1. Prescribing valproate for bipolar disorder
POMH-UK Topic 2e supplementary audit Screening for metabolic side effects of antipsychotic drugs in patients under the care of assertive outreach teams
POMH-UK Quality Improvement Programme. Topic 15a (baseline)
Prescribing valproate for bipolar disorder
Coventry and Warwickshire Partnership Trust
© 2016 The Royal College of Psychiatrists

2. Prescribing valproate for people with bipolar disorder
Valproate has some efficacy in the treatment of acute episodes of mania and is one of the treatment strategies recommended by NICE for the prevention of relapse in people with bipolar disorder.
Like all medicines, valproate is associated with side effects and it is important that adequate attention is paid to reviewing both the benefits and harms associated with this treatment.
Valproate is a known major human teratogen and the MHRA has recently reminded prescribers of the association of in-utero exposure to valproate with neural tube defects, cardiac malformations, childhood autism and reductions in IQ.

3. Method
POMH-UK invited all member NHS Trusts, Health Boards and relevant healthcare organisations to participate in baseline of prescribing valproate for bipolar disorder.
55 Trusts participated in this baseline audit, submitting data for 6,705 patients from 678 clinical teams.  Demographic, clinical and service-related data were collected for each patient.
The Prescribing Observatory for Mental Health (POMH-UK) invited all member National Health Service (NHS) Trusts, Health Boards and relevant healthcare organisations in the United Kingdom providing specialist mental health services to participate in an audit-based quality improvement programme focussing on prescribing practice for prescribing valproate in bipolar disorder. Staff from each organisation were invited to attend one of several regional workshops to discuss and review the aims, objectives and methodology of the proposed audit. Comment and discussion at the workshops led to refinements of the audit methodology and data collection tool. All Trusts and clinical teams were self-selected in that they chose to participate; All participating Trust/healthcare organisations (hereafter referred to as ‘Trusts’) are listed in alphabetical order in Appendix A of the report.
Demographic, clinical and service related data were collected for each eligible patient. A copy of the data collection tool can be found in Appendix B of your report. The POMH-UK lead for each participating Trust will be sent an Excel dataset containing their Trust’s data. This allows Trusts to conduct further analyses on their own data should they wish.

4. The total national sample

5. Demographic characteristics of the national sample
Key demographic characteristics
TNS
N=6,705
Subgroup prescribed valproate
N= 2,416
Subgroup not prescribed valproate
N=4,289
Gender
Male
2,648 (40%)
1,186 (49%)
1,462 (34%)
Female
4,057 (60%)
1,230 (51%)
2,827 (66%)
Ethnicity
White/White British
5,159 (77%)
1,850 (77%)
3,309 (77%)
Asian/Asian British
482 (7%)
198 (8%)
284 (7%)
Black/Black British
409 (6%)
156 (6%)
253 (6%)
Mixed or other
655 (10%)
212 (9%)
443 (10%)
Age
Mean age in years (SD)
47 (13)
49 (13)
46 (13)
16-25 years
372 (6%)
100 (4%)
272 (6%)
26-35 years
1,061 (16%)
298 (12%)
763 (18%)
36-45 years
1,458 (22%)
478 (20%)
980 (23%)
46-55 years
1,879 (28%)
711 (29%)
1,168 (27%)
56-65 years
1,324 (20%)
576 (24%)
748 (17%)
66 years and over
611 (9%)
253 (10%)
358 (8%)
Clinical service
Adult community mental health team
5,853 (87%)
2,026 (84%)
3,827 (89%)
Acute adult psychiatric ward or Psychiatric intensive care unit
539 (8%)
250 (10%)
289 (7%)
Forensic services
132 (2%)
74 (3%)
58 (1%)
Adult home treatment team/crisis intervention team
114 (2%)
38 (2%)
76 (2%)
Adult inpatient rehabilitation services
47 (1%)
22 (1%)
25 (1%)
Tertiary affective disorders service
20 (<1%)
6 (<1%)
14 (<1%)
This table shows the demographic characteristics of the total patient sample and subgroups prescribed and not prescribed valproate. The table demonstrates that, compared with women, men who have a diagnosis of bipolar disorder are more likely to be prescribed valproate.
The prevalence of valproate prescribing is higher in inpatient (46%) than community settings (34%).

