The New Image of Diagnostic Accuracy

SAN DIEGO—“Various uses of quantitative EEG are emerging as possible ways to predict positive and adverse psychotropic medication responses,” reported Daniel A. Hoffman, MD, and while no one is ready to toss out the DSM-IV just yet, there is now increased evidence that the use of referenced EEG (rEEG) can sometimes do better than clinical diagnostic techniques in determining which psychotropic drugs will help an individual patient or in predicting whether a particular patient will do better without any medication at all.

According to Mark Schiller, MD, rEEG is a patented system that uses EEG and quantitative EEG (QEEG) to characterize features of brain function underlying a broad range of psychiatric syndromes. In the procedure, a patient’s EEG data are compared against a large, clinical outcome database of heterogeneous EEG/QEEG results and diverse medication responses. The patient’s EEG data are then mathematically classified and correlated with neuroactive medications likely to improve brain function in that particular case. The growing EEG/QEEG database currently includes children from age 6 to adults age 90 and covers a broad range of DSMM diagnoses.

In a previous multisite study presented by Drs. Hoffman and Schiller and colleagues at the 158th Annual Meeting of the American Psychiatric Association, 77% of 247 patients with treatment-refractory psychiatric disorders who underwent rEEG received subsequent medication changes as a result of information obtained through that testing. These medication changes were ones “that the psychiatrist would never have chosen without the aid of the rEEG,” Dr. Hoffman said.

Biomarker Basis

“rEEG is surfacing as a way to provide psychiatrists with a set of clinically useful biomarkers to guide physicians’ pharmacotherapeutic choices,” Dr. Hoffman said. Based on the number of such biomarkers, physicians can then determine how likely a patient is to respond to a particular type of medication, he explained. In cases where the rEEG report comes back showing a low biomarker prevalence, Dr. Hoffman has found, many of these patients feel better without any medications, during follow-up that so far has lasted two to nine months.

“Whether some of them will need medications later has yet to be determined, but in all cases, if they should, the rEEG report suggests that from a physiological perspective, they had not been on the right psychotropics to date and that implementing the correct medications should make a significant difference.”

Case in Point

In an update at the 17th Annual Meeting of the American Neuropsychiatric Association, Dr. Hoffman described the difference that rEEG made in the cases of three patients at the Neuro-Therapy Clinic in Englewood, Colorado.

The first was a 33-year-old woman who came in with her husband; both expressed discouragement and doubt that they would ever be able to live a normal life because of her depression and anxiety. At the time of her visit, the patient had tried 22 psychotropic medications. “Despite the challenging medication discontinuation tapering for the rEEG testing, the patient was feeling so well without medication that to date, she has decided to only use trazodone for sleep,” Dr. Hoffman reported. Her scores on the Beck Anxiety and Beck Depression scales both decreased significantly at follow-up.

There was also a 29-year-old woman with bipolar disorder. She was taking six psychotropic drugs “yet still felt suicidal, labile, sleep deprived, and exhausted,” Dr. Hoffman said. Following rEEG, which showed low biomarker prevalence, she went off all medications and said she felt “wonderful.” At two-month follow-up, she remained symptom-free and medication-free.

The third case was a 15-year-old male who had been diagnosed with oppositional defiant disorder and ADHD and had been on dextroamphetamine for five years. His medication was tapered off prior to the rEEG evaluation, and he remained medication-free thereafter; his parents reported that his behavior was back to where it had been before he took the stimulant drug.

Reasons for rEEG

Other reasons to consider the use of rEEG include the likelihood of increased remission rates as well as lower health care costs, according to Dr. Hoffman. He added that in reviewing his cases in which rEEG was used, he found that fewer medications were needed, medication compliance increased, and patients recovered more quickly.

“By targeting the medication response with objective evidence, the previously reluctant practitioner might now choose to use a medication with a higher side-effect profile. Having a neurophysiologic basis for that decision increases the comfort level and likelihood of the prescriber using these medications with greater confidence and increased success,” he said. “Certainly, more controlled research seems warranted to pursue rEEG’s place in modern psychiatry.”

—Jean McCann