’re met with it, you know, baleen and what that can potentially mean. Right? We each have one copy of of each. The mat was what we would call them, it would be a slower metabolizer. So they would break down dopamine and norepinephrine slower, Val, Val will be faster. And Valmet would be moderate or an in between most people end up being Valmet. The funny thing about it is that, you know being on the extremes of anything, just gives you a smaller operating window, but it’s not in itself a problem. Right, so you can be met met and perfectly fine valve and are perfectly fine. It’s just a smaller operating window. So if you have a head injury, my valve owls may tolerate it less than the Met. Why? Because they burn down dopamine, norepinephrine quicker. There’s a tendency when you have that head injury, it’s harder to turn that brain on. So you need something to kind of turn it on. And now you already burn through dopamine quickly, you already had an issue turning your brain on. So it’s gonna be a little bit more of a challenge to get dopamine to that frontal lobe. Right. So you’re thinking about what stimulatory for them. The truth is Ivan on the other end to the Met met, individuals will also have some issues at times, the scans may look a little bit better, because it still looks a little bit more plump and active. But they will still have issues regulating those pathways. Now there’s other patterns we’ll see relation to it might impact Yes, frontal lobe activity. I’ve seen it impact limbic activity. So the limbic brain just things are just more active on people who burn down dopamine and norepinephrine slower. Are there benefits to having more dopamine and norepinephrine? Yes, you know, there’s potentially language about benefits executive function benefits, versus individuals who burn it up, you know, quicker. So there’s pros and cons to either and you have to be aware of what those pros and cons with. I’ll even add that it even impacts things like your estrogen metabolism, right. So if your complement met your burden on estrogen slower than someone who’s comped, Val Val, who moves through us, so understanding your hormones becomes important in this if a woman has a head injury in the past decade. And depending on where she’s at hormone wise, that can impact things if she has PCOS. Definitely impact things too. She has PCOS. And she’s met met. Right. So you can have these kind of very high estrogen states. So now they’re foggy, the mood is off. So it becomes part of the treatment plan, right? It’s not just giving them an SSRI, you might need to, but you might need to do other things to support them hormonally, you might need to do other things to support conductivity.

 

Dr. Will Van Derveer  18:25

Man a great example. Well, yeah, the knee bones connected to the thigh bone, I guess. So with all of these integrative aspects of care and health, really. And so would you say, I’m curious for you know, again, for the folks who are maybe practicing in more conventional settings, you know, maybe they’re in even, you know, qualified mental health centers, public clinics. Has it been your experience in working with these tools, particularly genomics and SPECT? Have those tools helped you rely less on pharmacology to get the results that you’re looking for? Do you think with your patients, I’m just wondering about, I’m thinking about my own journey and sort of over decades of, you know, gradually, you know, never eliminating medication, I’m not negative on medication. I think medication has a really important role in the integrative psychiatry toolkit for sure. And it’s critical for some people to function. Having said that, I definitely prescribe a lot less benzodiazepines and less antidepressants over the years, as I’ve learned about these interconnected webs of health that we have to support to, to feel good. So yeah, I’m just curious about that as far as your experience with, you know, coming out of fellowship, and has there been a shift over time in terms of going less to pharmacology with your treatment plans?

 

Dr. Daniel Emina  19:52

Oh, 100% One of the favorite things about this work I get a lot of reasons I’ve enjoyed being at clinic and continue to be at the clinic is that I love adding tools to toolbelt. And all of this, you know, the fact that we can have a better assessment understanding of the person individually there, Brian, that genomics, that gut testing their hormones, whatever it may be, it means that I can be more targeted in my treatment options. Right? And it’s not just Alright, well, let’s try this new, this other Med, there was this new man I heard about that might help. And those they might help. But it doesn’t necessarily mean that it covers all the mechanisms that that individual needs to target, right, if their testosterone is too low, I got to treat that too. And frankly, that means I can keep them at a lower dose of the Med, if I did have to give them a medication, which then means less side effects, it maybe gives us an opportunity for eventually be able to titrate off the med because we got their brain healthier. And then they see the med as the tool that it is. It’s a hammer, use a hammer away and either use a hammer, fix the thing work on the thing, some people Yes, need to continue to use a hammer or something all the time. Some don’t always need to use that particular tool forever. But they need to maybe use others and some of those others may be more natural, easier in the body in a short and long term.

 

Dr. Will Van Derveer  21:10

Yeah. 100% agree. And trying to get to, you know, wherever possible getting to the root cause of, for example, the person with low testosterone, do they have sleep apnea? Is that what’s driving the low tea, as opposed to, you know, it’s menopause, or whatever the other diagnosis might be? So not just slapping tea on somebody and not doing, you know, polysomnogram to try to get to the bottom of it. Yeah.

 

Dr. Daniel Emina  21:36

Or identifying the head injury that they did have. Because we see that a lot, right? They have a head injury, they forgot about it, they thought it wasn’t a big deal. You see it on the scans, you do the labs, you see that their hormones are low, because they’re basically hypo pituitary. All these years, they depress someone’s been given an antidepressant they came to see us because they were depressed. And then we find out hey, you had sleep apnea, you had a head injury, your testosterone is low. Okay, let’s treat you to stop, Sharon. But you got to start treating your sleep apnea. And regarding your head injury, there’s tools to actually help your brain heal, even though this is an old head injury, get an H bot, do 40 sessions and 60 sessions. One of the questions I think we discussed over email was that, yes, the brain changes too. Right? So often we’ll have people especially going through a protocol like that comeback get scanning in six months or a year or something, see your brain change? That’s very encouraging.

 

Dr. Will Van Derveer  22:32

Right, absolutely. See the change? Yeah, absolutely. Well, this is so much fun to wrap with you about these topics, and I could go on forever and ever. One thing that we like to ask our guests, as we start to wrap up is if you had access to a billboard that you could put a one line on that everyone in the world would see once. What would you want them to know? What would you like to say to them?

 

Dr. Daniel Emina  22:58

That’s a deep question. And I’m a person of faith. So it usually ends up it’s going to lead into a more faith based answer. But I believe that each end is going to be longer than one sentence. But I’d have to find a way to make it shorter. No problem, I believe, I believe that every one of us matter. And we all exist on this earth for a particular reason. It’s not the same reason for everybody. We don’t need to accomplish what the other person accomplished. We had our particular journey. And I do believe that, again, being a person of faith, I’m a believer, there’s a God hears about each and every one of us. So I think in this journey, it’s about discovering what is what’s our journey, embracing that and appreciating that journey.

 

Dr. Will Van Derveer  23:49

Beautiful. It’s Steven art. Daniel. Thank you.

 

Dr. Daniel Emina  23:53

Thank you so much. Well, it’s been a blessing to be on again. Thanks for being here. This is awesome. Thank you so much.

 

Dr. Will Van Derveer  24:03

We look forward to connecting with you again on the next episode of the higher practice Podcast where we explore what it takes to achieve optimal mental health.