SPECT Brain Scans and Mental Health (Part 1) – Daniel Emina – HPP 121

SPEAKERS

Dr. Daniel Emina, Dr. Will Van Derveer

 

Dr. Will Van Derveer  00:05

Thank you for joining us for the higher practice Podcast. I’m Dr. Will Van Derveer with Keith Kurlander and this is the Podcast where we explore what it takes to achieve optimal mental health. This episode is part one of a two part conversation with Daniel Emina about a very different approach to assessment of psychiatric presentations. I’m gonna start here with a nerd alert. Daniel and I love going deep into functional medicine and neuroscience rabbit holes. So we did that quite a bit on this episode. If you have any questions that arise about these topics, feel free to connect with me on Twitter @willvanderveer that’s all lowercase all one word, wi ll VA n d e r v e r and I’ll be happy to respond there. Dr. Daniel Emina is a child and adolescent and adult psychiatrist who earned his medical degree from UCLA and completed his residency 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 entails development of best practices, treatment strategies, quality control, mentorship, technology, implementation and outreach. He’s also the co author of a recent book called The suicide solution published by Salem books, which offers a unique holistic approach to the treatment of suicidality through scientifically and theologically informed strategies. His clinical tools include psychotherapy, psychopharmacology, pharmacogenetics, functional imaging, TMS, and integrative therapies to optimize brain health and function. So this conversation, for me, was really informative and fun and interesting to hear about this radical, different approach. Maybe it’s not that radical, but Dr. Daniel Amen has kind of polarized people who some people really love his work. Some people are quite skeptical, but we’ll let the audience decide for themselves. I personally was really impressed with the scientific rigor and the theoretical basis of, as Dr. Daniel Amen says, examining the Oregon that we’re treating in mental health. Hello, Daniel, welcome to the show.

 

Dr. Daniel Emina  02:43

Hey, well, thank you so much for having me on. I’m a little intimidated by your past guests. But I’m so excited to be here, kind of talk about my experience, and especially my experience with neuroimaging and at the admin clinics in particular. So thanks so much for having me on.

 

Dr. Will Van Derveer  02:57

It’s awesome to have you and I’m really excited about this conversation. I’ve been looking forward to this for a while, you have, from what I can tell profession, inside of psychiatry, that’s, it’s pretty unique, you know, and not a lot of practitioners are working the way you are in the Amen clinic and also some of the more integrative aspects of that work that I think I didn’t know about, on the face of it, of how things are done there. So I’d love for you to just introduce us to how that you know what that practice setting is like for you what kinds of tools you all are deploying there, who’s a good referral for that kind of setting? What you like about it? I’ll just let you riff on it.

 

Dr. Daniel Emina  03:42

Oh, no, those are great questions. I think to even understand why we’re there, I think it might be helpful to kind of get a little bit of a background of where I’ve come into psychiatry a little bit and how I ended up with them and clinics. So I actually trained at UCLA spent some time also University of Hawaii, board certified in general, adult psychiatry and also Child and Adolescent Psychiatry. On my transition from fellowship, I was looking for different opportunities and interviewed a lot of different places and actually even got a particular job already. And then an opportunity came up with the Amen Clinics and I spent some time researching them. Pros and cons with all of it spoke with Daniel, amen. Rob Johnson, the medical director had some really good conversations and really learned about how they look at psychiatry loses very unique perspective. And it just it blew my mind it was quite a bit different than how I had been taught. I actually, by the time I was leaving fellowship I was it was a little kind of a little cocky a little bit of like, I’m good. I can I can handle anything. And then you start going into the real world and you find out oh, there’s there’s a lot more there and then you get introduced to what Amen clinics is Winning like, Whoa, I haven’t considered any of this. So initially hate I joined on because I was just blown away by the ideas and the way of practicing psychiatry that they do. And we do, which is even evolved since then. And now eight years along, I think honestly, I’d probably thought all right, maybe I’ll go do two years. It’s almost like a fellowship, learn a little bit, then I’ll move on. But I kept learning I kept learning each year is a new challenge, a new scale to pick up. And it’s one of the reasons I’ve stayed now one of the associate medical directors there. And is bringing it back to kind of your question, one of the reasons that I was intrigued by them in clinics is, we looked at the organ we treat, it seems simple, but it’s, it is fundamental, but also, it creates a significant paradigm shift in the way you treat patients had moved from these diagnosis and an algorithm to a more intentional patient centered plan. So even the idea of seeing that individual’s brain, and then which then opens up this mix of it’s like the Pandora’s box of like, whoa, this depression looks different than that depression. What does that mean? Right? And that question, leads you to start asking better questions right, about things that would naturally lead us into the path of integrative medicine, integrative psychiatry, started and considered toxicities talk and split and mold, considering inflammation, other infectious processes, head injuries, and it’s kind of just opened up the can of worms of potential treatment options and treatment modalities. So again, we do quite a bit there. And I will talk a bit more about it as we go through but gives you a little bit of a short intro of what we do.