6. Clinical characteristics of the total national sample
Key demographic characteristics
Total sample N=6,705
Subsample prescribed valproate
N=2,416
Subsample not prescribed valproate
N=4,289
Diagnosis of bipolar disorder
ICD-10 F31 diagnostic code for bipolar disorder
5,782 (86%)
2,118 (88%)
3,664 (85%)
No ICD-10 code for bipolar disorder but current clinical diagnosis of bipolar disorder
802 (12%)
259 (11%)
543 (13%)
No ICD-10 code for bipolar disorder but currently has a provisional or differential diagnosis of bipolar disorder
121 (2%)
39 (2%)
82 (2%)
Current phase of bipolar
Current episode hypomanic (F31.0)
456 (7%)
190 (8%)
266 (6%)
Current episode manic (F31.1, F31.2)
546 (8%)
273 (11%)
273 (6%)
Current episode depressed (F31.3, F31.4, F31.5)
914 (14%)
655 (15%)
Current episode mixed affective state (F31.6)
289 (4%)
102 (4%)
187 (4%)
Current stable, in partial or full remission
3,575 (53%)
1,270 (53%)
2,305 (54%)
Unclear
583 (9%)
211 (9%)
372 (9%)
Other
342 (5%)
111 (5%)
231 (5%)
Rapid cycling
Yes
220 (3%)
103 (4%)
117 (3%) No
6,485 (97%)
2,313 (96%)
4,172 (97%)
Other current psychiatric diagnoses within ICD-10 categories
F00-F09
64 (1%)
30 (1%)
34 (1%)
F10-F19
766 (11%)
331 (14%)
435 (10%)
F20-F29
285 (4%)
121 (5%)
164 (4%)
F30, F32-F39 excluding bipolar disorder
188 (3%)
50 (2%)
138 (3%)
F40-F48
370 (6%)
95 (4%)
275 (6%)
F50-F59
62 (1%)
19 (1%)
43 (1%)
F60-F69
556 (8%)
170 (7%)
386 (9%)
F70-F79
26 (1%)
36 (1%)
F80-F89
58 (1%)
28 (1%)
F90-F98
15 (1%)
F99
22 (<1%)
7 (<1%)
15 (<1%)
Number of current psychiatric diagnoses
Bipolar disorder only
4,621 (69%)
1,667 (69%)
2,954 (69%)
One other
1,735 (26%)
621 (26%)
1,114 (26%)
Multiple
349 (5%)
128 (5%)
221 (5%)
This table shows the clinical characteristics of the total patient sample and subgroups prescribed and not prescribed valproate. The data in this table suggest that valproate may be particularly used to target episodes of elevated mood. Otherwise, the clinical characteristics of the sub-groups prescribed or not prescribed valproate are similar.
The point prevalence of rapid cycling at 3% of those with a diagnosis of bipolar disorder in our sample seems to be low. For example, the findings of a large epidemiological study suggest that the 12-month prevalence of rapid cycling is around a third of those with a lifetime diagnosis of bipolar disorder (Lee et al, 2010).

7. Patient clinical setting and current phase of bipolar disorder
Acute (PICU and adult psychiatric ward)
Adult home treatment/
crisis team
Adult community mental health team
Hypomania (n=456)
75 (16%)
16 (4%)
346 (76%)
Mania (n=546)
220 (40%)
30 (5%)
273 (50%)
Depressed (n=914)
81 (9%)
24 (3%)
799 (87%)
Currently stable (n=3,575)
49 (1%)
25 (1%)
3,412 (95%)

8. Initiation of valproate
Practice standard 1: Do not routinely prescribe valproate for women of child-bearing age
The standards are derived from NICE Guideline for Bipolar Disorder (NICE CG185, 2014)
The audit data presented provide evidence of compliance for your Trust and the national sample with specific recommendations from this NICE guideline.
Where valproate was newly prescribed for a woman of child-bearing age (50 years of age or younger), there was no documented discussion about the need for contraception in almost half and a similar proportion were not informed about the potential teratogenic effects of this medication. In just over a quarter of these women, there was nothing documented to suggest there had been any discussion at all about the potential benefits or side effects of the newly initiated valproate treatment.
Women of child-bearing age were prescribed slightly lower doses of valproate than men. However in the vast majority of these women the dose of valproate prescribed is known to be associated with at least a three-fold increase in the risk of having a child with a major congenital malformation.

