"Jim Phelps is a lovely and thoughtful man whose work with patients I deeply respect, but he should read the whole VA/DOD guidelines before suggesting that we didn’t raise concerns about risks over benefits, or take into consideration patient preferences. See pages 54-55 https://www.healthquality.va.gov/guidelines/MH/bd/VA-DoD-CPG-BD-Full-CPGFinal508.pdf
Second, Jim sees people at the margins, so it fits you, but don’t mistake his clinical practice, with his admitted bias (mostly confirmation bias) about the results of his practice. People see him because they haven’t responded to treatment but the are not average patients.
Evidence is by definition limited; only some things are studied, and only in some populations. Guidelines are not a substitute for clinical decision making. Reasonable people can disagree, but our guideline does not put effectiveness over risk. At all.
Our synopsis is here, but it behooves clinicians to read the whole guideline. As an an important caveat: those factors that experts say imply bipolar disorder (family history, poor response to antidepressant, etc.) have very poor predictive value. They cannot be used to make a diagnosis.
"We have to be more open and comfortable with uncertainty, with ourselves and with our patients." ~ Very much respect for you, Dr. Phelps, and your approach to the overwhelming challenge of supporting suffering people from within a framework that a) struggles to achieve a level of understanding that can justifiably confer confidence, and b) typically pressures the practitioner to behave misleadingly as though certainty rules. Thank you, on behalf of your patients and all the others you have and will influence, for stepping into that more vulnerable space of not-knowing.
I really appreciate the patient-centered thesis of this interview. I wonder what you think about cross-tapering with fluoxetine to discontinue troublesome anti-depressants? I have had a few patients who have done the single or several-bead-a-day approach with venlafaxine, though this has been uncommon in my practice. I am particularly interested in the idea of weighing risk equally with, or greater than, efficacy in the case of anti-psychotics. There should be more research on algorithms that minimize risk vs gaining a slight margin of efficacy. This is really refreshing.
I'll see if Jim has anything to say. I haven't had personal experience with using fluoxetine to taper in my clinical work, although I am aware that the recommendation exists. It makes a certain degree of sense. The withdrawal patient community has generally discouraged doing so, based on the idea that it doesn't adequately safeguard against withdrawal from the original med and it just exposes the person to another antidepressant.
In this interview with Dr. Phelps, among so many compelling exchanges, the following lines stuck with me: "You’ve previously written about the thorny problem of differential diagnosis of mixed states, that bipolar mixed states are nearly impossible to differentiate from depression that is comorbid with posttraumatic stress disorder, or generalized anxiety disorder, or attention-deficit disorder." It stuck with me in part because this problem has been a significant one for me as a patient, and has never been addressed - let alone with intelligence - by any clinician I have seen. Curiosity led me to follow up on Dr. Phelps's previous writing on this subject. This in turn led me to the Bipolar Spectrum Diagnosis Scale that he recommends.
As I reviewed the questions on the BSDS I found that a large majority of them could be responded to with "yes" by a person with PMDD - premenstrual dysphoric disorder. I mention this because I realized that in all the discussions of differential diagnosis, psychopathology, and etiology here on Psychiatry at the Margins, I haven't seen mention of women's and reproductive psychiatry.
First - I may have missed something, as I haven't read everything yet! Up to now I've been browsing and searching on other topics. Second, this takes nothing away from the brilliance, care, and nuance of everything I've read here. I mention it though because now that I've noticed it seems noteworthy. It's an important area that I'd be grateful to see explored with the depth and intelligence I've enjoyed on this site - and especially relevant when it comes to differential diagnosis, a frequent topic.
Many questions come to mind - differential diagnosis vs. comorbidity of PMDD and bipolar disorders? Is lack of attention to this differentiation one possible factor behind statistics showing significantly more women than men receive a bipolar diagnosis, especially bipolar II? How does the rise in research in women's and reproductive psychiatry intersect with broader contemporary debates in neurobiology and psychopathology? And, in particular, what new avenues of research into whole-body biological correlates of psychiatric conditions might be suggested by what is learned from women's experiences of major mental, cognitive, and emotional changes that are tied to changes in all organ systems, as happens during pregnancy?
Maybe you have a brilliant colleague who will want to share their research and thinking on such topics.
Thanks for considering these thoughts, and for all the work and conversations you share here.
