Comments & Controversies

Concerns about valproate

I read Dr. Jain and Ms. Beste’s Pearl on treating alopecia developing during valproate use ("Valproate-induced hair loss: What to tell patients," Current Psychiatry, November 2011, p. 74) with some dismay.

Valproate is a valuable drug that has demonstrated efficacy in treating bipolar disorder; however, valproate use is associated with substantial side effects for women and developing fetuses.

I take no issue with any of the points made in the article, but I am concerned about the failure to mention critical side effects associated with valproate, including:

• weight gain and metabolic side effects
• for women, polycystic ovary syndrome—a serious and difficult-to-treat complication
• danger to fetuses—recent research suggests marked reductions in intelligence quotient in babies exposed to valproate in utero.¹

We would be wise to remind ourselves of these issues whenever considering initiating or continuing valproate therapy.

Edward Pontius, MD, DFAPA
Private Practice
Brunswick, ME

The authors respond

The concerns expressed by Dr. Pontius regarding clinical use of valproate are genuine and worthy. The purpose of our article was to call attention to a lesser-known side effect of valproate and how to intervene. We assumed that clinicians would discuss with patients the teratogenicity of valproate, along with other common side effects—weight gain, pancreatitis, effect on liver function tests, thrombocytopenia, and polycystic ovary syndrome—before initiating the drug. Such discussion about valproate was beyond the scope of our article, but we thank Dr. Pontius for bringing these concerns to our attention.

Shailesh Jain, MD, MPH, ABDA
Regional Chair
Associate Professor
Department of Psychiatry

Beth Beste, MS
Fourth-Year Medical Student
Texas Tech University Health Sciences Center, Permian Basin
Odessa, TX

Domains of excellence

I want to thank Dr. Nasrallah, whose monthly comments I find interesting and provocative, for his first-of-its-kind description of the “ideal” psychiatrist’s role and identity (“The model psychiatrist: 7 domains of excellence,” From the Editor, Current Psychiatry, November 2011, p. 5-6). This article should be mandatory reading and discussion material for every psychiatry residency program. For this elder psychiatrist, it was a thoughtful review of where I have been and where I am going in my field.

Ronald Blank, MD
Private Practice
Easthampton, MA

Additional traits

I find Current Psychiatry to be exceedingly useful for myself and the physician assistant students I teach. I agree with the 7 domains in Dr. Nasrallah’s editorial (“The model psychiatrist: 7 domains of excellence,” From the Editor, Current Psychiatry, November 2011, p. 5-6). However, I would like to add 2 more traits:

• The role that a psychiatrist plays in his or her family, especially with their children, because ignoring one’s family in the pursuit of clinical sainthood is not a mark of greatness
• The psychiatrist today is more of a team member than team leader. Failure to recognize this role creates intolerable stresses on the treatment environment in which the psychiatrist works. This does not minimize the need for personal excellence, but it certainly helps decrease destructive narcissism.

Kim J. Masters, MD
Medical Director
Three Rivers Midlands Campus Residential Treatment Center
West Columbia, SC

Concerns about valproate

I read Dr. Jain and Ms. Beste’s Pearl on treating alopecia developing during valproate use ("Valproate-induced hair loss: What to tell patients," Current Psychiatry, November 2011, p. 74) with some dismay.

Valproate is a valuable drug that has demonstrated efficacy in treating bipolar disorder; however, valproate use is associated with substantial side effects for women and developing fetuses.

I take no issue with any of the points made in the article, but I am concerned about the failure to mention critical side effects associated with valproate, including:

• weight gain and metabolic side effects
• for women, polycystic ovary syndrome—a serious and difficult-to-treat complication
• danger to fetuses—recent research suggests marked reductions in intelligence quotient in babies exposed to valproate in utero.¹

We would be wise to remind ourselves of these issues whenever considering initiating or continuing valproate therapy.

Edward Pontius, MD, DFAPA
Private Practice
Brunswick, ME

The authors respond

The concerns expressed by Dr. Pontius regarding clinical use of valproate are genuine and worthy. The purpose of our article was to call attention to a lesser-known side effect of valproate and how to intervene. We assumed that clinicians would discuss with patients the teratogenicity of valproate, along with other common side effects—weight gain, pancreatitis, effect on liver function tests, thrombocytopenia, and polycystic ovary syndrome—before initiating the drug. Such discussion about valproate was beyond the scope of our article, but we thank Dr. Pontius for bringing these concerns to our attention.

