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Cintrón Pastrana MA, Irizarry Flores JC, Rothschild AJ. Challenges in the Treatment of Psychotic Bipolar Depression. J Clin Psychopharmacol 2024; 44:407-412. [PMID: 38901001 DOI: 10.1097/jcp.0000000000001879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
BACKGROUND Psychotic bipolar depression (PBD) is a prevalent yet understudied psychiatric illness, and there are no specific guidelines or Food and Drug Administration-approved medications for its treatment. Recent studies suggest that some antipsychotics and mood stabilizers may be effective in managing bipolar depression; however, their effectiveness for PBD remains unclear. Given the urgent need for more focused research for managing PBD, we conducted a literature review to summarize the existing literature on PBD. METHODS We conducted an electronic literature search from the 1960s to 2023, utilizing PubMed, MEDLINE, EMBASE, and Google, and selected studies based on their relevance to PBD. FINDINGS PBD is a complex disorder, with 50%-75% of patients with bipolar disorder exhibiting psychotic features. This likelihood increases among those with a history of psychotic mania. Treatment guidelines often recommend a combination of mood stabilizers, antipsychotics, or electroconvulsive therapy, but they do not specify a first-line treatment. PBD symptoms can be masked by mixed high mood and energy feelings, potentially delaying diagnosis and treatment while increasing suicide risk. Limited research has evaluated outcomes of various treatments for PBD, and despite the lack of evidence for superior efficacy, in clinical practice, antipsychotics are frequently prescribed. Notably, combining an antipsychotic with selective noradrenaline reuptake inhibitors or tricyclic antidepressants may be effective, but including a mood stabilizer is necessary. CONCLUSION PBD poses a significant challenge in mental health due to its severity and the lack of consensus on optimal treatment approaches. There is a critical need for more dedicated clinical trials and research to answer key questions about the effective treatment of acute PBD, ideal follow-up care, traits of responders to different therapies, and decision models for subsequent treatments.
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Yan R, Marshall T, Khullar A, Nagle T, Knowles J, Malkin M, Chubbs B, Swainson J. Patient-reported outcomes on sleep quality and circadian rhythm during treatment with intravenous ketamine for treatment-resistant depression. Ther Adv Psychopharmacol 2024; 14:20451253241231264. [PMID: 38440104 PMCID: PMC10910882 DOI: 10.1177/20451253241231264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/18/2024] [Indexed: 03/06/2024] Open
Abstract
Background Intravenous (IV) ketamine is a rapid acting antidepressant used primarily for treatment-resistant depression (TRD). It has been suggested that IV ketamine's rapid antidepressant effects may be partially mediated via improved sleep and changes to the circadian rhythm. Objectives This study explores IV ketamine's association with changes in patient-reported sleep quality and circadian rhythm in an adult population with TRD. Methods Adult patients (18-64 years) with TRD scheduled for IV ketamine treatment were recruited to complete patient rated outcomes measures on sleep quality using the Pittsburgh Sleep Quality Index (PSQI) and circadian rhythm using the Morningness-Eveningness Questionnaire (MEQ). Over a 4-week course of eight ketamine infusions, reports were obtained at baseline (T0), prior to second treatment (T1), prior to fifth treatment (T2), and 1 week after eighth treatment (T3). Results Forty participants with TRD (mean age = 42.8, 45% male) were enrolled. Twenty-nine (72.5%) had complete follow-up data. Paired t tests revealed statistically significant improvements at the end of treatment in sleep quality (PSQI) (p = 0.003) and depressive symptoms (Clinically Useful Depression Outcome Scale-Depression, p < 0.001) while circadian rhythm (MEQ) shifted earlier (p = 0.007). The PSQI subscale components of sleep duration (p = 0.008) and daytime dysfunction (p = 0.001) also improved. In an exploratory post hoc analysis, ketamine's impact on sleep quality was more prominent in patients with mixed features, while its chronobiotic effect was prominent in those without mixed features. Conclusion IV ketamine may improve sleep quality and advance circadian rhythm in individuals with TRD. Effects may differ in individuals with mixed features of depression as compared to those without. Since this was a small uncontrolled study, future research is warranted.