Let's be careful about not confusing "guildelines" with actual data - most guidelines are extrememy basic and of little to no use for a psychiatrist (imo)
Comments by Michael Ostacher, MD, MPH on X/Twitter [who was involved in the development of the VA/DOD guidelines]: https://x.com/RecoveryDoctor/status/1891176349374820387
"Jim Phelps is a lovely and thoughtful man whose work with patients I deeply respect, but he should read the whole VA/DOD guidelines before suggesting that we didn’t raise concerns about risks over benefits, or take into consideration patient preferences. See pages 54-55 https://www.healthquality.va.gov/guidelines/MH/bd/VA-DoD-CPG-BD-Full-CPGFinal508.pdf
Second, Jim sees people at the margins, so it fits you, but don’t mistake his clinical practice, with his admitted bias (mostly confirmation bias) about the results of his practice. People see him because they haven’t responded to treatment but the are not average patients.
Evidence is by definition limited; only some things are studied, and only in some populations. Guidelines are not a substitute for clinical decision making. Reasonable people can disagree, but our guideline does not put effectiveness over risk. At all.
Our synopsis is here, but it behooves clinicians to read the whole guideline. As an an important caveat: those factors that experts say imply bipolar disorder (family history, poor response to antidepressant, etc.) have very poor predictive value. They cannot be used to make a diagnosis.
https://www.psychiatrist.com/jcp/synopsis-2023-us-department-veterans-affairs-department-of-defense-clinical-practice-guideline-management-bipolar-disorder/"
"We have to be more open and comfortable with uncertainty, with ourselves and with our patients." ~ Very much respect for you, Dr. Phelps, and your approach to the overwhelming challenge of supporting suffering people from within a framework that a) struggles to achieve a level of understanding that can justifiably confer confidence, and b) typically pressures the practitioner to behave misleadingly as though certainty rules. Thank you, on behalf of your patients and all the others you have and will influence, for stepping into that more vulnerable space of not-knowing.
Appreciate your comments, Joe!
I really appreciate the patient-centered thesis of this interview. I wonder what you think about cross-tapering with fluoxetine to discontinue troublesome anti-depressants? I have had a few patients who have done the single or several-bead-a-day approach with venlafaxine, though this has been uncommon in my practice. I am particularly interested in the idea of weighing risk equally with, or greater than, efficacy in the case of anti-psychotics. There should be more research on algorithms that minimize risk vs gaining a slight margin of efficacy. This is really refreshing.
I'll see if Jim has anything to say. I haven't had personal experience with using fluoxetine to taper in my clinical work, although I am aware that the recommendation exists. It makes a certain degree of sense. The withdrawal patient community has generally discouraged doing so, based on the idea that it doesn't adequately safeguard against withdrawal from the original med and it just exposes the person to another antidepressant.
In this interview with Dr. Phelps, among so many compelling exchanges, the following lines stuck with me: "You’ve previously written about the thorny problem of differential diagnosis of mixed states, that bipolar mixed states are nearly impossible to differentiate from depression that is comorbid with posttraumatic stress disorder, or generalized anxiety disorder, or attention-deficit disorder." It stuck with me in part because this problem has been a significant one for me as a patient, and has never been addressed - let alone with intelligence - by any clinician I have seen. Curiosity led me to follow up on Dr. Phelps's previous writing on this subject. This in turn led me to the Bipolar Spectrum Diagnosis Scale that he recommends.
As I reviewed the questions on the BSDS I found that a large majority of them could be responded to with "yes" by a person with PMDD - premenstrual dysphoric disorder. I mention this because I realized that in all the discussions of differential diagnosis, psychopathology, and etiology here on Psychiatry at the Margins, I haven't seen mention of women's and reproductive psychiatry.
First - I may have missed something, as I haven't read everything yet! Up to now I've been browsing and searching on other topics. Second, this takes nothing away from the brilliance, care, and nuance of everything I've read here. I mention it though because now that I've noticed it seems noteworthy. It's an important area that I'd be grateful to see explored with the depth and intelligence I've enjoyed on this site - and especially relevant when it comes to differential diagnosis, a frequent topic.
Many questions come to mind - differential diagnosis vs. comorbidity of PMDD and bipolar disorders? Is lack of attention to this differentiation one possible factor behind statistics showing significantly more women than men receive a bipolar diagnosis, especially bipolar II? How does the rise in research in women's and reproductive psychiatry intersect with broader contemporary debates in neurobiology and psychopathology? And, in particular, what new avenues of research into whole-body biological correlates of psychiatric conditions might be suggested by what is learned from women's experiences of major mental, cognitive, and emotional changes that are tied to changes in all organ systems, as happens during pregnancy?
Maybe you have a brilliant colleague who will want to share their research and thinking on such topics.
Thanks for considering these thoughts, and for all the work and conversations you share here.
Let's be careful about not confusing "guildelines" with actual data - most guidelines are extrememy basic and of little to no use for a psychiatrist (imo)