"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.
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.
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)