Bipolar treatments, including lifestyle and non-drug tools, by how useful and important they are in practice, graded by Dr. Phelps. From the Psychofarm podcast, July 2026: 13 ranked, each with the reason and the moment it was said.
It can change clinical practice. Start at the smallest dose, step up slowly with the patient in charge, and aim for a relatively low dose, which keeps the risks low.
“And my grade is S. And you put it in that upper left hand corner on purpose because we had talked about what things are likely to change people's clinical practice”
It would get an F on rigorous data since there is almost none, but it gets a B because it is important to watch, as it might one day replace lithium carbonate.
Placed in the middle because the data are so thin.
“Let's see. We don't have a tiers category for, who knows? Let's put it in the middle then. Let's give it a B for now. B, okay”
Using darkness on purpose, including amber glasses before bed and a very dark bedroom, helps make sleep regular and teaches patients to protect their circadian rhythm.
Placed when asked later where it went: "definitely up there" (34:50), the top tier.
“Thank you. Very similar to Dawn Simulators. And in fact, it's really actually just the same idea turned upside down to look at using darkness deliberately and the way that we're using light deliberately”
They work and are a useful tool, but they are a hassle, carry some risks, are expensive, and are hard to use correctly.
“Yeah. Because they work and it's a useful potential tool, but they're a hassle. They actually carry some risks. They're expensive. Hard to get people to actually use them really correctly”
It does something real, but for most people it is too hard to do long term. A more rational, Mediterranean-style diet is a reasonable version.
“Yeah, you can stop there at C. Because cool idea. I think by this time, really no question anymore as to whether or not it really actually does something”
Very low long-term risk and close to zero side effects when handled well. Best for the middle of the mood spectrum, and as an adjunct in bipolar one.
“So we've got low-dose lithium up there already. If we hadn't talked about that one first, Lamotrigine would go first. This is my absolute numero uno S category medication”
They make things worse in bipolar by promoting cycling and mixed states. They are not a never, but come after multiple other things.
The F was proposed by the host and accepted by the guest.
“Yeah, definitely do. Psychotherapies. And we should say SSRIs, antidepressants generally for treatment of bipolar, it's not a never use them. It's a use them after you've tried multiple other things”
An underappreciated tool that needs careful management. It carries real risks and should be avoided in women of reproductive age unless truly needed.
Placed at B, then bumped to A (55:42) partly to be provocative.
“Because it's an underappreciated tool. Yes, it can cause Stevens-Johnson syndrome. Yes, it is a teratogen. So using it in reproductive age women is a whole different ballgame”
Far more tolerable and similar in idea to carbamazepine, but the one large randomized trial was negative and sodium still needs watching.
“Moreover, it only has one randomized trial that I know of, one large one anyway. It was negative. So you're using something that has randomized trial evidence for it. It doesn't work”
These rankings are the hosts’ and guests’ opinions from one episode, for clinicians and the curious. They are education, not medical advice, and not a guide to choosing a treatment for any one person.
Educational content only. These resources are for education. They are not medical advice and not a substitute for clinical judgment, current guidelines, or individualized patient care.