9. Proportion of patients prescribed valproate within the total national sample and your Trust

10. Patients 50 years of age or younger across subgroups prescribed and not prescribed valproate
≤50 years of age
> 50 years of age
Male
N=1,490
Female
N=2,364
N=1,158
N=1,693
Prescribed valproate
648 (43%)
574 (24%)
538 (46%)
656 (39%)
Not prescribed valproate
842 (57%)
1,790 (76%)
620 (54%)
1,037 (61%)
As can be seen in the table, valproate is prescribed for one in four women of child-bearing age (defined as 50 years of age or younger).
Women of child-bearing age are less likely to be prescribed valproate
But 1 in 4 of such women are prescribed valproate.

11. Daily dose of valproate for men and women younger than 50 years of age
Teratogenic potential of valproate is dose-related
Daily dose of valproate lower for women than men
Vast majority of women prescribed a dose of valproate associated with at least 3-fold risk of major congenital malformation.
The MHRA ( has concluded that the teratogenic potential of valproate is greatest at higher doses, which they define as being above 1,000mg (1 gram) daily. They further conclude that the available data do not allow for the identification of a threshold dose below which there is no risk. A large registry study (Tomson et al, 2011) reported that the prevalence of major congenital malformations was 4.2% in neonates whose mothers were prescribed less than 700mg/day valproate during pregnancy. The respective figures for neonates born to mothers who were prescribed daily valproate doses of 700 to 1,499mg and 1,500mg and above were 9% and 23% respectively. Note that the recommended starting dose for valproate is above the lower threshold cited in this study.
Women of child-bearing age were prescribed slightly lower doses of valproate than men. However in the vast majority of these women the dose of valproate prescribed is known to be associated with at least a three-fold increase in the risk of having a child with a major congenital malformation.
The figures show that women are prescribed slightly lower doses of valproate than men. Nevertheless, the doses of valproate prescribed for the vast majority of women of childbearing age are known to be associated with a substantial risk of harm to an unborn child.

12. Initiation of valproate
Practice standard 2: If valproate is prescribed for a woman of child-bearing age, there should be documented evidence that the woman: a. is aware of the need to use adequate contraception b. Has been informed of the risks that valproate would pose to an unborn baby

13. Proportion of patients prescribed valproate who had information about adequate contraception and were informed of the risks that valproate would pose to an unborn baby
Documented evidence regarding woman’s childbearing potential or use of contraception
TNS
N = 74
No documented evidence of protection against pregnancy
48 (66%)
Takes oral contraceptive
9 (12%)
Patient has an IUD/coil fitted
4 (5%)
Patient has had an injectable contraceptive or implant fitted
6 (8%)
Other contraceptive method documented
Patient has undergone an oophorectomy/hysterectomy/endometrial ablation
1 (1%)
Documented evidence of the following:
TNS
N = 74
A general discussion regarding side effects and benefits of the treatment
49 (66%)
Discussion with the woman of the need for adequate contraception during valproate treatment
41 (55%)
The woman was informed of the risks to the foetus (tetragenicity, including neural tube defects/spina bifida) when valproate is taken during pregnancy
37 (50%)
The woman was informed of the implications for the longer-term cognitive development of the child (for example, neuro-development delay, autistic spectrum disorders) when valproate is taken during pregnancy
18 (24%)
The woman was given the MHRA leaflet that outlines the problems associated with valproate in pregnancy
6 (8%)
None of the above
20 (27%)
Where valproate was newly prescribed for a woman of child-bearing age (50 years of age or younger), there was no documented discussion about the need for contraception in almost half and a similar proportion were not informed about the potential teratogenic effects of this medication. In just over a quarter of these women, there was nothing documented to suggest there had been any discussion at all about the potential benefits or side effects of the newly initiated valproate treatment.

