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?
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