NEWPORT BEACH, Calif. — Daniel Amen is, by almost any measure, the most popular psychiatrist in America.
He is 58, lean, married, a father and grandfather, soft-spoken, balding, given to wearing black from head to toe, and possessed of a small, compact frame, weighing just under 150 pounds. He’s energetic and personable. Patients adore him.
He has arisen, like a modern-day American myth, from the fields northeast of San Francisco, where he ran a small-town clinic, to become the creator, chairman and CEO of the Amen Clinics, an empire that includes a string of psychiatric practices, a line of nutritional supplements, book publishing, DVD sales, and television and speaking engagements.
He says his businesses, including four clinics — three on the West Coast and one in Reston — employ 100 people, among them 16 psychiatrists, and grossed about $20 million last year. The clinics together see 1,200 patients per month. Two more clinics, one in New York and one in Atlanta, are scheduled to open later this year.
Some of his more than two dozen books, such as “Change Your Brain, Change Your Life,” have hit bestseller lists and, combined, have sold more than 1 million copies. His six PBS programs based on those books, including “Magnificent Mind at Any Age” and “Your Brain in Love,” are used during the nonprofit stations’ fundraising drives. He says the shows have aired some 50,000 times and generated about $40 million for PBS stations.
High-end motivational and business speaker Brendon Burchard features Amen at conferences, introducing him as “The number one neuroscience guy on the planet.” Joan Baez and Bill Cosby tout him. He has been on “Dr. Phil,” Larry King, “The View.” He is working with former pro football players, trying to help them recover from head trauma likely caused by hard hits on the field. Rick Warren, pastor of the massive Saddleback Church in California, which Amen attends, enlisted him to help create the church’s health and nutrition program.
This rise to fame and fortune has been accomplished in curious fashion. Amen is a distinguished fellow of the American Psychiatric Association (“Excellence, not mere competence, is the hallmark of a Distinguished Fellow,” the organization says). Yet he assails — if not ridicules — his own profession.
“Psychiatry is broken,” he is given to say, and psychiatrists “remain the only medical specialists that rarely look at the organ they treat.” He scoffs that diagnostic methods have scarcely progressed since “the days of Abe Lincoln.”
Those, however, are only jabs.
The uppercut of the Amen combination is the assertion that he has harnessed a type of brain imaging to transform psychiatric practice itself.
This is single photon emission computed tomography, SPECT, a type of nuclear imaging test that measures blood flow in organs of the body. Using a radioisotope injected into the bloodstream, it illuminates a path for a camera to record the flow. The technology is commonly used to detect cardiovascular disease and cancerous tumors. In neurology, it is mainly used to research broad outlines of brain function in groups of patients. In clinical practice, doctors use it to uncover evidence of strokes, epilepsy, trauma, some types of dementia and heavy drug use.
Amen says this is only the beginning.
He says he has taught himself — by scanning 45,000 people a total of 70,000 times — to apply SPECT, alongside clinical evaluations, as a diagnostic tool in 90 percent of his patients.
The brain activity he says he sees in these scans — areas of high and low activity — allows him to target those areas with specific treatments and medication, he says. A full initial session, including two scans, costs about $3,500.
Amen says this method has helped him identify new subtypes of anxiety, depression and attention deficit disorder, categories far more specific than even the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the benchmark of the field.
This is heady stuff — using brain imaging to find biomarkers for mental illnesses has been the great hope of psychiatry for at least two decades. In “Healing Anxiety and Depression,” published nearly a decade ago, Amen wrote of the thrill of this breakthrough: “We could change brain patterns, see it on a follow-up scan, optimize brain function, and subsequently help people heal from the inside out.”
The implications, he says, are vast.
One of his studies showed that although his patients had tried multiple doctors and medications before coming to Amen, 77 percent improved across all measures with his SPECT-enhanced treatment — remarkable success in such a difficult patient population.
“It will soon be malpractice to not use imaging in complicated cases,” he recently told a symposium at the American Psychiatric Association.
From his Web site:
“SPECT can specifically help people with ADHD [attention deficit hyperactivity disorder]. ... SPECT can specifically help people with anxiety and depression. ... SPECT can specifically help people overcome marital conflict. ... SPECT can specifically help people age better. ... SPECT can specifically help people with weight issues. ...”