14. Initiation of valproate
Practice standard 3: Prior to initiating treatment with valproate, the following should be documented in the clinical records: weight and/or BMI, the results of liver function tests (LFTs), and a full blood count (FBC)

15. Proportion of patients prescribed valproate who had test or measures documented in the 3 months before treatment was initiated in the TNS subsample (inpatient n =189/outpatient n=88)
Compared with outpatient settings, baseline physical health checks were more likely to be carried out in inpatient settings. This may partly reflect easier access to phlebotomy in inpatient settings. In one in four patients in inpatient settings and almost one in two in outpatient settings, there were no documented baseline tests/measures for any of the recommended parameters. This makes it difficult if not impossible to determine whether any abnormalities that are identified later are likely to be associated with valproate treatment or not.

16. Initiation of valproate
Practice standard 4: Patients prescribed valproate should receive written information about the use of this medicine specifically for treating bipolar disorder 

17. Written information about the use of valproate offered to inpatients starting treatment: TNS subsample (n=189)
In almost three quarters of inpatients, there was no documented evidence that information about valproate treatment was offered at the time that treatment was initiated. Where written information was provided, it was mostly in the form of a leaflet that addressed the use of this medicine in bipolar disorder.
It is assumed that all outpatients received, as a minimum, a manufacturer’s patient information leaflet (PIL) as this is packed with the medication and it is a legal requirement for dispensing pharmacists to provide it. However 2 in every 5 outpatients received sodium valproate, a preparation that is licensed for epilepsy but not for bipolar disorder. Therefore, such patients would have received a PIL covering the use of this preparation for epilepsy with no mention of bipolar disorder.

18. Early-on treatment review
Practice standard 5: Patients prescribed valproate should have an early, on-treatment review that includes screening for the common side effects of the medication (e.g. weight gain, nausea, tremor)
The standards are derived from NICE Guideline for Bipolar Disorder (NICE CG185, 2014)
The audit data presented provide evidence of compliance for your Trust and the national sample with specific recommendations from this NICE guideline.

19. Documented treatment review within 3 months of valproate initiation, TNS subsample (n=263) and your Trust (n=1)
The figure shows that around a quarter of patients did not have an early on-treatment review of the efficacy and tolerability of valproate. Where a review was documented, therapeutic response to valproate was more likely to be assessed than side effects.

20. Continuing valproate treatment
Practice standard 6: Body weight and/or BMI, blood pressure, plasma glucose and plasma lipids should be measured at least annually during continuing valproate treatment
The standards are derived from NICE Guideline for Bipolar Disorder (NICE CG185, 2014)
The audit data presented provide evidence of compliance for your Trust and the national sample with specific recommendations from this NICE guideline.

21. Documented evidence of test/measures over the past 12 months in the TNS subsample (n=1,976) and your Trust (n=39)
In almost half of the total national sample, screening for each of the four cardiometabolic risk factors (obesity, hypertension, elevated plasma glucose, dyslipidaemia) had been undertaken in the previous year. Compared with the sub-group who were not prescribed antipsychotic medication in addition to valproate, these proportions were only modestly higher in the sub-group who were co-prescribed antipsychotic medication. This suggests that a diagnosis of bipolar disorder is a major driver for undertaking the NICE-recommended physical health checks (NICE, 2014).

22. Treatment target 1: Serum valproate levels should not be routinely monitored unless there is evidence of ineffectiveness, poor adherence or poor tolerability/toxicity
In some cases, the evidence for practice recommendations falls short of supporting an audit standard, i.e. being applicable in 100% of cases. However, the evidence may be sufficient to support general guidance for good practice, allowing that deviation may be appropriate in a proportion of cases. For such treatment targets, clinicians may be particularly interested in how their practice benchmarks with their peers.