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Affiliation(s)
- Raymond Yan
- Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | | | - Atul Khullar
- Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Travis Nagle
- Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Jake Knowles
- Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Mai Malkin
- Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Brittany Chubbs
- Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer Swainson
- Cabrini Center, 3rd Floor, 16811-88 Ave NW, Edmonton, AB, Canada T5R 5YR
- Department of Psychiatry, University of Alberta, Canada
- Misericordia Community Hospital, Edmonton, Alberta, Canada
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Zhang J, Sun R, Cai Y, Peng B, Yang X, Gao K. Efficacy and Safety of Antidiabetic Agents for Major Depressive Disorder and Bipolar Depression: A Meta-Analysis of Randomized, Double-Blind, Placebo-Controlled Trials. J Clin Med 2024; 13:1172. [PMID: 38398483 PMCID: PMC10889473 DOI: 10.3390/jcm13041172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/22/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND This meta-analysis aimed to determine the efficacy and safety of antidiabetic agents in the treatment of major depressive disorder and bipolar depression. METHODS Randomized controlled trials (RCTs) of antidiabetic agents in major depressive disorder or bipolar depression were searched in three electronic databases and three clinical trial registry websites from their inception up to October 2023. The differences in changes in the depression rating scale scores from baseline to endpoint or pre-defined sessions, response rate, remission rate, rate of side effects and dropout rate between antidiabetic agents and placebo were meta-analyzed. RESULTS Six RCTs involving 399 participants were included in the final meta-analysis, which did not find that antidiabetics outperformed the placebo in reducing depressive symptoms. The standardized mean difference (SMD) in the depression scores from baseline to endpoint was 0.25 (95% CI -0.1, 0.61). However, a subgroup analysis found a significant difference between antidiabetics and placebos in reducing depressive symptoms in Middle Eastern populations, with an SMD of 0.89 (95% CI 0.44, 1.34). CONCLUSIONS The current meta-analysis does not support the efficacy of antidiabetics being superior to the placebo in the treatment of unipolar and bipolar depression. However, a subgroup analysis indicates that patients from the Middle East may benefit from adding an antidiabetic medication to their ongoing medication(s) for their depression. Larger studies with good-quality study designs are warranted.
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Affiliation(s)
- Jian Zhang
- Shenzhen Mental Health Center, Shenzhen Kangning Hospital, Shenzhen 518020, China; (J.Z.)
- Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, 10524 Euclid Ave, 12th Floor, Cleveland, OH 44106, USA
| | - Rongyi Sun
- Department of Psychiatry, School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Yang Cai
- Department of Psychiatry, School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Bo Peng
- Shenzhen Mental Health Center, Shenzhen Kangning Hospital, Shenzhen 518020, China; (J.Z.)
| | - Xi Yang
- Shenzhen Mental Health Center, Shenzhen Kangning Hospital, Shenzhen 518020, China; (J.Z.)
| | - Keming Gao
- Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, 10524 Euclid Ave, 12th Floor, Cleveland, OH 44106, USA
- Department of Psychiatry, School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
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Rodolico A, Cutrufelli P, Di Francesco A, Aguglia A, Catania G, Concerto C, Cuomo A, Fagiolini A, Lanza G, Mineo L, Natale A, Rapisarda L, Petralia A, Signorelli MS, Aguglia E. Efficacy and safety of ketamine and esketamine for unipolar and bipolar depression: an overview of systematic reviews with meta-analysis. Front Psychiatry 2024; 15:1325399. [PMID: 38362031 PMCID: PMC10867194 DOI: 10.3389/fpsyt.2024.1325399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 01/03/2024] [Indexed: 02/17/2024] Open
Abstract
Background Unipolar and bipolar depression present treatment challenges, with patients sometimes showing limited or no response to standard medications. Ketamine and its enantiomer, esketamine, offer promising alternative treatments that can quickly relieve suicidal thoughts. This Overview of Reviews (OoR) analyzed and synthesized systematic reviews (SRs) with meta-analysis on randomized clinical trials (RCTs) involving ketamine in various formulations (intravenous, intramuscular, intranasal, subcutaneous) for patients with unipolar or bipolar depression. We evaluated the efficacy and safety of ketamine and esketamine in treating major depressive episodes across various forms, including unipolar, bipolar, treatment-resistant, and non-resistant depression, in patient populations with and without suicidal ideation, aiming to comprehensively assess their therapeutic potential and safety profile. Methods Following PRIOR guidelines, this OoR's protocol was registered on Implasy (ID:202150049). Searches in PubMed, Scopus, Cochrane Library, and Epistemonikos focused on English-language meta-analyses of RCTs of ketamine or esketamine, as monotherapy or add-on, evaluating outcomes like suicide risk, depressive symptoms, relapse, response rates, and side effects. We included studies involving both suicidal and non-suicidal patients; all routes and formulations of administration (intravenous, intramuscular, intranasal) were considered, as well as all available comparisons with control interventions. We excluded meta-analysis in which the intervention was used as anesthesia for electroconvulsive therapy or with a randomized ascending dose design. The selection, data extraction, and quality assessment of studies were carried out by pairs of reviewers in a blinded manner. Data on efficacy, acceptability, and tolerability were extracted. Results Our analysis included 26 SRs and 44 RCTs, with 3,316 subjects. The intervention is effective and well-tolerated, although the quality of the included SRs and original studies is poor, resulting in low certainty of evidence. Limitations This study is limited by poor-quality SRs and original studies, resulting in low certainty of the evidence. Additionally, insufficient available data prevents differentiation between the effects of ketamine and esketamine in unipolar and bipolar depression. Conclusion While ketamine and esketamine show promising therapeutic potential, the current evidence suffers from low study quality. Enhanced methodological rigor in future research will allow for a more informed application of these interventions within the treatment guidelines for unipolar and bipolar depression. Systematic review registration [https://inplasy.com/inplasy-2021-5-0049/], identifier (INPLASY202150049).
