Dear Dr. Phelps,

Your website is extremely informative and interesting.  I commented you for providing the public with quality information on bipolar disease.

I have a comment both as a physician and as a patient.  The concept of the bipolar spectrum and harmful effects of antidepressant is very sound and logical.  But the proof must be in the pudding, that is I have seen probably over 150 bipolar patient with residual depression on mood stablizers alone or in combination.  I, myself, have had bouts of depression responding only to MAO inhibitors. My father and brother are both bipolar.  I have never responded to a mood stablizer as well.  So theorically your views and ideas are very appealing, but empirically I have not seen evidence in my patient population or in my self. Is this simply a matter of differences patient populations?

Sincerly,
Paul
 

Hello Paul 
Thanks for writing.  Not sure how to account for the different impressions we've each reached.  I thoroughly agree about pudding as proof.  I suspect I may hold back too long in some cases where someone like you might press ahead at least with an MAOI, if not routine antidepressants.  Yet I do so in part out of the concern about the potential to "do harm" with antidepressants.  I try to pay attention to the possibility that I'm at risk of "doing harm" by holding back too much! 

 I would agree that MAOI's probably have the least potential to do this kind of harm.  If there was one available without the dietary proscriptions, I'd probably turn to it more frequently as an empiric possibility for folks who seem to be more nearly unipolar with few features to raise the specter of "bipolar spectrum" risk (although the article a few years back in J Clin Psych entitled "the making of a user-friendly MAOI diet" really helped -- seen that one?)  

Someday I'd love to convene a group of practitioners to brainstorm over this particular issue.  Maybe we'll run into one another at some such convention (your name sounds familiar?  I'll keep it "filed" and hope to meet you sometime).  Thanks for taking the time to keep me thinking.  

Jim Phelps