23. Reasons for measuring plasma valproate levels and documented results (n=227)
Only a small minority (227/1976; 11%) of the total national sample had a documented valproate serum level in the previous year. This suggests that while valproate levels are not routinely monitored in the majority of patients who receive this treatment for bipolar disorder, up to 1 in 11 may receive such monitoring, often in the absence of a clear clinical rationale. In 72% (164/227) of these cases the test was conducted for reasons other than ineffectiveness of treatment, poor adherence or poor tolerability/side effects.
Where testing had been undertaken, the documented rationale for this and the test results are shown on the chart. Where the clinical rationale for testing was suspected non-adherence to treatment, the test results confirm this suspicion in the majority of cases. The pattern of test results associated with all other reasons for testing suggests that, overall, testing is unlikely to helpfully inform treatment plans in these cases.

24. Other aspects of national prescribing practice that may inform reflective practice sessions

25. Medications prescribed for patients currently in a depressive episode (n=914) 
Quetiapine and lamotrigine both alone and in combination are evidence-based treatments for bipolar depression and their use is supported by NICE for this indication. The evidence for the efficacy of antidepressants in the treatment of bipolar depression is more controversial: NICE concluded that the available evidence primarily supports the use of fluoxetine (ideally in combination with olanzapine) in the treatment of bipolar depression and is cautious about the use of antidepressants for the prevention of relapse (NICE, 2014).
This high prevalence of antidepressant prescribing seen in this audit is consistent with other surveys of prescribing practice (Levine et al, 2000).
We found that where an antidepressant is prescribed, clinicians do not preferentially select fluoxetine and that around a third of patients who are currently stable are prescribed antidepressants long-term. This suggests that clinicians may manage bipolar depression in a similar way to unipolar depression.
When interpreting this figure it should be borne in mind that the medications shown may have been started prior to the current episode of illness and therefore it cannot be assumed that they were initiated to treat this episode.

26. Medications prescribed for patients whose current phase of illness is manic (n=546)
Antipsychotic medication is the mainstay of treatment for episodes of mania. This is supported by NICE.
Acute treatment trials support the use of valproate in mania (Yildiz A et al, 2011) but network meta-analysis ranks it below the more efficacious dopamine antagonists; the strong evidence base for the latter has resulted in their acceptance as first line pharmacological treatment for mania. Valproate may be preferred, or instituted together with an antipsychotic drug (Grande I et al, 2015), when the plan is to continue it as long-term treatment. Valproate semisodium is effective in severe mania (Macritchie K et al, 2003) when the dose should be titrated upwards quickly to get control but it is also appropriate for the treatment of less severe manic states.
Valproate was frequently prescribed for patients who were experiencing an episode of mania – and indeed, elevated mood was the most common target symptom for newly initiated prescriptions for valproate.
When interpreting this figure it should be borne in mind that the medications shown may have been started prior to the current episode of illness and therefore it cannot be assumed that they were initiated to treat this episode.

27. Medications prescribed for patients whose current phase of illness is stable, in partial or full remission (n=3,575)
Valproate is endorsed by the 2014 NICE Guidelines for Bipolar Disorder (NICE CG185, 2014) as a second-line agent after lithium for long-term treatment of bipolar disorder. However data on valproate in long-term treatment are limited. The comparison with placebo is driven by a single RCT of valproate (as valproate semisodium, Depakote®) which showed rates for all relapse of 24% against placebo at 38% (Bowden CL et al, 2000). The absolute risk reduction was statistically non-significant (Goodwin GM et al, 2016).
The BALANCE trial compared valproate, lithium and the combination in a randomized, non-blind maintenance study with a run-in of the combination treatment to minimise drop-outs after randomization. Lithium alone and in combination with valproate was superior to valproate alone (Geddes JR, 2010).
The main evidence for a positive effect of valproate on the long term outcome of bipolar disorder comes from studies of it in combination with antipsychotics. When acute mania or depression responds to the combination of quetiapine with valproate or lithium, then continuing the combination, versus switching to lithium/ valproate monotherapy, is associated with a lower rate of relapse of both depression and mania (Vieta E et al, 2008),( Suppes T et al, 2009). For olanzapine (Tohen M et al, 2004) and aripiprazole (Marcus R et al, 2011), RCTs have shown that, when the combination of either drug with lithium or valproate is effective in treating acute mania, then continuing the combination is associated with a lower risk of manic relapse than switching to lithium or valproate alone.
When interpreting this figure it should be borne in mind that the medications shown may have been started prior to the current episode of illness and therefore it cannot be assumed that they were initiated to treat this episode.

