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The need for brain imaging in clinical psychiatry

  • Mary Davoren (a1), Anne Doherty (a1), Eugene Breen (a1), John Sheehan (a1) and Brendan D. Kelly (a1)...
Abstract
Aims and Method

To explore clinical indications for, and results of, brain imaging in general adult psychiatry. We reviewed the 100 most recent uses of brain imaging on in-patients at the Department of General Adult Psychiatry, Mater Misericordiae University Hospital, Dublin.

Results

Patients were of a mean age of 55.3 years. the most common indications for brain scans were cognitive impairment (33%) and other neurological concerns (e.g. seizures; 30%). Overall, 47% of scans were abnormal, with ischaemia (17%) and atrophy (10%) being the most common abnormalities. Patients with abnormal scans were older than those with normal scans (mean age 61.9 and 48.7 years respectively; P<0.001).

Clinical Implications

A high proportion of brain scans demonstrate abnormalities in general adult psychiatry patients, especially among older patients.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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1 Sharma, T, Sheringham, J. Brain imaging in psychiatry: what has it done for the patient? Hosp Med 2002; 63: 326–7.
2 Kelly, A, Teljur, C. A New National Deprivation Index for Health and Health Services Research: Short Report. Small Area Health Research Unit (Department of Public Health & Primary Care, Trinity College), 2004.
3 Mental Health Commission. Community Mental Health Services in Ireland: Activity and Catchment Area Characteristics 2004. Mental Health Commission, 2006.
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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The need for brain imaging in clinical psychiatry

  • Mary Davoren (a1), Anne Doherty (a1), Eugene Breen (a1), John Sheehan (a1) and Brendan D. Kelly (a1)...
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eLetters

The Need for Judicious use of Brain Imaging in Clinical Psychiatry

Pauline M Devitt, Senior Registrar in Psychiatry
29 August 2009

Davoren et al’s recent study has addressed an understudied area of clinical psychiatry. Their conclusion appears to be that because a high proportion (47%) of brain scans revealed abnormal findings, their use was appropriate. Appropriate use of neuroimaging can only be determined by a cost (including economic) benefit analysis and this was absent from their paper.

A number of authors have attempted to establish guidelines for the use of neuro-imaging in clinical psychiatry. Agzarian et al reviewed all CT brain scans that were requested by a psychiatric service over a 2 year period retrospectively and found that 95% of CT scans were normal andthe remaining 5% had abnormalities which were considered to be unrelated to the psychiatric condition and probably predated it.1 None of these patients had focal neurological signs and they concluded that the routine use of CT brains in psychiatric patients without focal neurological signs may not be justified.

Moles et al also reviewed 150 cases of psychiatric patients who received CT scans to exclude pathology and found that although 53% of CTscans were abnormal, only 11% influenced patient care and only 2% identified potentially reversible lesions.2 The authors also identified the following clinical factors as the most likely predictors of an abnormal scan -an abnormal cognitive examination, an abnormal neurologicalexamination and advanced patients age.

Hollister and Shah reviewed the use of neuro-imaging in a psychiatric hospital over a 2 year period and concluded that neuro-imaging was indicated in those psychiatric patients with cognitive impairment(to evaluate dementia), in those who developed new or unexplained neurological signs and in patients over the age of 50 years who developed a first psychotic break or personality change.3

However one study by Erhart et al in 2005 did conclude that MRI scanscould be useful in patients with suspected underlying medical problems, causing psychiatric symptoms.4 They reviewed the charts of 253 patients who underwent an MRI (not including those who were referred for evaluationof dementia) and discovered that 15% had findings that modified treatment recommendations and 2% had a new medical diagnosis requiring treatment.

Further audits of neuro-imaging in psychiatry which include analysis of effects on patient management will not only save money but also reduce non monetary costs such as anxiety/ panic (Marshall et al)5, radiation (Brenner & Hall)6, and other adverse effects.

References:1. Agzarian MJ, Chryssidis S, Davies RP, Pozza CH. Use of routine computedtomography brain scanning of psychiatry patients. Australasian radiology 2006; 50:27-28.

2. Moles JK, Franchina JJ, Sforza P. Increasing the Clinical Yield ofComputerised Tomography for Psychiatric Patients. Gen Hosp Psychiatry 1998; 20:282-291.

3. Hollister LE, Shah NN. Structural brain scanning in psychiatric patients: a further look. J Clin Psychiatry 1996 Jun; 57(6): 241-4.

4. Erhart SM, Young AS, Marder SR, Mintz J. Clinical utility of magnetic resonance imaging radiographs for suspected organic syndromes in adult psychiatry. J Clin Psychiatry 2005 Aug; 66(8): 968-73.

5. Marshall J, Martin T, Downie J, Malisza K. A Comprehensive Analysis of MRI Research Risks: In Support of Full Disclosure. Can. J. Neurol. Sci. 2007; 34: 11-175.

6. Brenner DJ, Hall EJ. Computed Tomography- An Increasing Source of Radiation Exposure. N Engl J Med 2007; 357:2277-84.

Pauline M. Devitt Senior Registrar in Psychiatry, Millmount Mental Health Clinic, Millmount, Drumcondra, Dublin. email:paulinedevitt@eircom.net, Tel 018378763 Fax 018378313. Declaration of interest: None.

Declan Murray Consultant Psychiatrist, Curam Mental Health Clinic, Swords, Co Dublin. Declaration of interest: None.
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Conflict of interest: None Declared

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