Evidence map›Paper›PMID 29088928›Full record

Trial reportThe American journal of psychiatry2017

GERI-BD: A Randomized Double-Blind Controlled Trial of Lithium and Divalproex in the Treatment of Mania in Older Patients With Bipolar Disorder.

Robert C Young, Benoit H Mulsant, Martha Sajatovic, Ariel G Gildengers, Laszlo Gyulai, Rayan K Al Jurdi, John Beyer, Jovier Evans, Samprit Banerjee, Rebecca Greenberg and 9 more

Open access · greenAbstract readRandomized Controlled Trial
In one paragraph

Trial report in The American journal of psychiatry, 2017. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 32 papers, 3 of them syntheses that pooled it.

0numbers the graph read from it
0cells of the map it votes in
32citing papers in PubMed, 3 pooled it
17.5field-weighted citation impact, top 1% of its field
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

32 citing papers in PubMed, 3 syntheses or guidelines pooled it, 194 citations in OpenAlex.

  1. Pooled it
  2. Lithium for acute mania.The Cochrane database of systematic reviews · 2019
    Pooled it
  3. Guideline
  4. Low Dose Lithium Treatment of Behavioral Complications in Alzheimer's Disease: Lit-AD Randomized Clinical Trial.The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry · 2022
    Trial
  5. Review
  6. Review
  7. The spectrum of bipolar disorder in older adults.Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology · 2026
    Review
  8. Review
  9. Review
  10. Article
  11. Review
  12. Review
  13. Article
  14. Article
  15. Article
  16. [Lithium treatment for affective disorders in old age].Zeitschrift fur Gerontologie und Geriatrie · 2023
    Review
  17. Article
  18. Review
  19. Review
  20. Updates in Geriatric Psychiatry.Focus (American Psychiatric Publishing) · 2021
    Article
4 · The record

Corrections and comments

5 · Who and what money

Authors and funding

19 authors at 1 institution in 1 country.