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Affiliation(s)
- Alessandro Rodolico
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Pierfelice Cutrufelli
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Antonio Di Francesco
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Andrea Aguglia
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Gaetano Catania
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
- University of Catania, Catania, Italy
| | - Carmen Concerto
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Alessandro Cuomo
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Andrea Fagiolini
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
- Clinical Neurophysiology Research Unit, Oasi Research Institute-IRCCS, Troina, Italy
| | - Ludovico Mineo
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Antimo Natale
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
- Department of Psychiatry, Adult Psychiatry Service (SPA), University Hospitals of Geneva (HUG), Geneva, Switzerland
| | - Laura Rapisarda
- Department of Biomedical and Biotechnological Sciences, Section of Pharmacology, University of Catania, Catania, Italy
| | - Antonino Petralia
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Maria Salvina Signorelli
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Eugenio Aguglia
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
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Yildiz A, Siafis S, Mavridis D, Vieta E, Leucht S. Comparative efficacy and tolerability of pharmacological interventions for acute bipolar depression in adults: a systematic review and network meta-analysis. Lancet Psychiatry 2023; 10:693-705. [PMID: 37595997 DOI: 10.1016/s2215-0366(23)00199-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Bipolar depression constitutes a major public health problem due to its substantial burden of disease. Although pharmacological interventions are available, guidelines required updated evidence synthesis to improve their current recommendations. In order to inform evidence-based prescribing, we investigated the comparative efficacy and tolerability of pharmacological interventions for acute bipolar depression. METHODS We conducted a systematic review and network meta-analysis. We searched for randomised controlled trials comparing pharmacological interventions with each other or placebo in adults with acute bipolar depression (type I, type II, or not otherwise specified), excluding those with substance misuse, unipolar depression, or schizophrenia, in MEDLINE, Embase, PsycINFO, Google Scholar, Cochrane Library, Web of Knowledge, CINAHL, and LILACS from database inception up to April 13, 2023. Criteria for eligibility were a duration of 2-16 weeks with masked outcome assessments, and we included combination, add-on design, and monotherapy studies. The co-primary outcomes were depressive symptoms, examined with standardised mean differences (SMDs), and manic switch, examined with odds ratios (ORs). We also investigated dropouts due to any reason, inefficacy, adverse events, and important side-effects as secondary outcomes. The confidence in the evidence was evaluated using Confidence-In-Network-Meta-Analysis (CINeMA). The study was registered with PROSPERO, CRD42020171726. RESULTS We analysed data from 101 randomised controlled trials covering 20 081 participants, 8063 men (41·7%) and 11 263 women (58·3%; sex not available in four studies), mean age 41·0 years (range of means 28·7-53·6 years), and 68 medications and placebo. Ethnicity data were not available. With moderate confidence in the evidence, olanzapine plus fluoxetine, quetiapine, olanzapine, lurasidone, lumateperone, cariprazine, and lamotrigine were more efficacious than placebo in reducing depressive symptoms, with SMDs ranging from 0·41 (95% CI 0·19-0·64) for olanzapine plus fluoxetine to 0·16 (0·03-0·29) for lamotrigine. Several other drugs might also be efficacious, but the confidence in the evidence was very low to low. Antidepressants as a class seem to be efficacious, but had a higher risk for manic switch compared to antipsychotics. Medications differed in their side-effect profiles. INTERPRETATION This is, to our knowledge, the largest network meta-analysis of pharmacotherapy for bipolar depression to date. Olanzapine plus fluoxetine, quetiapine, olanzapine, lurasidone, lumateperone, cariprazine, and lamotrigine were found to be more efficacious than placebo in adults with acute bipolar depression, with good confidence in the evidence, and to differ in their side-effect profiles. These findings can inform evidence-based care and the development of treatment guidelines internationally. FUNDING None.
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Affiliation(s)
- Ayşegül Yildiz
- Department of Psychiatry, Dokuz Eylül University, Izmir, Turkey
| | - Spyridon Siafis
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany.
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece
| | - Eduard Vieta
- Bipolar Disorders Program, Institute of Clinical Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Stefan Leucht
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
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Yap SY, Ng FL, Subramaniam M, Lim YM, Foo CN. Traditional Chinese Medicine Body Constitutions as Predictors for Depression: A Systematic Review and Meta-Analysis. Behav Sci (Basel) 2022; 12:423. [PMID: 36354400 PMCID: PMC9687208 DOI: 10.3390/bs12110423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/18/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022] Open
Abstract
Traditional Chinese medicine body constitution (TCMBC) reflects a person's vulnerability to diseases. Thus, identifying body constitutions prone to depression can help prevent and treat depression. The review aimed to assess and summarize the existing evidence that explores the relationship between TCMBC and depression. Psychology and Behavioral Sciences Collection, MEDLINE, PubMed, CNKI, Wanfang, SinoMed, Embase, VIP, CINAHL, and CMJ were searched from inception to April 2021. Observational studies assessing the association between TCMBC and depression were selected. The quality of the included studies were assessed using the Newcastle-Ottawa Scale (NOS). Eighteen studies were included in the systematic review and thirteen in the meta-analysis. The pooled odd ratios of developing depression for Qi-stagnation, Qi-deficiency, Yang-deficiency, Yin-deficiency, and Balanced constitutions were 3.12 (95% CI, 1.80-5.40; I2 = 94%), 2.15 (95% CI, 1.54-3.01; I2 = 89%), 1.89 (95% CI, 0.71-5.03; I2 = 81%), 1.41 (95% CI, 0.91-2.20; I2 = 57%), and 0.60 (95% CI, 0.40-0.90; I2 = 94%), respectively. The findings suggest that the evaluation of a person's TCMBC could be useful the in prevention and treatment of depression. However, more case-control and cohort studies are required to further confirm the association between TCMBC and depression.
