Chapter 7 178 dissertation) to the underlying disease for which valproic acid is used. Unfortunately, we do not know how often this imaginary example occurs in clinical practice. We (still) do not know the prevalence of patients with therapeutic concentrations of total valproic acid and elevated concentrations of free valproic acid. A study by Wallenburg mentioned that 37% of the requested laboratory measurements of free valproic acid concentrations, because the patients were at risk of having lowalbumin concentrations, showed unbound concentration above threshold (Wallenburg et al., 2017). Only 12% of themhad elevated total valproic acid concentrations. Future research should investigate the percentage of all patients, especially in an older population, that use valproic acid and have ‘normal’ total blood concentrations but have elevated free valproic acid concentrations. By knowing these numbers, not only can the costs and benefits of reporting the free fraction be weighed against each other, but one can also be more aware of its prevalence. If this missing information is at hand, taking the Wilson and Jungner criteria into account, screening for the elevated free concentration of valproic acid could be advised, as monitoring the total concentration is already part of international guidelines when valproic acid is used. This is important for avoiding intoxication in the future. However, equally or even more importantly is when the side effects of valproic acid stay subtle, such as cognitive impairment, and can easily be wrongly attributed to other causes, such as ageing. In particular, as more patients will suffer from these fewer extreme side effects, in contrast to our case study, these will still have a high impact on the health and quality of life of valproic acid users. Again, we cannot underscore often enough that this case report is a perfect example of why baseline MoCA scores should be considered in old age psychiatry as a standard procedure. As we have seen in the study of Needs in Bipolar Older Adults, for recovery, the ‘No or Met Needs’ are important not only in the ‘physical domain’ but also on the ‘social’ (or societal) level. The needs in this (these) later domain(s) can negatively affect quality of life, the number of needs, and doctor visits (Chapter 2). Recovery can occur in multiple areas: clinical, social, functional, and personal. Due to the patient’s perception that he or she still has care issues or unmet needs and has not fully recovered in one of these areas, he or she will continue to experience symptoms and ask for care. Even though in the clinical area, the patient has (largely) recovered in the eyes of the practitioner, this could (possibly) not be so in the eyes of the patient. If this is not recognised by the practitioner because it remains invisible or unknown to the practitioner, it will lead to misdiagnosis or, to put it mildly, to the treatment of only the clinical diagnosis and not of the bigger problem. Not being able to initiate a suitable ‘total’ treatment that can lead to a satisfactory recovery in other areas of this bigger problem can generate unnecessary extra costs. This
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