Medication and Obesity: The community feedback period for this idea began on 2/28/2019 and ended on 4/29/2019.

What is the problem that needs to be addressed? Please describe how it is related to mental health.
Reevaluation of including Depakote (Valproic Acid) in the formulary of an outpatient psychiatrist. Walk around a psychiatric ward or day program and you will run into quite a few people who are obese. The submitter’s experience is that females are impacted more significantly by this phenomenon than males. If you ask this group of obese people what medications they are taking, they will very likely list Depakote (100% rate as experienced by the submitter). The association between this particular drug and weight gain, metabolic syndrome, and diabetes – with its associated sequelae such as amputation, is statistically significant (https://www.ncbi.nlm.nih.gov/pubmed/24398897 https://www.ncbi.nlm.nih.gov/pubmed/15762830 https://www.ncbi.nlm.nih.gov/pubmed/14977465 https://www.rxabbvie.com/pdf/depakote.pdf
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4315115/). The combination of Depakote with an antipsychotic may increase the risk of weight gain associated morbidity/mortality.

Outpatient prescribing strategies are not standardized and many choices do exist. Some doctors continue the inpatient pharmacotherapy on an outpatient basis with no change. Some doctors titrate all inpatient medications to a different set of outpatient treatments. Some doctors prescribe monotherapy. Some doctors prescribe monotherapy with an “emergency” PRN for worsening symptoms. Some doctors go wild with polypharmacy. Physician agreement over what drugs are mood stabilizers isn’t consistent. Some health systems prescribe only risperdal because it “has the most safety data” (notice the claim isn’t because it is most safe).

With this diversity of expert opinion, asking the question “Can an outpatient mental health system function without Depakote?” is valid.

Why is this a concern for Orange County? What can Orange County and other counties learn from this project?
It is assumed that Orange County prefers to have residents that are less obese than more obese. It is also assumed that the sequelae from obesity are also undesireable. Healthcare providers that care for patients when activities of daily living are impaired – such as transfer – are placed at a greater risk for musculoskeletal injury when working with obese patients.

For the patient, weight gain impacts self-esteem, medication compliance and future life expectancy.

What is currently being done to resolve this problem in our county and throughout the United States? If applicable: Is it working; why or why not?
Psychiatric patients can be seen as likely to be lost to follow up and therefore thinking about long term morbidity and mortality hasn’t been a big priority. An unsubstantiated belief that keeping life expectancy low saves resources is a big hinderance to addressing morbidity and mortality nationwide.

What is new or different about this project idea? Please describe how this differs from what is already being done (Question 6). Please list any research that was done on this topic.
Can one run an outpatient health system without Depakote? This drug is on the WHO essential medications list with only two other options for bipolar disorder that some may consider outdated treatments. Just because the WHO says it is essential doesn’t mean that it must be used or is the best treatment for a particular (or any) patient.

What is the project idea? Please describe how this project will operate.
Recruit doctors into a coalition of outpatient prescribers that are willing to eliminate Depakote from their outpatient formulary. Can it be done? If so, then why keep Depakote on the formulary as an outpatient medication?

Additional Information:
Respondent skipped this question

February 13, 2019

2 comments

The choice of medication among prescribers is based on multiple factors including patient’s age, background, clinical history, response to past and current treatment regimes, presence and magnitude of side effects of medications, and other risk factors unique to the patient. All medications have risks and benefits. Medications are prescribed at a physician’s discretion after considering the benefits versus potential risks. As you suggested, there is a growing evidence suggestive of weight gain associated with Valproic Acid treatment.

However, recruiting physicians to eliminate any medication seems outside of the scope of Innovation.The purpose of an Innovation project is to evaluate the effectiveness of new and/or changed approaches and practices in mental health with a main focus on learning. What could we learn from having physicians eliminate Depakote from their outpatient formulary?

José R. Maldonado, M.D., FAPM, FACFE Professor of Psychiatry, Internal Medicine , Surgery, Emergency Medicine & Law at Stanford University started a benzodiazepine sparing protocol (https://www.ncbi.nlm.nih.gov/pubmed/28601135) for alcohol withdrawl because he didn’t think it was a good idea to give addicts benzodiazepines – an addictive class of drugs – to addicts. If he is successful then it will be about 17 years – 17 years being the lag time between new discovery and widespread implrementation – between his finalizing of the protocol and widespread adoption. He has already been working on it for about the past 5+ years. So, in 2037 – at the earliest – we may have a new standard for alcohol withdrawl treatment.

How do we get a doctor to attempt a Valproic Acid/Depakote sparing protocol? Whatever the answer is to that question – lets do that.

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