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Affiliation(s)
- Sin Yee Yap
- Centre for Cancer Research, M. Kandiah Faculty of Medicine and Health Sciences, Universiti Tunku Abdul Rahman, PT21144, Jalan Sungai Long, Bandar Sungai Long, Kajang 43000, Selangor, Malaysia
| | - Foong Leng Ng
- Centre for Cancer Research, M. Kandiah Faculty of Medicine and Health Sciences, Universiti Tunku Abdul Rahman, PT21144, Jalan Sungai Long, Bandar Sungai Long, Kajang 43000, Selangor, Malaysia
- Department of Traditional Chinese Medicine, M. Kandiah Faculty of Medicine and Health Sciences, Universiti Tunku Abdul Rahman, PT21144, Jalan Sungai Long, Bandar Sungai Long, Kajang 43000, Selangor, Malaysia
| | - Menaga Subramaniam
- Centre for Cancer Research, M. Kandiah Faculty of Medicine and Health Sciences, Universiti Tunku Abdul Rahman, PT21144, Jalan Sungai Long, Bandar Sungai Long, Kajang 43000, Selangor, Malaysia
| | - Yang Mooi Lim
- Centre for Cancer Research, M. Kandiah Faculty of Medicine and Health Sciences, Universiti Tunku Abdul Rahman, PT21144, Jalan Sungai Long, Bandar Sungai Long, Kajang 43000, Selangor, Malaysia
- Department of Pre-Clinical Science, M. Kandiah Faculty of Medicine and Health Sciences, Universiti Tunku Abdul Rahman, Lot PT21144, Jalan Sungai Long, Bandar Sungai Long, Kajang 43000, Selangor, Malaysia
| | - Chai Nien Foo
- Centre for Cancer Research, M. Kandiah Faculty of Medicine and Health Sciences, Universiti Tunku Abdul Rahman, PT21144, Jalan Sungai Long, Bandar Sungai Long, Kajang 43000, Selangor, Malaysia
- Department of Population Medicine, M. Kandiah Faculty of Medicine and Health Sciences, Universiti Tunku Abdul Rahman, PT21144, Jalan Sungai Long, Bandar Sungai Long, Kajang 43000, Selangor, Malaysia
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Bahji A, Bach P, Danilewitz M, Crockford D, el-Guebaly N, Devoe DJ, Saitz R. Comparative efficacy and safety of pharmacotherapies for alcohol withdrawal: a systematic review and network meta-analysis. Addiction 2022; 117:2591-2601. [PMID: 35194860 PMCID: PMC9969997 DOI: 10.1111/add.15853] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 01/30/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS There have been few head-to-head clinical trials of pharmacotherapies for alcohol withdrawal (AW). We, therefore, aimed to evaluate the comparative performance of pharmacotherapies for AW. METHODS Six databases were searched for randomized clinical trials through November 2021. Trials were included after a blinded review by two independent reviewers. Outcomes included incident seizures, delirium tremens, AW severity scores, adverse events, dropouts, dropouts from adverse events, length of hospital stay, use of additional medications, total benzodiazepine requirements, and death. Effect sizes were pooled using frequentist random-effects network meta-analysis models to generate summary ORs and Cohen's d standardized mean differences (SMDs). RESULTS Across the 149 trials, there were 10 692 participants (76% male, median 43.5 years old). AW severity spanned mild (n = 32), moderate (n = 51), and severe (n = 66). Fixed-schedule chlormethiazole (OR, 0.16; 95% CI, 0.04-0.65), fixed-schedule diazepam (OR, 0.16; 95% CI, 0.04-0.59), fixed-schedule lorazepam (OR = 0.19; 95% CI, 0.08-0.45), fixed-schedule chlordiazepoxide (OR = 0.21; 95% CI, 0.08-0.53), and divalproex (OR = 0.22; 95% CI, 0.05-0.86) were superior to placebo at reducing incident AW seizures. However, only fixed-schedule diazepam (OR, 0.19; 95% CI, 0.05-0.76) reduced incident delirium tremens. Oxcarbazepine (d = -3.69; 95% CI, -6.21 to -1.17), carbamazepine (d = -2.76; 95% CI, -4.13 to -1.40), fixed-schedule oxazepam (d = -2.55; 95% CI, -4.26 to -0.83), and γ-hydroxybutyrate (d = -1.80; 95% CI, -3.35 to -0.26) improved endpoint Clinical Institute Withdrawal Assessment for Alcohol-Revised scores over placebo. Promazine and carbamazepine were the only agents significantly associated with greater dropouts because of adverse events. The quality of evidence was downgraded because of the substantial risk of bias, heterogeneity, inconsistency, and imprecision. CONCLUSIONS Although some pharmacotherapeutic modalities, particularly benzodiazepines, appear to be safe and efficacious for reducing some measures of alcohol withdrawal, methodological issues and a high risk of bias prevent a consistent estimate of their comparative performance.
