TRUST

Can I trust what I see here?
(reviewed and revised, 10/2013)

My name is Jim Phelps. I’m a psychiatrist (that’s an M.D. doctor, who can prescribe medications for mental illness, as well as do psychotherapy).  I treat severe brain disorders like schizophrenia, bipolar disorder, and "treatment resistant depression".  Most people I see with depression have already had 3 different antidepressants and often at least one good psychotherapist, and they’re still struggling.  So over the years I’ve focused on how to treat that group of people.  Not all of them have "bipolar disorder", but that diagnosis is the most treatable reason to still be struggling after all this treatment.

So after telling the things you'll find on this site to many patients, I thought I’d just write them down.  It has been an easy way to make this story available.  You're welcome to it.  I’ve picked the stuff that most people want to know, and written it the way I tell it out loud. Hopefully by reading here you’ll learn enough to decide -- for yourself  -- whether any of this applies to you.

You might wonder: "what’s in it for Dr. Phelps?"  Good question, one you should ask of any website like this.   Here's the answer.  I built this site in the year 2000, and have added to it steadily since then.  The pages that I use with my patients, I keep fairly up to date.  (There are lots of other pages that are not regularly updated.) so it is a convenient resource for me, and I hope for my patients as well.

This site receives no financial support from pharmaceutical companies or my employer-hospital or anywhere else. In its first year, I asked two pharmaceutical companies for a grant to help me get it started.  That was in 2001 in 2003. Keeping a website up costs almost nothing, so I've not sought any further grants. Nice to be independent of that!  For many  more details, if you're skeptical (that's fine, and wise), see my Funding page. 

How do you decide what to trust?

Don’t believe what you read here.  Really.  Be as skeptical as you want. Bipolar disorder is not a disease you want to have, that’s for sure.  I really hope you’ll look at some of the many references in here.  When you see a name hanging like thisPhelps, click it.  Some have a little note telling you where the information referred to actually came from, but most links take you to the reference itself.  These references are what you should listen to.  They are written by national experts.

Don’t take it from me:  read, ask questions, wonder out loud.  This illness is extremely tricky, both in diagnosis and treatment.  Eventually I hope you’ll know enough to participate very actively in each decision about your care.

What you can do is evaluate the "evidence".  Most of the national experts whose opinion I refer to here have had to meet a tough standard of evidence for their research.  You should trust them over someone who has not had to test their theory.  If you know what a randomized clinical trial is, and why that is the best thing to trust, skip to the next section.

Randomized Trials

The best medical evidence comes from "randomized clinical trials".Sackett These research projects always have a placebo treatment as well as the medication or therapy being tested.  That’s crucial in the mental health business because a good placebo (one that patients have some reason to believe in) gets good results quite often, 25-30% of the time for many variations of depression and anxiety.   This means that one person out of every three or four who was given an inactive treatment, like a sugar pill, gets better anyway.  If you believe in a treatment, you may well get better.  Somehow something in you, something you already had, is getting mobilized to help you feel better.

That means that any "treatment" you are offered, if it costs money or has any risks, ought to work better than a placebo.  And the only way to know that is to test them, one against the other. With the same type of patients in each group.  Treated exactly the same way.  With a tough, easily measured definition of "better" agreed upon in advance.  That’s a randomized trial.  If you have a choice of a treatment that has been shown effective this way, versus one that has not— well, here’s how my teacher put it: "Jim, there are a lot of treatments out there; why don’t you start with the ones that have some evidence that they work?"

No substitute for evaluation

This site is not intended to substitute for evaluation by a mental health specialist.  If you have a suspicion about this diagnosis and do not have access to a psychiatrist (an M.D. doctor, who can prescribe medication), often a good local therapist (Ph.D., MSW, or LCSW) can be helpful with a diagnostic evaluation.  Even if you do have "bipolar disorder", the therapist may be able to help a lot with coping, adjusting, and handling your stresses (caused by the illness, or by something else!).

Once you are certain about the diagnosis, if it is impossible for you to get to a psychiatrist, you can approach your primary care doctor about treatment.  However, understand that primary care doctors are not well trained (with some wonderful exceptions) in handling complicated mood problems.

This site is also written for primary care doctors.  If you simply cannot find, afford, or get to a psychiatrist who is experienced in bipolar disorders, you will find a letter here you can take to your doctor.  It will explain that you have begun to wonder about bipolar disorder as an explanation for your symptoms, and introduce her or him to my site.

Please understand that many doctors will not wish to be "led" into territory in which they do not feel comfortable.  They may be making a wise judgement, focusing on areas of medicine in which they can be effective, and leaving other areas to specialists.  That’s practicing good medicine, ok? It’s their choice, it’s a very legitimate choice, and it may well be the best thing for you, if they chose to say "no" to your requests to be evaluated or treated by them for "bipolar disorder".  Here's a short essay on How to Talk to Doctors if you need some help with that step.  

Cautions

This site is basically a guide to the medical literature on bipolar variations.  Most important concepts will be referenced:  that means I am referring you to the source of the information.  In most cases you can click your way right to the source document from my reference.  When you find a statement without a reference, you may assume that is my view or opinion.  Where there is strong disagreement among experts, I will try to point that out.  If I offer an opinion in an area of controversy, I will try to make it clear that it is my opinion.

Opinions in medicine are not worth much.  It is too easy to be led by one’s own experience, which may not be representative of the "big picture" of an illness or treatment.  Several of my colleagues believe I’m "too far out", finding bipolar disorder lurking behind every rock and tree.  So you should interpret my opinions with caution.  I could be completely wrong.  As I tell my patients, "the proof is in the pudding".  The "right" approach is ultimately defined by "what works".  If you get better, and stay better, you were right about something!  That’s what matters.  The "label" was only supposed to help guide treatment, and indicate what other people you might be like, so that their experience could be a guide for you.  If you are better, you don’t much need any particular label anymore!

However, you must guard against false hope.  If you come to believe you might have Bipolar II, and get your hopes up about a new potential treatment, you could be very disappointed if the treatment doesn’t work.  In that case my information here could have hurt you.  So, you will be safer if you approach everything you read skeptically.  Wait for the treatment to be effective before you really believe the "diagnosis", ok?

Finally, from a legal point of view, please understand that I am offering this because I hope it will help people, but I am only stating my perspective.  Any actions you pursue based on this site are your responsibility, based on your learning.  

On to Diagnosis -->