At this point, you might think Daniel Amen is one of the most highly regarded psychiatrists in the land.
Not so. Officials at major psychiatric and neuroscience associations and research centers say his SPECT claims are no more than myth and poppycock, buffaloing an unsuspecting public.
None of the nation’s most prestigious medical organizations in the field — including the APA, the National Institute of Mental Health, the American College of Radiology, the Society of Nuclear Medicine and Molecular Imaging and the National Alliance on Mental Illness — validates his claims.
No major research institution takes his SPECT work seriously, none regards him as “the number one neuroscience guy,” and his revelations, which he presents to rapt audiences as dispatches from the front ranks of science, make the top tier of scientists roll their eyes or get very angry.
“In my opinion, what he’s doing is the modern equivalent of phrenology,” says Jeffrey Lieberman, APA president-elect, author of the textbook “Psychiatry” and chairman of Psychiatry at Columbia University College of Physicians and Surgeons. (Phrenology was the pseudoscience, popular in the early 19th century, that said the mind was determined by the shape of the skull, particularly its bumps.) “The claims he makes are not supported by reliable science, and one has to be skeptical about his motivation.”
“I think you have a vulnerable patient population that doesn’t know any better,” says M. Elizabeth Oates, chair of the Commission on Nuclear Medicine, Board of Chancellors at the American College of Radiology, and chair of the department of radiology at the University of Kentucky.
“A sham,” says Martha J. Farah, director of the Center for Neuroscience & Society at the University of Pennsylvania, summing up her thoughts on one of Amen’s most recent scientific papers.
“I guess we’re all amateurs except for him,” says Helen Mayberg, a psychiatry, neurology and radiology professor at Emory School of Medicine and one of the most respected researchers into depression and brain scanning. “He’s making claims that are outrageous and not supported by any research.”
“I can’t imagine clinical decisions being guided by an imaging test,” says Steven E. Hyman, former director of the National Institute of Mental Health and current director of the Stanley Center for Psychiatric Research at the Broad Institute of MIT and Harvard.
The APA, in fact, has twice issued papers that dispute “claims being made that brain imaging technology ... was useful for making a clinical diagnosis and for helping in treatment selections.”
The most recent paper was published last month. It was the work of 12 doctors who spent three years assessing the latest research. The summary: “There are currently no brain imaging biomarkers that are currently clinically useful for any diagnostic category in psychiatry.”
Four years ago, Robert Burton, the author and former associate chief of the department of neurosciences at the University of California at Mount Zion Hospital, wrote a harsh article on Salon.com about Amen’s work. The headline was “Brain Scam.” When recently told that Amen was still in business and grossed $20 million last year, Burton asked for the dollar figure to be repeated.
“Oh, my God,” he said. “Just oh, my God. At some point this gets to be obscene — that’s just my bias — but oh, my God.”
* * *
Amen’s career is very troubling, for one of two things must be true.
One, Daniel Gregory Amen, born in 1954 in Encino, Calif., son of Lebanese immigrants, is 20 years ahead of virtually the entire psychiatric field (he says about three dozen other clinics use SPECT scans, but few as profusely as he does), and the establishment has failed to recognize a historic breakthrough.
Or, two, the man has grown fabulously wealthy — he lives in a $4.8 million mansion overlooking the Pacific Ocean — by selling patients a high-priced service that has little scientific validity, yet no regulatory body has made a move to stop him.
Amen has no doubt which is fact.
“There are 2,700 scientific articles on my Web site that show the underlying basis for our work,” Amen said recently in an interview. “None of [his detractors] have called me and said, ‘You’ve got the world’s largest database of scans, what can I learn from you?’ Instead, they call me a snake oil salesman and a charlatan.”
He’s an affable man. He grew up devoutly Catholic, one of seven children of a successful grocer, and hewed to the family belief in faith, hard work and ambition. He joined the Army after high school, spent nearly three years in Germany, mostly as an X-ray technician, came home, married and got a medical degree at Oral Roberts University Medical School.
He thought he’d be a pediatrician, but wound up “falling in love” with psychiatry.
“If I’m a surgeon and I take out a kidney, I helped that person for one instance,” he said. “But if I help you optimize your mind, I’m helping you to be a better mom, and that has potential to help a family for generations.”