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Affiliation(s)
- Anees Bahji
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
- British Columbia Centre for Substance Use, Vancouver, BC, Canada
| | - Paxton Bach
- British Columbia Centre for Substance Use, Vancouver, BC, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Marlon Danilewitz
- Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - David Crockford
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Nady el-Guebaly
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Daniel J. Devoe
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Richard Saitz
- Department of Community Health Sciences, School of Public Health, Boston University School of Public Health, Boston, MA, USA
- Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
- Clinical Translational Science Institute, Boston University, Boston, MA, USA
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Misiak B, Kowalski K, Stańczykiewicz B, Bartoli F, Carrà G, Samochowiec J, Samochowiec A, Frydecka D. Appetite-regulating hormones in bipolar disorder: A systematic review and meta-analysis. Front Neuroendocrinol 2022; 67:101013. [PMID: 35792198 DOI: 10.1016/j.yfrne.2022.101013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/21/2022] [Accepted: 06/29/2022] [Indexed: 11/04/2022]
Abstract
Impaired hormonal regulation of appetite may contribute to higher cardiovascular risk in bipolar disorder (BD). We performed a systematic review and meta-analysis of studies investigating peripheral blood levels of appetite-regulating hormones in BD and controls. A total of 32 studies were included. Leptin and insulin levels were significantly elevated in patients with BD during euthymia, but not in other mood states. Greater differences in the number of male participants between patients with BD and healthy controls were associated with higher effect size estimates for the levels of insulin. There were significant positive correlations of effect size estimates for the levels of adiponectin with the percentage of individuals with type I BD and duration of BD. Our findings point to the mechanisms underlying high rates of cardiometabolic comorbidities in BD. Moreover, they suggest that investigating hormonal regulation of appetite might help to understand differences in the neurobiology of BD types.
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Affiliation(s)
- Błażej Misiak
- Department of Psychiatry, Division of Consultation Psychiatry and Neuroscience, Wroclaw Medical University, Pasteura 10 Street, 50-367 Wroclaw, Poland.
| | - Krzysztof Kowalski
- Department of Psychiatry, Division of Consultation Psychiatry and Neuroscience, Wroclaw Medical University, Pasteura 10 Street, 50-367 Wroclaw, Poland
| | - Bartłomiej Stańczykiewicz
- Department of Psychiatry, Division of Consultation Psychiatry and Neuroscience, Wroclaw Medical University, Pasteura 10 Street, 50-367 Wroclaw, Poland
| | - Francesco Bartoli
- Department of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48 - 20900, Monza, Italy; Department of Mental Health & Addiction, ASST Nord Milano, Viale Matteotti, 83 - 20099, Sesto SG, Milano, Italy
| | - Giuseppe Carrà
- Department of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48 - 20900, Monza, Italy; Department of Mental Health & Addiction, ASST Nord Milano, Viale Matteotti, 83 - 20099, Sesto SG, Milano, Italy; Division of Psychiatry, University College London, 149 Tottenham Court Road, W1T 7NF London, UK
| | - Jerzy Samochowiec
- Department of Psychiatry, Pomeranian Medical University, Broniewskiego 26 Street, 71-460 Szczecin, Poland
| | - Agnieszka Samochowiec
- Department of Clinical Psychology, Institute of Psychology, University of Szczecin, Krakowska 69 Street, 71-017 Szczecin, Poland
| | - Dorota Frydecka
- Department and Clinic of Psychiatry, Wroclaw Medical University, Pasteura 10 Street, 50-367 Wroclaw, Poland
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Bahji A, Zarate CA, Vazquez GH. Efficacy and safety of racemic ketamine and esketamine for depression: a systematic review and meta-analysis. Expert Opin Drug Saf 2022; 21:853-866. [PMID: 35231204 PMCID: PMC9949988 DOI: 10.1080/14740338.2022.2047928] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Racemic ketamine and esketamine have demonstrated rapid antidepressant effects. We aimed to review the efficacy and safety of racemic and esketamine for depression. RESEARCH DESIGN AND METHODS We conducted a PRISMA-guided review for relevant randomized controlled trials of racemic or esketamine for unipolar or bipolar major depression from database inception through 2021. We conducted random-effects meta-analyses using pooled rate ratios (RRs) and Cohen's standardized mean differences (d) with their 95% confidence intervals (CI). RESULTS We found 36 studies (2903 participants, 57% female, 45.1 +/- 7.0 years). Nine trials used esketamine, while the rest used racemic ketamine. The overall study quality was high. Treatment with any form of ketamine was associated with improved response (RR=2.14; 95% CI, 1.72-2.66; I2=65%), remission (RR=1.64; 95% CI, 1.33-2.02; I2=39%), and depression severity (d=-0.63; 95% CI, -0.80 to -0.45; I2=78%) against placebo. Overall, there was no association between treatment with any form of ketamine and retention in treatment (RR=1.00; 95% CI, 0.99-1.01; I2<1%), dropouts due to adverse events (RR=1.56; 95% CI, 1.00-2.45; I2<1%), or the overall number of adverse events reported per participant (OR=2.14; 95% CI, 0.82-5.60; I2=62%) against placebo. CONCLUSIONS Ketamine and esketamine are effective, safe, and acceptable treatments for individuals living with depression.