Robert C YoungFrom the Department of Psychiatry and the Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, and New York Presbyterian Hospital, New York; the Department of Psychiatry, University of Toronto, and the Centre for Addiction and Mental Health, Toronto; the Department of Psychiatry, University of Pittsburgh, Pittsburgh; the Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland; the Department of Psychiatry, Louis Stokes Cleveland VA Medical Center, Cleveland; the Department of Psychiatry, University of Pennsylvania, Philadelphia, and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia; the Department of Psychiatry, Baylor College of Medicine, and the Michael E. DeBakey VA Medical Center, Houston; the Department of Psychiatry, Duke University Medical College, Durham, N.C.; and NIMH, Bethesda, Md.
Benoit H MulsantFrom the Department of Psychiatry and the Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, and New York Presbyterian Hospital, New York; the Department of Psychiatry, University of Toronto, and the Centre for Addiction and Mental Health, Toronto; the Department of Psychiatry, University of Pittsburgh, Pittsburgh; the Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland; the Department of Psychiatry, Louis Stokes Cleveland VA Medical Center, Cleveland; the Department of Psychiatry, University of Pennsylvania, Philadelphia, and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia; the Department of Psychiatry, Baylor College of Medicine, and the Michael E. DeBakey VA Medical Center, Houston; the Department of Psychiatry, Duke University Medical College, Durham, N.C.; and NIMH, Bethesda, Md.
Martha SajatovicFrom the Department of Psychiatry and the Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, and New York Presbyterian Hospital, New York; the Department of Psychiatry, University of Toronto, and the Centre for Addiction and Mental Health, Toronto; the Department of Psychiatry, University of Pittsburgh, Pittsburgh; the Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland; the Department of Psychiatry, Louis Stokes Cleveland VA Medical Center, Cleveland; the Department of Psychiatry, University of Pennsylvania, Philadelphia, and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia; the Department of Psychiatry, Baylor College of Medicine, and the Michael E. DeBakey VA Medical Center, Houston; the Department of Psychiatry, Duke University Medical College, Durham, N.C.; and NIMH, Bethesda, Md.
Ariel G GildengersFrom the Department of Psychiatry and the Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, and New York Presbyterian Hospital, New York; the Department of Psychiatry, University of Toronto, and the Centre for Addiction and Mental Health, Toronto; the Department of Psychiatry, University of Pittsburgh, Pittsburgh; the Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland; the Department of Psychiatry, Louis Stokes Cleveland VA Medical Center, Cleveland; the Department of Psychiatry, University of Pennsylvania, Philadelphia, and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia; the Department of Psychiatry, Baylor College of Medicine, and the Michael E. DeBakey VA Medical Center, Houston; the Department of Psychiatry, Duke University Medical College, Durham, N.C.; and NIMH, Bethesda, Md.
Laszlo GyulaiFrom the Department of Psychiatry and the Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, and New York Presbyterian Hospital, New York; the Department of Psychiatry, University of Toronto, and the Centre for Addiction and Mental Health, Toronto; the Department of Psychiatry, University of Pittsburgh, Pittsburgh; the Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland; the Department of Psychiatry, Louis Stokes Cleveland VA Medical Center, Cleveland; the Department of Psychiatry, University of Pennsylvania, Philadelphia, and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia; the Department of Psychiatry, Baylor College of Medicine, and the Michael E. DeBakey VA Medical Center, Houston; the Department of Psychiatry, Duke University Medical College, Durham, N.C.; and NIMH, Bethesda, Md.
Rayan K Al JurdiFrom the Department of Psychiatry and the Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, and New York Presbyterian Hospital, New York; the Department of Psychiatry, University of Toronto, and the Centre for Addiction and Mental Health, Toronto; the Department of Psychiatry, University of Pittsburgh, Pittsburgh; the Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland; the Department of Psychiatry, Louis Stokes Cleveland VA Medical Center, Cleveland; the Department of Psychiatry, University of Pennsylvania, Philadelphia, and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia; the Department of Psychiatry, Baylor College of Medicine, and the Michael E. DeBakey VA Medical Center, Houston; the Department of Psychiatry, Duke University Medical College, Durham, N.C.; and NIMH, Bethesda, Md.
John BeyerFrom the Department of Psychiatry and the Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, and New York Presbyterian Hospital, New York; the Department of Psychiatry, University of Toronto, and the Centre for Addiction and Mental Health, Toronto; the Department of Psychiatry, University of Pittsburgh, Pittsburgh; the Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland; the Department of Psychiatry, Louis Stokes Cleveland VA Medical Center, Cleveland; the Department of Psychiatry, University of Pennsylvania, Philadelphia, and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia; the Department of Psychiatry, Baylor College of Medicine, and the Michael E. DeBakey VA Medical Center, Houston; the Department of Psychiatry, Duke University Medical College, Durham, N.C.; and NIMH, Bethesda, Md.
Jovier EvansFrom the Department of Psychiatry and the Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, and New York Presbyterian Hospital, New York; the Department of Psychiatry, University of Toronto, and the Centre for Addiction and Mental Health, Toronto; the Department of Psychiatry, University of Pittsburgh, Pittsburgh; the Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland; the Department of Psychiatry, Louis Stokes Cleveland VA Medical Center, Cleveland; the Department of Psychiatry, University of Pennsylvania, Philadelphia, and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia; the Department of Psychiatry, Baylor College of Medicine, and the Michael E. DeBakey VA Medical Center, Houston; the Department of Psychiatry, Duke University Medical College, Durham, N.C.; and NIMH, Bethesda, Md.
Samprit BanerjeeFrom the Department of Psychiatry and the Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, and New York Presbyterian Hospital, New York; the Department of Psychiatry, University of Toronto, and the Centre for Addiction and Mental Health, Toronto; the Department of Psychiatry, University of Pittsburgh, Pittsburgh; the Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland; the Department of Psychiatry, Louis Stokes Cleveland VA Medical Center, Cleveland; the Department of Psychiatry, University of Pennsylvania, Philadelphia, and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia; the Department of Psychiatry, Baylor College of Medicine, and the Michael E. DeBakey VA Medical Center, Houston; the Department of Psychiatry, Duke University Medical College, Durham, N.C.; and NIMH, Bethesda, Md.