Shailesh Jain, MD, MPH, ABDA
Regional Chair
Associate Professor
Department of Psychiatry

Beth Beste, MS
Fourth-Year Medical Student
Texas Tech University Health Sciences Center, Permian Basin
Odessa, TX

Domains of excellence

I want to thank Dr. Nasrallah, whose monthly comments I find interesting and provocative, for his first-of-its-kind description of the “ideal” psychiatrist’s role and identity (“The model psychiatrist: 7 domains of excellence,” From the Editor, Current Psychiatry, November 2011, p. 5-6). This article should be mandatory reading and discussion material for every psychiatry residency program. For this elder psychiatrist, it was a thoughtful review of where I have been and where I am going in my field.

Ronald Blank, MD
Private Practice
Easthampton, MA

Additional traits

I find Current Psychiatry to be exceedingly useful for myself and the physician assistant students I teach. I agree with the 7 domains in Dr. Nasrallah’s editorial (“The model psychiatrist: 7 domains of excellence,” From the Editor, Current Psychiatry, November 2011, p. 5-6). However, I would like to add 2 more traits:

• The role that a psychiatrist plays in his or her family, especially with their children, because ignoring one’s family in the pursuit of clinical sainthood is not a mark of greatness
• The psychiatrist today is more of a team member than team leader. Failure to recognize this role creates intolerable stresses on the treatment environment in which the psychiatrist works. This does not minimize the need for personal excellence, but it certainly helps decrease destructive narcissism.

Kim J. Masters, MD
Medical Director
Three Rivers Midlands Campus Residential Treatment Center
West Columbia, SC

Concerns about valproate

I read Dr. Jain and Ms. Beste’s Pearl on treating alopecia developing during valproate use ("Valproate-induced hair loss: What to tell patients," Current Psychiatry, November 2011, p. 74) with some dismay.

Valproate is a valuable drug that has demonstrated efficacy in treating bipolar disorder; however, valproate use is associated with substantial side effects for women and developing fetuses.

I take no issue with any of the points made in the article, but I am concerned about the failure to mention critical side effects associated with valproate, including:

• weight gain and metabolic side effects
• for women, polycystic ovary syndrome—a serious and difficult-to-treat complication
• danger to fetuses—recent research suggests marked reductions in intelligence quotient in babies exposed to valproate in utero.¹

We would be wise to remind ourselves of these issues whenever considering initiating or continuing valproate therapy.

Edward Pontius, MD, DFAPA
Private Practice
Brunswick, ME

The authors respond

The concerns expressed by Dr. Pontius regarding clinical use of valproate are genuine and worthy. The purpose of our article was to call attention to a lesser-known side effect of valproate and how to intervene. We assumed that clinicians would discuss with patients the teratogenicity of valproate, along with other common side effects—weight gain, pancreatitis, effect on liver function tests, thrombocytopenia, and polycystic ovary syndrome—before initiating the drug. Such discussion about valproate was beyond the scope of our article, but we thank Dr. Pontius for bringing these concerns to our attention.

Shailesh Jain, MD, MPH, ABDA
Regional Chair
Associate Professor
Department of Psychiatry

Beth Beste, MS
Fourth-Year Medical Student
Texas Tech University Health Sciences Center, Permian Basin
Odessa, TX

Domains of excellence

I want to thank Dr. Nasrallah, whose monthly comments I find interesting and provocative, for his first-of-its-kind description of the “ideal” psychiatrist’s role and identity (“The model psychiatrist: 7 domains of excellence,” From the Editor, Current Psychiatry, November 2011, p. 5-6). This article should be mandatory reading and discussion material for every psychiatry residency program. For this elder psychiatrist, it was a thoughtful review of where I have been and where I am going in my field.

Ronald Blank, MD
Private Practice
Easthampton, MA

Additional traits

I find Current Psychiatry to be exceedingly useful for myself and the physician assistant students I teach. I agree with the 7 domains in Dr. Nasrallah’s editorial (“The model psychiatrist: 7 domains of excellence,” From the Editor, Current Psychiatry, November 2011, p. 5-6). However, I would like to add 2 more traits:

• The role that a psychiatrist plays in his or her family, especially with their children, because ignoring one’s family in the pursuit of clinical sainthood is not a mark of greatness
• The psychiatrist today is more of a team member than team leader. Failure to recognize this role creates intolerable stresses on the treatment environment in which the psychiatrist works. This does not minimize the need for personal excellence, but it certainly helps decrease destructive narcissism.

Kim J. Masters, MD
Medical Director
Three Rivers Midlands Campus Residential Treatment Center
West Columbia, SC