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Affiliation(s)
- Anees Bahji
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada;,British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Carlos A. Zarate
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Gustavo H. Vazquez
- Department of Psychiatry, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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Comparative Efficacy and Tolerability of Antipsychotics for Juvenile Psychotic Disorders: A Systematic Review and Network Meta-Analysis. J Clin Psychopharmacol 2022; 42:198-208. [PMID: 35020712 DOI: 10.1097/jcp.0000000000001506] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Psychotic disorders produce important morbidity and disability in children and adolescents. There have been few relevant treatment trials, encouraging assessment of research aimed at testing efficacy and safety of antipsychotics for juveniles. We aimed to compare the short- and long-term efficacy and safety of antipsychotics to treat psychotic disorders among children and adolescents. METHODS Four major bibliographic databases (PubMed, MEDLINE, PsycINFO, and EMBASE) were searched for clinical trials of antipsychotics in children or adolescents, from database inception to May 2021. We searched for clinical trials comparing antipsychotics with control conditions for juvenile psychosis based on blinded review by 2 independent investigators (C.S.Y. and M.L.). We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses and applied the Cochrane risk-of-bias tool to appraise study quality. One reviewer (A.B.) performed data abstraction which was confirmed by 2 independent, blinded reviewers (C.S.Y. and M.L.). Primary outcomes were scores rating psychosis symptoms and dichotomized retention in treatment protocols versus dropouts because of adverse events. Effect sizes were pooled using frequentist random-effects network meta-analysis modeling to generate summary rate ratios (RRs) and Cohen d standardized mean differences. RESULTS Systematic searching generated 1330 unique records. Of these, short-term (n = 15, for 6 [3-12] weeks) and long-term (n = 10, for 12 [6-60] months) treatment trials involved 2208 (39.2% females; median age, 15.3 years), and 1366 subjects (35.0% females; median age, 15.6 years), respectively. Short-term reduction of psychosis scores ranked clozapine (d = -1.35; 95% confidence interval [CI], -1.97 to -0.73]), molindone (-1.22; 95% CI, -1.68 to -0.75), olanzapine (-1.12; 95% CI, -1.44 to -0.81), and risperidone (-0.93; 95% CI, -1.22 to -0.63) as the most effective agents. In longer-term treatment, only lurasidone was effective. Clozapine (RR, 12.8) and haloperidol (RR, 5.15) led to more all-cause and adverse event-related dropouts. There were few trials/drug (1 each for aripiprazole, asenapine, lurasidone, molindone, paliperidone, and ziprasidone, short term; aripiprazole, clozapine, haloperidol, lurasidone, and molindone, long-term). Heterogeneity and inconsistency were high, especially in long-term trials, without evidence of publication bias. CONCLUSIONS Some antipsychotics were effective and tolerated short term, but longer-term evidence was very limited. The overall paucity of trials and of adequate controls indicates that more well-designed randomized controlled trials are required for adequate assessment of antipsychotic drug treatment for juveniles. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021232937.
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Bartoli F, Cavaleri D, Bachi B, Moretti F, Riboldi I, Crocamo C, Carrà G. Repurposed drugs as adjunctive treatments for mania and bipolar depression: A meta-review and critical appraisal of meta-analyses of randomized placebo-controlled trials. J Psychiatr Res 2021; 143:230-238. [PMID: 34509090 DOI: 10.1016/j.jpsychires.2021.09.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/28/2021] [Accepted: 09/01/2021] [Indexed: 01/08/2023]
Abstract
Several drugs previously tested in clinical trials and approved for different indications have been repurposed for bipolar disorder. We carried out a systematic meta-review of meta-analyses of randomized placebo-controlled trials investigating repurposed drugs as adjunctive treatments for mania and bipolar depression. We performed a critical appraisal using 'A MeaSurement Tool to Assess systematic Reviews' Version 2 (AMSTAR 2). We synthesized results on efficacy, tolerability, and safety, assessing evidence quality according to the 'Grading of Recommendations, Assessment, Development and Evaluations' (GRADE) approach. Our systematic search identified nine eligible studies investigating 12 drugs, four for mania and eight for bipolar depression. The quality of reporting was heterogeneous according to AMSTAR 2. In mania, allopurinol (for symptoms reduction and remission at 4-8 weeks) and tamoxifen (for response and symptoms reduction at 4-6 weeks) showed higher efficacy than placebo, with low and very low quality of evidence, respectively. Concerning bipolar depression, modafinil/armodafinil (for response, remission, and symptoms reduction at 6-8 weeks) and pramipexole (for response and symptoms reduction at 6 weeks) were superior to placebo, despite the low quality of evidence. Results on the efficacy of celecoxib and N-acetylcysteine were of low quality and limited to certain outcomes. Overall, the lack of evidence of high and moderate quality does not allow us to draw firm conclusions on the clinical utility of repurposed drugs as adjunctive treatments for mania and bipolar depression, highlighting the need for additional research.