 

Dr. Will Van Derveer  06:57

And it’s really helpful. This comment about you know, examining the organ that we’re treating reminds me of, I think it was a TED Talk by Amen some years ago, were I remember that being kind of a punch line that stuck with me in the back of my head and thinking to myself, wow, I’ve been psychiatrists for, you know, I don’t know, when I watched that. I was probably like, at least 15 years into my career. And I was thinking, I don’t examine the organ that I’m treating like, you know, that is a really memorable, kind of quip about one of many limitations in our field in psychiatry, right. And so I’m so curious to get a little deeper into with eight years and you have enough experience, I think, to comment about these patterns, like you’re talking about different depressions look differently. What are you seeing in terms of are we looking at subtypes of depression that have different patterns on scans?

 

Dr. Daniel Emina  07:53

So the questions right, so at Amen Clinics, I think was founded, I think was 80 and 89. And I think Daniel Amen started doing spec in 91. Okay, and he was super excited. He was so excited. He can stop telling people about it. And then the backlash started, there was backlash of there’s not enough science related to it, right? Which is frustrating because if you literally go on PubMed, and I did this like last night just to like, see where it’s at. If you type in brain SPECT, you’ll pull up at least 15,000 scientific research articles. So there’s there’s ongoing research, not just old stuff, there’s actually new stuff that’s still getting published in the use of spec. And understanding the brain. SPECT itself is different than you know, CTS, MRIs, F MRIs, PET scans, and each modality has its pros and cons. That’s just the truth of it. Each modality has its pros and cons to be like a cardiologist, when they want to examine the heart. The modality of listening to the heart has its benefits. That EKG that measures the electrical activity has its benefits and provides its own unique picture. You might even want to do an echocardiogram and actually look at the heart. We’re using basically sound waves, right? So there’s different modalities that provide a different picture. And that will influence the decisions that clinician will eventually go about making to treat that patient. And that’s one of the things we saw with spec that it provided extra information that allowed us to see our patients differently. The fact that he saw Daniel Amon, this is way before I got there started looking at the brains it forced him to think a bit different about psychiatric diagnosis. One of the things that people often think of naming clinics for is ADHD treatment. And the fact that he was breaking down multiple subtypes of ADHD, this was blasphemous back then it was like you got your inattentive, and hyperactive, it was as blasphemous. And then he went even further and said there’s different subtypes of depression and anxiety and addiction and people were like, What are you talking about and was blasphemous, right? And it really came of the fact that you can have two individuals that come in and say I am depressed, fill out a PHQ, nine and have the whatever Depression Inventory, come up with a value related to it that qualifies them for depression. But if you actually look at the individual answers, there’s like multiple iterations that could have still led to depression. Right for each individual, right? So it’s one of the reasons I say depression can be heterogeneous, right? It’s not the same thing for each person. And right, that maps the same way to the brain. It’s not the same thing for each person. Different people go present with different looking scans. Yes.

 

Dr. Will Van Derveer  10:41

So just for our listeners, who maybe not, I want to ask you to give us just a little bit more of a primer on the different imaging pieces that are out there, CT, fMRI, SPECT, PET scan, that would be really helpful. But before we, before I ask you to do that, I want to just elaborate a little bit of what you said about the PHQ nine. So the PHQ nine, for those of you who are listening who haven’t heard of that, or you don’t not familiar with that is a rating scale that’s commonly used in mental health clinics to assess the severity of depression, particularly. It’s a nine point scale. That’s why it’s called PHQ, nine. And you can answer zero through three. So three is serious symptoms, zeros, no symptoms on each of the nine. So what I hear you saying, which makes total sense to me is that, you know, one person whose score is, let’s say, we see a lot of people in the high teens or low 20s, more severe depression, they could have all threes on the first half of their PHQ, nine questions. And then they could have zeros on the second half and have the same score as a person who has zeros on the first half and threes on the second half. And the first and second half of the PHQ. Nine is actually really important because, well, at least particularly item nine, which is the suicide question, suicidality. So that that has a big impact on how you’re going to, you know, treat that individual. So anyway, go ahead and tell us Daniel about like, what are the pros and cons just from a bird’s eye view of different imaging techniques? And particularly why, you know, you feel like are the immune clinic settled on SPECT over say, PET, or fMRI, for example?

