{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,9]],"date-time":"2026-10-09T14:44:22Z","timestamp":1791557062503,"version":"4.3.4"},"reference-count":20,"publisher":"BMJ","issue":"4","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2018,3,5]]},"published-print":{"date-parts":[[2018,4]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>To review prescribing practice concerning valproate, an established human teratogen, for the management of bipolar disorder in women of childbearing age.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>The Prescribing Observatory for Mental Health conducted a baseline clinical audit in the UK, as part of a quality improvement programme.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>Six hundred and forty-eight clinical teams from 55 mental health Trusts submitted retrospective treatment data relating to patients with a diagnosis of bipolar disorder.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Of the audit sample of 6705 patients, 3854 were 50 years of age or younger. Valproate was prescribed for 24% of women and 43% men in this age group, and the mean dose of valproate was lower in women (1196\u2009mg) than in men (1391\u2009mg). For only half of such women was there documented evidence that information had been provided on the risks for the unborn child and the need for adequate contraception. Valproate was more often used in men to treat mania and aggression, while the most common treatment targets in women were hypomania and relapse prevention.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Despite explicit recommendations in national treatment guidelines and published safety alerts and warnings regarding the use of valproate in women of childbearing age, current prescribing of this medication to such women in the context of the treatment of bipolar disorder falls short of best practice, particularly with regard to provision of information regarding the risks associated with exposure to valproate during pregnancy. While women younger than 50 years of age were less likely to be prescribed valproate than men in the same age group, and at a lower dosage, it is unclear to what extent this reflects clinicians\u2019 concerns about teratogenicity or is driven by perceptions of the indication for valproate, and the dosage required, for the treatment of different phases of the disorder in men and women.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2017-020450","type":"journal-article","created":{"date-parts":[[2018,4,13]],"date-time":"2018-04-13T02:52:54Z","timestamp":1523587974000},"page":"e020450","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":29,"title":["A UK clinical audit addressing the quality of prescribing of sodium valproate for bipolar disorder in women of childbearing age"],"prefix":"10.1136","volume":"8","author":[{"given":"Carol","family":"Paton","sequence":"first","affiliation":[{"name":"Prescribing Observatory for Mental Health (POMH-UK), Royal College of Psychiatrists, London, UK"},{"name":"The Centre for Psychiatry, Imperial College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John","family":"Cookson","sequence":"additional","affiliation":[{"name":"Tower Hamlets Centre for Mental Health, Royal London Hospital, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"I Nicol","family":"Ferrier","sequence":"additional","affiliation":[{"name":"Institute of Neuroscience, Newcastle University, Newcastle, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sumera","family":"Bhatti","sequence":"additional","affiliation":[{"name":"Prescribing Observatory for Mental Health (POMH-UK), Royal College of Psychiatrists, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elizabeth","family":"Fagan","sequence":"additional","affiliation":[{"name":"Prescribing Observatory for Mental Health (POMH-UK), Royal College of Psychiatrists, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas R E","family":"Barnes","sequence":"additional","affiliation":[{"name":"Prescribing Observatory for Mental Health (POMH-UK), Royal College of Psychiatrists, London, UK"},{"name":"The Centre for Psychiatry, Imperial College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2018,4,12]]},"reference":[{"key":"2025121514315466000_8.4.e020450.1","unstructured":"National Institute for Health and Care Excellence. Bipolar disorder: assessment and management. CG185. 2014 https:\/\/www.nice.org.uk\/guidance\/cg185?unlid=10051896022016726214857."},{"key":"2025121514315466000_8.4.e020450.2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(11)60873-8"},{"key":"2025121514315466000_8.4.e020450.3","doi-asserted-by":"publisher","DOI":"10.1177\/0269881116636545"},{"key":"2025121514315466000_8.4.e020450.4","doi-asserted-by":"publisher","DOI":"10.1016\/j.jad.2009.10.033"},{"key":"2025121514315466000_8.4.e020450.5","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(82)90908-4"},{"key":"2025121514315466000_8.4.e020450.6","doi-asserted-by":"publisher","DOI":"10.1016\/S1474-4422(11)70107-7"},{"key":"2025121514315466000_8.4.e020450.7","doi-asserted-by":"publisher","DOI":"10.1136\/jnnp-2013-306318"},{"key":"2025121514315466000_8.4.e020450.8","doi-asserted-by":"publisher","DOI":"10.1016\/S1474-4422(12)70103-5"},{"key":"2025121514315466000_8.4.e020450.9","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa0803531"},{"key":"2025121514315466000_8.4.e020450.10","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2013.2270"},{"key":"2025121514315466000_8.4.e020450.11","unstructured":"Report from Agence Nationale de S\u00e9curit\u00e9 du M\u00e9dicament and Caisse Nationale de l\u2019Assurance Maladie des Travailleurs Salari\u00e9s. Exposition in utero \u00e0 l\u2019acide valpro\u00efque et aux autres traitements de l\u2019\u00e9pilepsie et des troubles bipolaires et risque de malformations cong\u00e9nitales majeures (MCM) en France. France: Agence Nationale de S\u00e9curit\u00e9 du M\u00e9dicament and Caisse Nationale de l\u2019Assurance Maladie des Travailleurs Salari\u00e9s, 2017."},{"key":"2025121514315466000_8.4.e020450.12","unstructured":"Agency EM . PRAC recommends strengthening the restrictions on the use of valproate in women and girls. 2014. EMA\/612389\/2014 http:\/\/www.ema.europa.eu\/docs\/en_GB\/document_library\/Press_release\/2014\/10\/WC500175208.pdf"},{"key":"2025121514315466000_8.4.e020450.13","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(17)31866-4"},{"key":"2025121514315466000_8.4.e020450.14","unstructured":"National Institute for Clinical Excellence (NICE). Newer drugs for epilepsy in adults. Technology Appraisal 76. 2004 https:\/\/www.nice.org.uk\/guidance\/ta76"},{"key":"2025121514315466000_8.4.e020450.15","doi-asserted-by":"publisher","DOI":"10.1177\/0269881107077222"},{"key":"2025121514315466000_8.4.e020450.16","doi-asserted-by":"publisher","DOI":"10.1007\/s00737-007-0175-y"},{"key":"2025121514315466000_8.4.e020450.17","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1192\/pb.bp.110.030106","article-title":"Improving adherence to NICE guidance for bipolar illness: valproate use in women of childbearing potential","volume":"35","author":"Mace","year":"2011","journal-title":"Psychiatrist"},{"key":"2025121514315466000_8.4.e020450.18","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1155\/2015\/520784","article-title":"Valproate Prescribing in Women of Childbearing Age: An Audit of Clinical Practice","volume":"2015","author":"Atturu","year":"2015","journal-title":"Advances in Psychiatry"},{"key":"2025121514315466000_8.4.e020450.19","unstructured":"Medicines and Healthcare products Regulatory Agency. Toolkit on the risks of valproate medicines in female patients. 2016 https:\/\/www.gov.uk\/government\/publications\/toolkit-on-the-risks-of-valproate-medicines-in-female-patients (accessed Aug 2016)."},{"key":"2025121514315466000_8.4.e020450.20","unstructured":"Medicines and Healthcare products Regulatory Agency and NHS Improvement. Resources to support the safety of girls and women who are being treated with valproate. London: Medicines and Healthcare products Regulatory Agency and NHS Improvement. 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