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Affiliation(s)
- Francesco Bartoli
- Department of Medicine and Surgery, University of Milano-Bicocca, via Cadore 48, 20900, Monza, Italy
| | - Daniele Cavaleri
- Department of Medicine and Surgery, University of Milano-Bicocca, via Cadore 48, 20900, Monza, Italy.
| | - Bianca Bachi
- Department of Medicine and Surgery, University of Milano-Bicocca, via Cadore 48, 20900, Monza, Italy
| | - Federico Moretti
- Department of Medicine and Surgery, University of Milano-Bicocca, via Cadore 48, 20900, Monza, Italy
| | - Ilaria Riboldi
- Department of Medicine and Surgery, University of Milano-Bicocca, via Cadore 48, 20900, Monza, Italy
| | - Cristina Crocamo
- Department of Medicine and Surgery, University of Milano-Bicocca, via Cadore 48, 20900, Monza, Italy
| | - Giuseppe Carrà
- Department of Medicine and Surgery, University of Milano-Bicocca, via Cadore 48, 20900, Monza, Italy; Division of Psychiatry, University College London, 149 Tottenham Court Rd, Bloomsbury, London, W1T 7BN, United Kingdom
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Bahji A, Mesbah-Oskui L. Comparative efficacy and safety of stimulant-type medications for depression: A systematic review and network meta-analysis. J Affect Disord 2021; 292:416-423. [PMID: 34144366 DOI: 10.1016/j.jad.2021.05.119] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/28/2021] [Accepted: 05/31/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Globally, depression impacts nearly 300 million people, and roughly half do not achieve remission with standard first-line therapies. For such individuals, augmentation strategies are often helpful at reducing the severity of depression. While there are many potential adjunctive medication choices, psychostimulants are among the more controversial options. OBJECTIVES The present review sought to clarify the comparative efficacy and safety of different stimulant-like medications to treat depression. METHODS We conducted a systematic review and network meta-analysis of randomized, controlled trials (RCTs) using psychostimulant medications to treat adults with depression. Outcomes were pooled using rate ratios (RRs) for dichotomous outcomes (e.g., response, adverse events) and standardized mean differences (SMDs) for continuous outcomes (e.g., change in depression scores). RESULTS We identified 37 eligible studies (ranging from 1958 to 2016). We assessed nine psychostimulants: methylphenidate (n=14), dextroamphetamine (n=9), modafinil (n=6), lisdexamphetamine (n=3), methylamphetamine (n=3), pemoline (n=2), atomoxetine (n=1), desipramine (n=1), and imipramine (n=1). Overall, psychostimulants demonstrated efficacy for depression, reduced fatigue and sleepiness, and appeared well-tolerated. However, there was inconsistent evidence across particular psychostimulants. For example, the only psychostimulant which demonstrated efficacy for depression-in terms of both symptom severity and response rates-was methylphenidate. CONCLUSIONS While our review suggests that some psychostimulants-particularly methylphenidate-appear well-tolerated and demonstrate some efficacy for depression, as well as fatigue and sleepiness, the strength of evidence in our estimates was low to very low for most agents given the small sample sizes, few RCTs, and imprecision in most estimates. A lack of consistent evidence precludes a definitive hierarchy of treatments and points to a need for additional, high-quality RCTs.
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Affiliation(s)
- Anees Bahji
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada; British Columbia Centre for Substance Use, Vancouver, British Columbia, Canada.
| | - Lia Mesbah-Oskui
- Department of Neurology, University of British Columbia, Vancouver, British Columbia, Canada; Department of Medicine, Queen's University, Kingston, Ontario, Canada
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Bahji A, Zarate CA, Vazquez GH. Ketamine for Bipolar Depression: A Systematic Review. Int J Neuropsychopharmacol 2021; 24:535-541. [PMID: 33929489 PMCID: PMC8299822 DOI: 10.1093/ijnp/pyab023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/12/2021] [Accepted: 04/27/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Ketamine appears to have a therapeutic role in certain mental disorders, most notably unipolar major depressive disorder. However, its efficacy in bipolar depression is less clear. This study aimed to assess the efficacy and tolerability of ketamine for bipolar depression. METHODS We conducted a systematic review of experimental studies using ketamine for the treatment of bipolar depression. We searched PubMed, MEDLINE, Embase, PsycINFO, and the Cochrane Central Register for relevant studies published since each database's inception. We synthesized evidence regarding efficacy (improvement in depression rating scores) and tolerability (adverse events, dissociation, dropouts) across studies. RESULTS We identified 6 studies, with 135 participants (53% female; 44.7 years; standard deviation, 11.7 years). All studies used 0.5 mg/kg of add-on intravenous racemic ketamine, with the number of doses ranging from 1 to 6; all participants continued a mood-stabilizing agent. The overall proportion achieving a response (defined as those having a reduction in their baseline depression severity of at least 50%) was 61% for those receiving ketamine and 5% for those receiving a placebo. The overall response rates varied from 52% to 80% across studies. Ketamine was reasonably well tolerated; however, 2 participants (1 receiving ketamine and 1 receiving placebo) developed manic symptoms. Some participants developed significant dissociative symptoms at the 40-minute mark following ketamine infusion in 2 trials. CONCLUSIONS There is some preliminary evidence supporting use of intravenous racemic ketamine to treat adults with bipolar depression. There is a need for additional studies exploring longer-term outcomes and alterative formulations of ketamine.