28. Clinical reasons/target symptoms for starting valproate (n=277)
In three out of every five patients who recently started treatment with valproate, the target symptoms were those of mania/hypomania. The use of valproate in this phase of illness is consistent with the recommendations in NICE guidelines for the treatment of bipolar disorder.

29. Data from each Trust are presented by code.
Trust-level findings
Analyses presented in this section were conducted for each Trust individually and for the total sample to allow benchmarking.
Data from each Trust are presented by code.
Your Trust code is code 040

30. Trust findings for practice standard 1
Proportion of patients with bipolar disorder prescribed valproate by Trust
The Trusts with the lowest proportion of women 50 years of age or younger prescribed valproate are on the left hand side of the Figure and the Trust with the highest proportion are on the right.

31. Trust findings for practice standard 3
Proportion of patients prescribed valproate who had BMI/weight measure documented in the 3 months before treatment was initiated, at Trust level and in the TNS subsample (n=227)
The Trusts with the highest proportion of patients for whom documented evidence of BMI/weight was measured in the 3 months before treatment was initiated are on the left hand side of the Figure and the Trust with the lowest proportion are on the right.

32. Trust findings for practice standard 3
Proportion of patients prescribed valproate who had liver function test (LFTs) documented in the 3 months before treatment was initiated, at Trust level and in the TNS subsample (n=227)
The Trusts with the highest proportion of patients for whom documented evidence of liver function tests was measured in the 3 months before treatment was initiated are on the left hand side of the Figure and the Trust with the lowest proportion are on the right.

33. Trust findings for practice standard 3
Proportion of patients prescribed valproate who had full blood count (FBC) documented in the 3 months before treatment was initiated, at Trust level and in the TNS subsample (n=227)
The Trusts with the highest proportion of patients for whom documented evidence of full blood count was measured in the 3 months before treatment was initiated are on the left hand side of the Figure and the Trust with the lowest proportion are on the right.

34. Trust findings for practice standard 4
Proportion of patients who received written information about the use of valproate: inpatients only (n=189)
The Trusts with the highest proportion of inpatients who received written information about the use of valproate are on the left hand side of the Figure and the Trust with the lowest proportion are on the right.

35. Trust findings for practice standard 5
Documented evidence of review of therapeutic response within 3 months of valproate initiation as part of an early on-treatment review (n=263), by Trust
The Trusts with the highest proportion of patients for whom documented evidence of review of therapeutic response within 3 months of valproate initiation are on the left hand side of the Figure and the Trust with the lowest proportion are on the right.

36. Trust findings for practice standard 5
Documented evidence of weight gain or other common side effects of valproate as part of an early on-treatment review (n=263), by Trust
The Trusts with the highest proportion of patients for whom documented evidence of review of weight gain or other common side effects of valproate are on the left hand side of the Figure and the Trust with the lowest proportion are on the right.

37. Trust findings for practice standard 5
Documented evidence of undertaking FBC and/or LFTs as part of an early on-treatment review (n=263), by Trust
The Trusts with the highest proportion of patients for whom documented evidence of undertaking FBC and/or LFTs as part of an early-on treatment review are on the left hand side of the Figure and the Trust with the lowest proportion are on the right.

38. Trust findings for practice standard 5
Documented evidence of information relating to medication adherence as part of an early on-treatment review (n=263), by Trust
The Trusts with the highest proportion of patients for whom documented evidence of medication adherence as part of an early-on treatment review are on the left hand side of the Figure and the Trust with the lowest proportion are on the right.

39. Trust findings for practice standard 6
Documented evidence that body weight and/or BMI have been measured over the past 12 months (n=1,976), by Trust
The Trusts with the highest proportion of patients for whom documented evidence of that body weight and/or BMI have been measured are on the left hand side of the Figure and the Trust with the lowest proportion are on the right.