He eventually reenlisted and did his psychiatric internship and residency at Walter Reed Army Medical Center in Washington. By the late 1980s, he had finished his military obligations, secured board certifications in both adult and child psychiatry, and taken a job at Solano Park Hospital in Fairfield, Calif. He also started his own practice.
His early work was regarded as “progressive and promising in its time,” APA president Dilip V. Jeste wrote in an e-mail, saying it was this work that led to Amen’s “distinguished fellow” status.
Amen also, it turned out, had a knack for turning complex psychological issues into pithy advice. In 1989, he wrote a self-help article for Parade Magazine: “How to Get Out of Your Own Way.” In addition to the $4,000 paycheck, he said he got “something like 10,000 letters” and an appearance on CNN.
“It was then I realized I could have an impact far, far beyond my office,” he said in an interview.
Two years later, he attended a seminar on SPECT at his hospital. “It totally changed everything,” he said.
* * *
It is midday in Amen’s office on a recent afternoon, and 16-year-old Savannah fidgets on the couch. She is sitting next to her mom. She has been his patient since she was 7, and he has given her a diagnosis of “overfocused attention deficit disorder.”
His office is a small rectangle of brown and beige, one wall set with windows, another in a warm shade of cranberry. There is a couch, a coffee table, a bookcase, his wooden desk and two large computer screens for displaying scans, and a curio cabinet filled with plush and ceramic penguins (mementos from patients, after he wrote a book that featured a penguin). A sealed plastic bag with sliced fresh vegetables rests on the table.
This office, near the John Wayne Airport in Orange County, is amenable to patients flying in — he says he has treated people from 90 countries — and Savannah and her mother, Kathi, have flown in for a two-day update.
Amen is low-key and reassuring. He asks about school, how she’s sleeping, about her dosage of Adderall, how she’s getting along with her mom.
“Good,” she says, in reply to the last query, then gives a self-conscious laugh. “Better when I’m on my meds.”
He goes over her most recent brain images. “Your brain looks better than the last one we saw,” he says. “You have a very lovely brain.”
But he points out the result of a QEEG study, which measures electrical activity. When her eyes are closed, her brain activity is high, he says, but when she opens her eyes, “your mind is just on fire.”
“She gets tortured with her thoughts,” says her mother, nodding, going on to relay some of her daughter’s troubling behavior: argumentative, always interrupting, writes on herself, cuts her own hair, once dyed it pink —
“It wasn’t supposed to be permanent,” Savannah says.
“Sssh,” says Kathi, gently.
“And it was on all her clothes — ”
At the end of the hour-long session, Amen refills her Adderall prescription (for the ADD), and recommends a supplement from his line, Serotonin Mood Support (for the “overfocused part”) as well as exercise and careful attention to her diet.
“She should be happier and less argumentative,” he says.
It is a small tableau: a girl, her mom, a doctor and a complicated mental condition that may never go away.
This is the base issue of psychiatry, replicated in thousands of doctor’s offices. It goes to the mystery of humanity, of personality, of human beings seeking to understand themselves, and what a terrible, clawing-around-in-the-dark idea we have about it all.
* * *
The brain is a sponge-like mass of 100 billion nerve cells sitting in an electrically charged soup of chemicals. These nerve cells, or neurons, which make quadrillions of connections to other neurons, is, essentially, you.
These wet flaps of cortex, this vast wiring of nerves and synapses — somehow they encode personalities, memories, love affairs, dark obsessions and bright joys, the composition of Beethoven’s Ninth and Shakespeare’s “Macbeth.” No one really knows how.
The maladies of the brain are even more complex.
Here are glittering knives in the kitchen of self-destruction, the echoing voices in the hallways that do not exist and, finally, the vast black empty plain of depression, a mental expanse so desolate that many who encounter it cannot picture a way to escape.
It was less than 100 years ago, in this country, that enlightened medical opinion held that the insane and feeble-minded should be sterilized.
Lobotomized, too. About 40,000 or so were performed, a movement led by D.C.-based Walter Jackson Freeman II, who developed some of his ideas at Saint Elizabeth’s Hospital. He perfected his “transorbital lobotomy” with an ice pick from a kitchen drawer and a hammer. He did this through the eye socket. (He was eventually stripped of his medical license and died in disgrace.)