Dr. Daniel Emina  12:22

Yeah, the truth, by the way on, what we settled on is that, I think there’s probably going to be an ongoing evolution of what we settled on and things may look different. I use the cardiology example for like a very specific reason. Because I mentioned that you might listen to the heart, you might use electrical activity related to the heart, you might image the heart, using an echo, you could even do a CT, you can do a lot of different ways of looking at the heart. And those would provide particular angles and pals allows you to, to evaluate the function and health of that heart. But they all answer a particular question. One of the reasons we went with SPECT, it’s a mix of reasons. Okay, so I’m gonna give a very short explanation of spec, because we could spend the whole time talking about just imaging modalities and the pros and cons of each, right. And if you had a radiologist on here, dude, they would even say more and go back and forward and all that it would be a lot. The cool thing about SPECT is that it looks at blood flow. So we’re looking at blood flow patterns in the brain. Why is that important is that blood flow for the most part equates to activity in the brain. So increased blood flow, increased activity, lower blood flow, lower activity. That’s an oversimplification, but it gives you a sense of what the amount of activity you can have in someone’s brain. And because there’s been so many scans that have been done, you know, they mean clients who have done over 200,000, but others have done even more, whatever very good idea of, you know what falls within healthy normal as far as the amount of activity you’ll see. Now, within healthy normal, you can still present with symptoms, you can still technically get depressed or having anything but the likelihood of it is significantly lower. Right. So if you fall within that healthy range, you’re less likely to present with symptoms above that range, maybe more likely to present below that range, maybe more likely to present. So within that healthy range, less likely to have a concern outside that range, more likely to present with a concern. The thing is, you’re it’s it’s specific to the area of the brain you’re looking at. Right so if you’re seeing decreased activity in your frontal lobes, there’s a mix of symptoms you may present with, right more inattention, more focus related concerns, more impulsivity related concerns, even certain types of depression and such may have an impact your ability to be as empathetic, right, depending on what patterns were seen in your frontal lobes. increased activity in the frontal lobes can even be problematic. increased activity in certain parts of the limbic brain can be problematic. It just matters where it’s throwing up. Now, when you start using one of those modalities, you get good at using that particular modality. So, you know, in this case SPECT, you just get good at it, you build a database of it, you know, what it can do what and what it can’t do. It might not see everything, but it can, you know, there’s it can see enough to allow you to ask, ask questions you need to, and it prompts that workup you may need to, to eventually, you know, start suspect, again, looking at blood flow, MRI, different mechanism of how it does it. And I’m gonna leave that to the radiologist to explain because it’s usually quite a bit harder to explain MRI. And on top of MRI, there’s something else called functional MRI, MRI usually is more focused on structure. So looking at the structure of the brain, it’s using the magnetic properties of pretty much all elements. So even in our body, it particularly is looking at like oxygenated versus deoxygenated blood. So there’s that piece, but it’s looking at structure in general. Now, there’s another algorithm that’s run for fMRI, which is functional MRI, which is looking at activity patterns. So that’s actually one of the biggest areas of new research is using fMRI to do some of the same things we’ve been doing for the last 30 years or so. Pet is another way you can look at activity levels too. And that’s more using glucose metabolism, there’s some other ways you can get pet to work to pet is pretty much the priciest find a bit more radiation, MRI, no none. As far as the radiation is concerned, you do get a bit of radiation with SPECT. And there’s obviously last not necessary the last one, but one of the other ones is CT, like, and that’s one of the ones you go into the ER, you broke a leg, you had a car accident, though scan Europe from head to toe, right? For the most part, that still also ends up being structural, even though there’s other variants of that, that you can create a functional picture with. So why did we go with SPECT? Because one it was more accessible. Pricing wise, it actually still even though it’s very expensive for those machines, it’s still quite a bit cheaper than an fMRI is still quite a bit cheaper than a PET scan. And its ability to, it’s not as finicky. In some ways. Some of the the reasons people actually criticize SPECT is actually some things that work