40. Trust findings for practice standard 6
Documented evidence that blood pressure has been measured over the past 12 months (n=1,976), by Trust
The Trusts with the highest proportion of patients for whom documented evidence of that blood pressure has been measured are on the left hand side of the Figure and the Trust with the lowest proportion are on the right.

41. Trust findings for practice standard 6
Documented evidence that plasma glucose has been measured over the past 12 months (n=1,976), by Trust
The Trusts with the highest proportion of patients for whom documented evidence of that plasma glucose has been measured are on the left hand side of the Figure and the Trust with the lowest proportion are on the right.

42. Trust findings for practice standard 6
Documented evidence that plasma lipids has been measured over the past 12 months (n=1,976), by Trust
The Trusts with the highest proportion of patients for whom documented evidence of that plasma lipids has been measured are on the left hand side of the Figure and the Trust with the lowest proportion are on the right.

43. Trust findings for treatment target 1
Reasons for measuring plasma valproate levels (n=1,976), by Trust
The Trusts with the highest proportion of reasons for measuring plasma valproate levels which included routine monitoring and other reasons for measuring plasma valproate (including no reason documented) are on the right hand side of the Figure and the Trust with the lowest proportion are on the left hand side.
For interpretation of performance against treatment target 1, see slide 23.

44. Team-level findings
Analyses presented in this section were conducted for each clinical team from your Trust individually, for your total Trust sample and for the total national sample to allow benchmarking.
Data from each Trust clinical team are presented by code only.
Only the POMH-UK lead for your Trust or organisation has the key to team codes. You should contact this person if you need to identify data for your own particular team.

45. Practice standard 1 Proportion of patients with bipolar disorder prescribed valproate, in the TNS and your Trust

46. Practice standard 3 (1 of 3) Proportion of patients prescribed valproate who had BMI/weight measure documented in the 3 months before treatment was initiated, in the TNS subsample (n=277)
No patients were treated with valproate for 6 months or less in your Trust, therefore we have not provided team level graphs for this standard.

47. Practice standard 3 (2 of 3) Proportion of patients prescribed valproate who had liver function tests (LFTs) documented in the 3 months before treatment was initiated, in the TNS subsample (n=277)
No patients were treated with valproate for 6 months or less in your Trust, therefore we have not provided team level graphs for this standard.

48. Practice standard 3 (3 of 3) Proportion of patients prescribed valproate who had full blood count (FBC) documented in the 3 months before treatment was initiated, in the TNS subsample (n=277)
No patients were treated with valproate for 6 months or less in your Trust, therefore we have not provided team level graphs for this standard.

49. Practice standard 4 Proportion of patients who were inpatients and written information about the use of valproate received, in the TNS subsample (n=189)
No inpatients were treated with valproate for 6 months or less in your Trust, therefore we have not provided team level graphs for this standard.

50. Practice standard 5 (1 of 3) Documented evidence of review of therapeutic response within 3 months of valproate initiation, in the TNS subsample (n=263) and your Trust (n=1)

51. Practice standard 5 (2 of 3) Documented evidence of weight gain or other common side effects of valproate, in the TNS subsample (n=263) and your Trust (n=1)

52. Practice standard 5 (3 of 3) Documented evidence of information relating to medication adherence as part of an early on-treatment review, in the TNS subsample (n=263) and your Trust (n=1)

53. Practice standard 6 (1 of 4) Documented evidence that body weight and/or BMI have been measured over the past 12 months, in the TNS subsample (n=1,976) and your Trust (n=39)

54. Practice standard 6 (2 of 4) Documented evidence that blood pressure has been measured over the past 12 months, in the TNS subsample (n=1,976) and your Trust (n=39)

55. Practice standard 6 (3 of 4) Documented evidence that plasma glucose have been measured over the past 12 months, in the TNS subsample (n=1,976) and your Trust (n=39)

56. Practice standard 6 (4 of 4) Documented evidence that plasma glucose have been measured over the past 12 months, in the TNS subsample (n=1,976) and your Trust (n=39)