The idea that mental illnesses could be treated with medication gained favor in the 1950s. By 1986, when the Food and Drug Administration approved fluoxetine hydrochloride (Prozac), the field was thought to have entered a new, sophisticated age.
In this theory of depression, the chief actors were chemicals, seratonin chief among them, that transmitted electrical impulses from one neuron to the next. The theory held that when serotonin (and its cousins, dopamine and norepinephrine) was running low, neurons could not “talk” to each other, and depression was thus born or affected.
The new class of drugs — Prozac, Zoloft, Paxil and others — were known as SSRIs (selective serotonin reuptake inhibitors) because they kept serotonin from being absorbed out of the brain’s synapses, the gaps between neurons. Within a decade, they became some of the most widely prescribed drugs in America.
By the mid-2000s, the picture wasn’t quite so optimistic. It turned out that many clinical trials in which the drugs didn’t work well had not been made public. Some books and medical reports said the drugs might, in fact, be turning an episodic disease into a chronic one. Lawsuits charged that they caused suicides.
This unhappiness seemed to crystallize in 2010, with the publication of two books about the ennui in the field. Daniel Carlat, then a professor at Tufts University, wrote “Unhinged: The Trouble With Psychiatry — A Doctor’s Revelations About a Profession in Crisis.” Psychologist Irving Kirsch, now associate director of placebo studies at Harvard Medical School, published “The Emperor’s New Drugs: Exploding the Antidepressant Myth.”
Kirsch and his team said their research, which reviewed all studies that drug companies submitted to the FDA to get approval for six widely prescribed antidepressants, showed that the SSRIs worked little better than placebos.
When “60 Minutes” reported on Kirsch’s work earlier this year, the APA blasted the segment as “dangerous and irresponsible,” and the drug companies defended their products. But there was no doubt that wholesale belief in SSRIs had crumbled.
It has been against this melancholy backdrop that Daniel Amen emerged with two things everyone wanted.
One is called Hope. The other is its even more powerful sister. Belief.
* * *
Amen’s first scan patient, back in the early 1990s, was Sandy.
She was 40, had ADD and had tried to kill herself the night before their initial meeting. In his telling — it is his Genesis story, and he has told it many times — the resulting scan showed a precipitous drop in activity in her prefrontal cortex, the brain’s decision-making center, when she tried to concentrate.
When he showed her the scan, she wept. “You mean it’s not my fault?”
Realizing it was a “biological, not moral” problem, she accepted the diagnosis, took her medications and was greatly helped.
“I thought, ‘Whoa. Pictures matter. You get great compliance,’ ” Amen says.
There was excitement about the possibilities of SPECT, but within a few years, most clinicians and researchers realized SPECT’s limitations and moved on. Amen remained entranced.
Earl Henslin, an author and psychologist in Brea, Calif., thought him a near genius. Henslin’s practice has since referred 3,000 patients to Amen.
“If at all possible, I’m motivating my patients to get that scan at the first session,” Henslin says. “They see that scan and they’re willing to take responsibility.”
After those first scans, Amen began the process of becoming certified to carry out scans himself. First, he underwent 200 hours of training to obtain his radioactive materials license from the Institute of Nuclear Medicine Education. Then, he carried out the required 1,000 hours of clinical supervision in reading scans.
And when his nephew nearly died from a brain cyst that was revealed only by a SPECT scan, his insight became a mission.
“I realized there are a lot of kids ... who we as a profession throw away,” he told an APA seminar recently, his voice rising. “We send them off to residential treatment, and when we don’t fix them, they end up in jail or they end up on the street, and that is criminal when we have tools that can help them today.”
He scanned himself, his children, his new wife, his parents, and boys who dated his daughters longer than four months. He created MindWorks Press to publish some of his own books. He co-wrote a chapter on neuroimaging in the “Comprehensive Textbook of Psychiatry,” published peer-reviewed papers (mostly in small journals) and established himself among a set of his peers.
Robert Johnson, medical director of Sierra Tucson, a residential treatment facility in Arizona, met Amen more than a decade ago and credits his courage in “trying to move the field forward,” by both traditional and alternative medicine.