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Affiliation(s)
- Anees Bahji
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada; British Columbia Centre for Substance Use, Vancouver, British Columbia, Canada; Research in Addiction Medicine Scholars [RAMS] Program, Boston University Medical Centre, Boston, MA, USA
| | - Carlos A Zarate
- Section Neurobiology and Treatment of Mood Disorders, Division of Intramural Research Program, National Institute of Mental Health, Bethesda, Maryland, USA
| | - Gustavo H Vazquez
- Department of Psychiatry, Queen’s University, Kingston, Ontario, Canada,Correspondence: Gustavo Vazquez, MD, PhD, FRCPC, Professor of Psychiatry, Queen’s University Medical School, 752 King Street West, Kingston, ON K7L 4X3, Canada ()
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Bahji A, Pierce M, Wong J, Roberge JN, Ortega I, Patten S. Comparative Efficacy and Acceptability of Psychotherapies for Self-harm and Suicidal Behavior Among Children and Adolescents: A Systematic Review and Network Meta-analysis. JAMA Netw Open 2021; 4:e216614. [PMID: 33861328 PMCID: PMC8052594 DOI: 10.1001/jamanetworkopen.2021.6614] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Self-harm and suicidal behavior are associated with substantial morbidity and mortality among children and adolescents. The comparative performance of psychotherapies for suicidality is unclear because few head-to-head clinical trials have been conducted. OBJECTIVE To compare the efficacy of psychotherapies for the treatment of self-harm and suicidality among children and adolescents. DATA SOURCES Four major bibliographic databases (PubMed, MEDLINE, PsycINFO, and Embase) were searched for clinical trials comparing psychotherapy with control conditions from inception to September 2020. STUDY SELECTION Randomized clinical trials comparing psychotherapies for suicidality and/or self-harm with control conditions among children and adolescents were included after a blinded review by 3 independent reviewers (A.B., M.P., and J.W.). DATA EXTRACTION AND SYNTHESIS The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed for data abstraction, and the Cochrane risk of bias tool was used to evaluate study-level risk of bias. Data abstraction was performed by 1 reviewer (A.B.) and confirmed by 2 independent blinded reviewers (J.W. and M.P.). Data were analyzed from October 15, 2020, to February 15, 2021. MAIN OUTCOMES AND MEASURES The primary outcomes were dichotomized self-harm and retention in treatment. The secondary outcomes were dichotomized all-cause treatment discontinuation and scores on instruments measuring suicidal ideation and depressive symptoms. Effect sizes were pooled using frequentist random-effects network meta-analysis models to generate summary odds ratios (ORs) and Cohen d standardized mean differences (SMDs). Negative Cohen d SMDs or ORs less than 1 indicated that the treatment reduced the parameter of interest relative to the control condition (eg, signifying a beneficial association with suicidal ideation). RESULTS The systematic search generated 1272 unique records. Of those, 44 randomized clinical trials (5406 total participants; 4109 female participants [76.0%]) from 49 articles were selected (5 follow-up studies were merged with their primary clinical trials to avoid publication bias). The selected clinical trials spanned January 1, 1995, to December 31, 2020. The median duration of treatment was 3 months (range, 0.25-12.00 months), and the median follow-up period was 12 months (range, 1-36 months). None of the investigated psychotherapies were associated with increases in study withdrawals or improvements in retention in treatment compared with treatment as usual. Dialectical behavioral therapies were associated with reductions in self-harm (OR, 0.28; 95% CI, 0.12-0.64) and suicidal ideation (Cohen d SMD, -0.71; 95% CI, -1.19 to -0.23) at the end of treatment, while mentalization-based therapies were associated with decreases in self-harm (OR, 0.38; 95% CI, 0.15-0.97) and suicidal ideation (Cohen d SMD, -1.22; 95% CI, -2.18 to -0.26) at the end of follow-up. The quality of evidence was downgraded because of high risk of bias overall, heterogeneity, publication bias, inconsistency, and imprecision. CONCLUSIONS AND RELEVANCE Although some psychotherapeutic modalities appear to be acceptable and efficacious for reducing self-harm and suicidality among children and adolescents, methodological issues and high risk of bias prevent a consistent estimate of their comparative performance.
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Affiliation(s)
- Anees Bahji
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Pierce
- Department of Psychiatry, Queen’s University, Kingston, Ontario, Canada
- Division of Child and Youth Mental Health, Queen’s University, Kingston, Ontario, Canada
| | - Jennifer Wong
- Department of Psychiatry, Queen’s University, Kingston, Ontario, Canada
- Division of Child and Youth Mental Health, Queen’s University, Kingston, Ontario, Canada
| | - Johanne N. Roberge
- Department of Psychiatry, Queen’s University, Kingston, Ontario, Canada
- Division of Child and Youth Mental Health, Queen’s University, Kingston, Ontario, Canada
| | - Iliana Ortega
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Scott Patten
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Response to commentary on the comparative efficacy of esketamine vs. ketamine meta-analysis: Putting the cart before the horse? J Affect Disord 2021; 282:258-260. [PMID: 33418376 PMCID: PMC8202174 DOI: 10.1016/j.jad.2020.12.069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 12/20/2020] [Indexed: 11/20/2022]
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