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Letter to the Editor Regarding the Article, “Lithium in Late-Life Mania: A Systematic Review” [Letter]

Authors Shah K , Mansuri Z, Jain S

Received 3 April 2021

Accepted for publication 15 April 2021

Published 28 April 2021 Volume 2021:17 Pages 1229—1230


Checked for plagiarism Yes

Editor who approved publication: Dr Roger Pinder

Kaushal Shah, 1 Zeeshan Mansuri, 2,* Shailesh Jain 3,*

1Department of Psychiatry, Griffin Memorial Hospital, Norman, OK, USA; 2Department of Psychiatry, Boston Children’s Hospital/Harvard Medical School, Boston, MA, USA; 3Department of Psychiatry, Texas Tech University Health Science Center at Odessa/Permian Basin, Odessa, TX, USA

*These authors contributed equally to this work

Correspondence: Kaushal Shah Email [email protected] 

View the original paper by Fazio and colleagues

Dear editor

We read the article “Lithium in late-life mania: a systematic review” by Fazio et al with great interest.1 The authors conducted this systematic review to evaluate lithium’s role in treating mania in late-life onset bipolar disorder (BD). The study assessed the efficacy and tolerability of lithium for treating late-life onset BD based on the published literature utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.1

However, we humbly like to bring the reader’s attention to the study’s methodology section that can influence the study results. We have mentioned these concerns below in the order of their appearance in the article:

  1. Medical Subject Headings (MeSH) Terms: Contrary to the author’s claim, five out of ten terms utilized to search literature are not MeSH terms. The MeSH is the controlled term developed by the National Library of Medicine (NLM).2 It provides a robust search experience that can include synonyms. Search terms that are not MeSH, “geriatric,” “elderly,” “late-life,” “efficacy,” and “tolerability.”
  2. Boolean Operators and Search String: Authors have used “AND” and “OR” boolean operators in the search string, “Bipolar Disorder OR Mania AND Lithium AND geriatric OR elderly OR aged OR late-life AND efficacy AND tolerability OR safety.” However, the authors did not use parentheses for nesting the concept per the study objective.3,4 Unfortunately, not utilizing parentheses would command databases to search literature not as per the study’s objective and yield an incorrect number of articles in the literature search.4,5
  3. Selection Criteria: While searching the literature, authors have used the MeSH term “aged,” defined as a person between 65 and 79 as per NLM. However, the study’s selection criteria include a population above 55, which potentially excludes several pieces of literature on this topic.
  4. PRISMA Flowchart: The number of articles screened (n=1065) is less than identified literature after duplication removal (n=442,570), and the authors did not provide the rationale on this either in the methods section or in Figure 1.1

We believe that these findings and comments are constructive and would help improve the quality of the manuscript.


S.J. and Z.M. share equal credentials for senior authorship in this communication.


The authors report no conflicts of interest in this communication.


1. De Fazio P, Gaetano R, Caroleo M, et al. Lithium in late-life mania: a systematic review. Neuropsychiatr Dis Treat. 2017;13:755–766. doi:10.2147/NDT.S126708

2. National Library of Medicine. Medical subject headings; 2021. Avaiilable from: Accessed March 30, 2021.

3. PubMed. PubMed user guide; 2021. Avaiilable from: Accessed March 30, 2021.

4. Ecker ED, Skelly AC. Conducting a winning literature search. Evid Based Spine Care J. 2010;1(01):9–14. doi:10.1055/s-0028-1100887

5. NLM technical bulletin. Pubmed: basic boolean search hints; 1997. Avaiilable from: Accessed March 30, 2021.

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