to its strengths, the way you’re able to do the image, the timing, from getting the tracer to when you can actually even still complete an image, quite a bit of some of those things actually allow us to get the images we get, and get them more consistently. The fact that we have our own clinics, and we train our readers. And actually we’re building out a built out on reading software like, and this is more of a machine learning based reading software, which is really one of the things we’re building, and super exciting right now. So we have been very consistent results between readers irrespective of who’s reading the scan. Right? So short answer there we went was fact because Why did it become more available, there was a lot of cool research on using it in psychiatry, we built up a strong enough and large enough database that we now have had a good understanding of what it meant for our client base. And as we were doing the work, and this is Dr. Him and as he was doing the work, you started to see the benefits of it come through. So I know I’m being long winded here, but I’ll give just give you an idea of what I mean here, SPECT really comes down to do you see good activity in that brain? does it fall within that range? And if not, is it too little? Is it too much? Based on that, then you start asking yourself questions will Why am I seeing this particular pattern? In the Why am I seeing this pattern that just drastically created a paradigm shift in how Dr. Amen saw his patients? Because now he started looking at like, why is that there? What does that mean? Which actually opened up the door after integrative psychiatry, because we started to see, wait, this person has Lyme disease. Interesting. That’s an interesting pattern. We’re starting to see that. Wow. And the people that have Lyme disease tend to have this particular pattern. Oh, substance use cannabis weed. I thought it was healthy and great for the brain and everything. Whoa, well look at this pattern. Old environmental toxins. One of the first big ones, you know, was the head trauma in particular, right, seeing that having head injuries was not a benign thing. Right. I just had a new evaluation this morning, young kid 13 And no one can remember the head injury. But as we dug a little bit deeper, they like Well there was that one time that you fell and hit your head on the wall and And we can actually see this on the scan you’re seeing decreases cerebellar you’re seeing decreases the prefrontal cortex, you’ve seen even a slight change in the angle of the cingulate, which is a part of the brain to This almost looks a little bent, headed and remember that, wow, head injuries hurt people. That’s actually one of the one of the biggest things I’ve have seen working here is like even small head injuries will have a significant impact on people’s lives. The injury that they felt like 9, 10, 12, 13, all of a sudden, they can’t focus as much. All of a sudden people are going, you’re lazy, why aren’t you getting your work done? And it changes their lives. Right? Just a little little head injury. But again, it’s you start asking this question and you start going, well, this someone has a head injury, what do you do about it? Can you treat it head injury? Alright, let’s see what we can do. Let’s throw a bunch of things on it. And let’s rescan them and see if it changes anything. Wow. Oh, it did. Now that helps us refine our plans and our treatment plans, right. Other things like hypoxic injuries, another big one I learned was sleep apnea is not benign. It shows up even years decades before you can start seeing these decreases expression, the parietal lobes and longitudinal fissure. I jump all over people. Now if I see that pattern, like, if someone tells you, You snore, yeah, they say you have sleep apnea. Yeah, but I can’t stand the machine. I’m like, you’re gonna get dementia, if you don’t treat it. Right, it could be at 40, or whatever it is. And you start seeing those decreases there. You treat them differently. While factions hybrid early detection, right, early detection is huge. So quite a bit there becomes this decision support tool. And I could, as you see, I could talk about it for days, probably.

 

Dr. Will Van Derveer  21:51

No, I love it. It’s so fascinating. And, of course, you know, probably a lot of people listening are familiar with some of the, let’s say, naysayers or critics or, you know, it’s not ready for primetime and so forth. And it’s kind of hard for me to argue with 200,000 scans and developing a database. In the very same way that Neurofeedback which is widely accepted, has a database that’s based on, you know, if not hundreds of 1000s Millions of brain scans and defining what’s normal, what’s the bandwidth of normal, what’s the range? And then what are the patterns you see? So why not SPECT Scans if neurofeedback is so widely accepted, and even covered by insurance, in some cases, and so forth? Yeah, makes perfect sense. But the tools is obviously a lot higher resolution. Am I right about that and the SPECT versus that? brainwaves, electrical brainwaves?

