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Editor—Shulman et al report an increase in the prescription of valproate for elderly patients with bipolar disorder in Canada (and corresponding decrease in prescription of lithium).1 A similar pattern has been observed in the United States over the past decade or so.2 As the authors note, this change has occurred despite the limited evidence supporting the use of valproate and may indeed reflect concerns about lithium toxicity in elderly patients.
The BALANCE trial (www.psychiatry.ox.ac.uk/balance/), which is currently recruiting in the United Kingdom and soon to begin recruiting in the United States, should provide reliable evidence about the use of both lithium and valproate in bipolar disorder.3 A recent trial comparing lithium, valproate, and placebo did not find a significant difference between the treatments, probably because the inclusion of an untreated control arm meant that it was difficult to recruit patients who were judged at substantial risk of relapse. The observed rate of relapse, and consequently statistical power, in this trial was much lower than anticipated.4,5
BALANCE does not have an untreated control group, and so recruitment of a broad range of patients should be possible to make the results applicable to most future patients. To make widespread participation feasible, BALANCE has simple procedures and does not entail additional clinic appointments or extra investigations. Unlike other trials that often routinely exclude older adults, BALANCE has no upper age restriction and so the results will directly inform practice in both younger and older patients. We therefore encourage old age psychiatrists to recruit patients so that the results will be as informative as possible.
Competing interests: None declared.