A National Survey of Nursing Home Clinicians to Explain Increased Valproate Prescribing

Abstract

Objectives

Valproate, an anti-seizure medication (ASM) approved for seizures, bipolar mania, and migraine prophylaxis, is increasingly used in nursing homes (NHs) for reasons unclear. Mandated NH reporting of ASMs began in October 2024, a requirement for other psychotropics since 2012. This study surveyed NH clinicians to explain why valproate is prescribed and why such prescribing is increasing.

Design

National cross-sectional survey. Developed by a multidisciplinary team using pilot data and existing literature, conducted anonymously via SurveyMonkey (November 2024–April 2025), and leveraging convenience sampling through crowdsourcing.

Setting

United States’ NHs.

Participants

A total of 159 NH clinician prescribers: 58% female, 73% white; 57% physicians, 43% advanced practice providers; 60% holding geriatric or psychiatric certifications.

Results

Ninety-seven percent of clinicians reported that off-label valproate use for psychiatric symptoms drove observed prevalence increases, while 74% affirmed such use individually. Few clinicians attributed gains to FDA-approved prescribing indications. Eighty-five percent identified efforts to reduce antipsychotics and benzodiazepines as key contributors to increases. Infrequent valproate dose reduction, staffing shortages, and limited access to nonpharmacologic interventions were also highlighted as causative factors. Generally, clinicians consider valproate low-to-moderate risk (93%) and effective for psychiatric symptoms in NHs (77%), though not superior to alternatives.

Conclusions

Clinicians report that perceived increases in NH valproate use are primarily off-label, and may reflect strategies to manage psychiatric symptoms while circumventing regulatory scrutiny emphasizing other psychotropic medications. They believe policies targeting high-risk psychotropic reduction while overlooking ASMs have driven unmonitored ASM increases with unclear safety and efficacy implications. Whether incorporating ASMs into reporting mandates existing for other psychotropics closes these regulatory gaps remains uncertain.