Anthony, a 21-year-old patient who was referred to The Post by the Reston clinic, spoke on the condition his last name not be used. He said he received a diagnosis of depression and anxiety at age 9 and was put on Zoloft. After years of failed treatments at different clinics, he said, the intake evaluations, therapy sessions and scans with Amen’s staff have been transformative.
“The results [of the scan] were a little disconcerting, but I’m glad to have it,” Anthony said in a telephone interview. “They recommended a couple of new medications, some holistic and dietary changes. It’s been almost three months, and I’m not perfect, but I feel better than I have in a really long time.”
“His work has had a huge impact on the addiction field,” says David Smith, founder of the Haight-Ashbury Free Medical Clinic in San Francisco and a legendary figure in addiction medicine. “He’s a very open guy, a good guy.”
These supporters attribute the fierce criticism of Amen as the inevitable response to being a trailblazer in a staid profession.
“He’s been the lightning rod, but this is not a one-man show,” says Theodore Henderson, a psychiatrist in Colorado and a member of the Brain Imaging Council of the Society of Nuclear Medicine. (He says he uses SPECT in 15 percent of his cases.)
The Brain Imaging Council, in fact, was intrigued by — if skeptical of — Amen’s work in the mid-1990s, remembers former president Michael Devous. He says the group offered to let Amen analyze a large series of SPECT scans of psychiatric patients and a control group.
“We promised that whatever the results we would publish them with Dr. Amen as a co-author,” Devous wrote in an e-mail. “If this was successful, it would provide him with a level of legitimacy he had not had. The offer was made over the phone, by me, and he declined. He has steadfastly denied this ever occurred. ...He has threatened to sue me over it several times.”
Amen still says it never happened: “Michael has trouble with the truth.”
But by decade’s end, Amen found ways to take his message straight to the public.
* * *
“Change Your Brain, Change Your Life,” a book targeting a self-help audience, made the New York Times bestseller list. That “doubled our business,” Amen says.
His first PBS show, in 2008, doubled it again.
This self-produced hour-long show, based on that bestseller, was composed of tips to improve one’s health based on his research. It was picked up by a company that distributes content for independent PBS stations to air during fundraising drives. Callers who made pledges got a selection of Amen’s books and materials.
The show first aired in New Jersey and quickly caught on at stations across the country. Buoyed by the airtime, the book returned to bestseller lists; it has now sold 700,000 copies.
These shows — critics call them infomercials — are now a staple of PBS fundraising. Amen’s latest effort, “Use Your Brain to Change Your Age,” has aired 2,300 times on PBS outlets so far this year, his logs show.
(Maryland Public Television has aired his shows 252 times, drawing about $400,000 in donations, a network executive said. The station declined comment on the validity of Amen’s shows. A WETA official said the station had aired his most recent show six times in June, raising $68,000.)
A lot of what Amen touts on these shows — exercise; eat your vegetables; watch your weight; get a good night’s sleep; take your vitamins; don’t drink, smoke, do drugs or run into things with your head — is so old-fashioned it might well be attributed to John Kellogg, the nation’s first healthy-living guru more than a century ago.
And, like Kellogg, Amen is a busy entrepreneur (Kellogg developed Corn Flakes, with his brother). Amen has promoted his supplements and churned out books, while his wife, Tana, writes “brain healthy” cookbooks. He produces op-ed pieces (once suggesting all presidential candidates be subject to brain scans) and promotes his research with NFL players, saying he has helped them recover from brain injuries.
Marianne Phillips, a California-based general manager for FranklinCovey, a training and consulting firm, swears by Amen’s lifestyle advice. “I lost 60 pounds, but that’s not the big thing. The big thing was how much better my brain worked.”
Today, you can log in on his Web site for diet plans, lifestyle changes, support groups, supplements and DVDs.
In a video promotion on one of his Web sites, an announcer gushes: “When Dr. Amen’s patients naturally changed their brain chemistry, with his ‘Change Your Brain, Change Your Body System,’ they became thinner, smarter and happier — all at the same time!”
* * *
Meanwhile, the disconnect between Amen’s public image and professional reputation among the elite in the field has come to defy logic.