Dr. Daniel Emina  22:51

So really good question there, because that’s one thing that can come up as far as like resolution and the different tools right fMRI, really what’s called spatial resolution is really amazingly small and acute. The temporal resolution, the timing of the changes you can pick up is really, really acute. And SPECT has its timing, temporal resolution and spatial resolution. Even neurofeedback, or, excuse me, qEEGs have their own benefit of what you can pick up each thing provides its own picture, I really do eventually believe we’ll probably have some combination tool in the future, where we look at the brain in different ways, and might include some version of an fMRI, some other version of SPECT. My own personal thoughts are that fMRI is almost too finite, it’s almost too good at picking up small changes that I think even being anxious while getting the scan can impact it. Even a bus I mean, there’s actually stories on this there was like a I think it was a subway going by there was some paper that’s published was created artifact and fMRI day Oh, wow. It’s so sensitive that it can impact things, right? We have a little bit more leeway with SPECT and what it does. So even though it’s temporal resolution may be a little different, it does still allow us to almost gather. So it’s actually several resolutions more in the minutes. So it gives us more of a sense of like, what’s the brain like over time, not just in this milliseconds of changes,

Dr. Will Van Derveer  24:27

right? In those minutes of time? Is it part of the routine to assign tasks inside the the scanner to see what happens?

Dr. Daniel Emina  24:35

So great question. Great question. So we we attempt to do two scans. Usually for most individuals, we do a resting scan and a concentration scan. The rest of them scan as they get the tracer the tracer goes with blood flow flows to the brain settles in into the brain and starts to emit a gamma ray. That gamma ray is what’s picked up in the camera. So At camera level, there’s not much going on beyond just picking up that high energy gamma ray just released, right? So by the camera they don’t, I mean, they just have to sit still, for the most part on the resting scan, we haven’t sit still not do very much on a concentration scan, we have them do a concentration task, which is, and this is standardized for all the patients. It’s a contest performance test. So it allows us to compare individuals to individuals because the same test right, and that allows us to see the brain at rest and the brain concentrating for our individuals. And that helps us figure out things like actually distorted things that show up a little bit better and concentration like ADHD, certain things that show up a little bit better in a resting state, maybe earlier signs of like dementia, earliest signs of toxicity, that sort of other things that we might see a little bit better on a resting scan that we might see in a concentration scan. So we would we like getting those those two pictures.

 

Dr. Will Van Derveer  25:56

And if the presentation was, let’s say, PTSD, do a different kind of task? It comes up for me thinking about if you put someone’s attention on a traumatic event, and they have PTSD and probably going to see a massive shift and blood flow? Is that part of the or you just do the Connors task and the concentration plus the resting for everybody?

 

Dr. Daniel Emina  26:20

Yep, yep. And this is the beauty. This is again, why I think this is for some people, they think of it as a limitation of SPECT, but actually think it’s a benefit of SPECT. Because of that temporal resolution. There’s an element of just capturing what the brain tends to just be like, whereas it’s almost like not necessarily a pure resting state. But what’s its baseline concentration is there what’s what does it normally just fall back into. So for instance, you mentioned PTSD, there’s a diamond pattern, a diamond plus pattern we tend to see, and it’s the combination of what we’ll see in from cingulate activation, basal ganglia bilateral basal ganglia activation, some thalamus activation, and some activation that’s usually into the insula. And we’ll pick up that particular pattern and there’s usually a high risk of that person has experienced PTSD. I think of it like this, their baseline limbic state is just elevated, the threat detection is just elevated, it’s just looking for something right, irrespective of their thinking about it or not thinking about it is just elevated. And it’s a powerful tool when you can show that to somebody and be like, it’s very valid and it’s actually probably one of the biggest parts of scans, validation that people will feel it’s not, they’re not just crazy, right? It reduces stigma, it makes it a medical thing, not a moral thing. It’s not a weakness. Think one of the reasons why people continue to come to it and look to the clinic for those SPECT scans.

 

Dr. Will Van Derveer  27:55

Thank you for joining us for this part one of a two part conversation on the higher practice Podcast. I’m Dr. Will VanDerveer, with Keith Kurlander under and this is the Podcast where we explore what it takes to achieve optimal mental health.