Few top researchers and scientists say that SPECT is anything but a research tool of limited clinical use in identifying strokes, brain injuries and the like. It is helpful in group studies, to say broad things about groups of patients, but not specific things about individual patients. And, researchers say, SPECT has largely since been surpassed by technologies such as PET and functional MRIs, which give images of far greater clarity. It’s no longer viewed as cutting edge.
The APA first debunked many of Amen’s SPECT claims in a 2005 report. In 2008, Carlat, the Tufts professor and author, went to California to test Amen’s clinic. He then wrote, in Wired Magazine, that the black-clad Amen looked “more like a Miami maitre d’ than a psychiatrist,” that the SPECT scan was “spectacularly meaningless” and that Amen’s analysis of it reminded him of a “shrewd palm reader.”
(Amen says Carlat asked to be scanned for free, refused to completely fill out medical forms and misrepresented the nature of the article he was writing.)
In 2010, Thomas Insel, director of the NIMH, wrote on his blog that while the technology “might be playing in prime time on some TV infomercials, brain-imaging experts say we’re not quite there yet.”
Earlier this year, Anissa Abi-Dargham, a highly regarded professor of clinical psychiatry and radiology at Columbia who has done extensive work with brain imaging, spoke at an APA symposium on the limits of SPECT. She listened to Amen’s hour-long lecture there.
Reached by phone recently, she said: “Had I known what this was, I would have never agreed to be part of it. It was not a scientific debate. It was propaganda for his clinics.”
Amen replies that the “pro-SPECT” side clearly won the debate: “People usually underestimate me when they debate me.”
* * *
It might be fair, at this point in the story, to consider two things.
One, clinical psychiatry is often as much art as science. There is no test for depression or bipolar disorder, as there is for cholesterol or blood sugar levels. In most cases, success is determined by patients’ perceptions and behavior. If they say they feel better, and act like it, then they are. No psychiatrist bats 1.000, and there is no X-ray to prove a mental break has been healed.
Amen says more than one-third of his patients are referrals from previous patients, indicating their trust in him. The California Medical Board has no record of any substantiated claim against Amen; Virginia and Washington state online databases show no litigation record. Even Carlat, who dismissed Amen’s SPECT claims, said that in their one-on-one session Amen was “an excellent psychiatrist — focused, compassionate, patient.”
Two — and this is perhaps related — there is the remarkable work of Kirsch, the Harvard psychologist, who has studied placebos for 30 years.
His book, summarizing the research of others, documents that the more expensive and sophisticated the placebo, the better it works. A placebo capsule works better than a placebo tablet, and a placebo injection works better than a capsule, and a placebo surgery trumps them all.
So, the potential “placebo plus” effect for a high-tech computer brain scan costing thousands and presented as the best technique in the world — coupled with good counseling and improved diet — would be huge, he says.
It’s a thought.
Still, Kirsch — who had not heard of Amen — was troubled.
He says that it is incumbent upon Amen, as a scientist and practicing psychiatrist whose work has come under scrutiny, to prove his theory to a scientific standard.
“Before you start promulgating this and marketing it and profiting from it, you should ethically be bound to demonstrate it scientifically in a peer-reviewed, respected journal,” Kirsch said, and then you must have it tested by others.
Otherwise, you might as well get a pair of ponies, a buckboard and a traveling salvation show: “You’re just going down the path of being a snake oil salesman.”
* * *
After work, Amen drives home via toll road in his black Cadillac Escalade, then up a winding drive to his gated community in Newport Coast.
There is a fountain at the entrance of his Italianate home, lots of marble and a swimming pool and a vast kitchen. The western rooms have a view of the Pacific.
He acknowledges that his practice has done well financially, but that’s hardly against the law. He is not troubled by misgivings. “It’s a good business that helps people.”
He stands on the balcony, a chill air blowing in, a quarter moon floating over the ocean, the twinkling lights of Los Angeles falling away to the north. Tana is downstairs. The chef has retired from the kitchen. Tinkerbell, the family’s toy poodle, is sleepy.
Amen is leaning on the railing, chatting warmly about his family, idly pointing out Kobe Bryant’s mansion somewhere down the mountain thisaway, the nightly Disney fireworks in Anaheim thataway, the hour drawing onto midnight.
It is, by any measure, a Masters of the Universe kind of perch.
Neely Tucker is a Washington Post reporter. To comment on this article, send e-mail to firstname.lastname@example.org.