Rebecca GreenbergFrom the Department of Psychiatry and the Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, and New York Presbyterian Hospital, New York; the Department of Psychiatry, University of Toronto, and the Centre for Addiction and Mental Health, Toronto; the Department of Psychiatry, University of Pittsburgh, Pittsburgh; the Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland; the Department of Psychiatry, Louis Stokes Cleveland VA Medical Center, Cleveland; the Department of Psychiatry, University of Pennsylvania, Philadelphia, and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia; the Department of Psychiatry, Baylor College of Medicine, and the Michael E. DeBakey VA Medical Center, Houston; the Department of Psychiatry, Duke University Medical College, Durham, N.C.; and NIMH, Bethesda, Md.
Patricia MarinoFrom the Department of Psychiatry and the Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, and New York Presbyterian Hospital, New York; the Department of Psychiatry, University of Toronto, and the Centre for Addiction and Mental Health, Toronto; the Department of Psychiatry, University of Pittsburgh, Pittsburgh; the Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland; the Department of Psychiatry, Louis Stokes Cleveland VA Medical Center, Cleveland; the Department of Psychiatry, University of Pennsylvania, Philadelphia, and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia; the Department of Psychiatry, Baylor College of Medicine, and the Michael E. DeBakey VA Medical Center, Houston; the Department of Psychiatry, Duke University Medical College, Durham, N.C.; and NIMH, Bethesda, Md.
Mark E KunikFrom the Department of Psychiatry and the Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, and New York Presbyterian Hospital, New York; the Department of Psychiatry, University of Toronto, and the Centre for Addiction and Mental Health, Toronto; the Department of Psychiatry, University of Pittsburgh, Pittsburgh; the Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland; the Department of Psychiatry, Louis Stokes Cleveland VA Medical Center, Cleveland; the Department of Psychiatry, University of Pennsylvania, Philadelphia, and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia; the Department of Psychiatry, Baylor College of Medicine, and the Michael E. DeBakey VA Medical Center, Houston; the Department of Psychiatry, Duke University Medical College, Durham, N.C.; and NIMH, Bethesda, Md.
Peijun ChenFrom the Department of Psychiatry and the Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, and New York Presbyterian Hospital, New York; the Department of Psychiatry, University of Toronto, and the Centre for Addiction and Mental Health, Toronto; the Department of Psychiatry, University of Pittsburgh, Pittsburgh; the Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland; the Department of Psychiatry, Louis Stokes Cleveland VA Medical Center, Cleveland; the Department of Psychiatry, University of Pennsylvania, Philadelphia, and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia; the Department of Psychiatry, Baylor College of Medicine, and the Michael E. DeBakey VA Medical Center, Houston; the Department of Psychiatry, Duke University Medical College, Durham, N.C.; and NIMH, Bethesda, Md.
Marna BarrettFrom the Department of Psychiatry and the Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, and New York Presbyterian Hospital, New York; the Department of Psychiatry, University of Toronto, and the Centre for Addiction and Mental Health, Toronto; the Department of Psychiatry, University of Pittsburgh, Pittsburgh; the Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland; the Department of Psychiatry, Louis Stokes Cleveland VA Medical Center, Cleveland; the Department of Psychiatry, University of Pennsylvania, Philadelphia, and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia; the Department of Psychiatry, Baylor College of Medicine, and the Michael E. DeBakey VA Medical Center, Houston; the Department of Psychiatry, Duke University Medical College, Durham, N.C.; and NIMH, Bethesda, Md.
Herbert C SchulbergFrom the Department of Psychiatry and the Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, and New York Presbyterian Hospital, New York; the Department of Psychiatry, University of Toronto, and the Centre for Addiction and Mental Health, Toronto; the Department of Psychiatry, University of Pittsburgh, Pittsburgh; the Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland; the Department of Psychiatry, Louis Stokes Cleveland VA Medical Center, Cleveland; the Department of Psychiatry, University of Pennsylvania, Philadelphia, and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia; the Department of Psychiatry, Baylor College of Medicine, and the Michael E. DeBakey VA Medical Center, Houston; the Department of Psychiatry, Duke University Medical College, Durham, N.C.; and NIMH, Bethesda, Md.
Martha L BruceFrom the Department of Psychiatry and the Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, and New York Presbyterian Hospital, New York; the Department of Psychiatry, University of Toronto, and the Centre for Addiction and Mental Health, Toronto; the Department of Psychiatry, University of Pittsburgh, Pittsburgh; the Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland; the Department of Psychiatry, Louis Stokes Cleveland VA Medical Center, Cleveland; the Department of Psychiatry, University of Pennsylvania, Philadelphia, and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia; the Department of Psychiatry, Baylor College of Medicine, and the Michael E. DeBakey VA Medical Center, Houston; the Department of Psychiatry, Duke University Medical College, Durham, N.C.; and NIMH, Bethesda, Md.
Charles F ReynoldsFrom the Department of Psychiatry and the Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, and New York Presbyterian Hospital, New York; the Department of Psychiatry, University of Toronto, and the Centre for Addiction and Mental Health, Toronto; the Department of Psychiatry, University of Pittsburgh, Pittsburgh; the Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland; the Department of Psychiatry, Louis Stokes Cleveland VA Medical Center, Cleveland; the Department of Psychiatry, University of Pennsylvania, Philadelphia, and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia; the Department of Psychiatry, Baylor College of Medicine, and the Michael E. DeBakey VA Medical Center, Houston; the Department of Psychiatry, Duke University Medical College, Durham, N.C.; and NIMH, Bethesda, Md.
George S AlexopoulosFrom the Department of Psychiatry and the Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, and New York Presbyterian Hospital, New York; the Department of Psychiatry, University of Toronto, and the Centre for Addiction and Mental Health, Toronto; the Department of Psychiatry, University of Pittsburgh, Pittsburgh; the Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland; the Department of Psychiatry, Louis Stokes Cleveland VA Medical Center, Cleveland; the Department of Psychiatry, University of Pennsylvania, Philadelphia, and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia; the Department of Psychiatry, Baylor College of Medicine, and the Michael E. DeBakey VA Medical Center, Houston; the Department of Psychiatry, Duke University Medical College, Durham, N.C.; and NIMH, Bethesda, Md.
GERI-BD Study GroupFrom the Department of Psychiatry and the Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, and New York Presbyterian Hospital, New York; the Department of Psychiatry, University of Toronto, and the Centre for Addiction and Mental Health, Toronto; the Department of Psychiatry, University of Pittsburgh, Pittsburgh; the Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland; the Department of Psychiatry, Louis Stokes Cleveland VA Medical Center, Cleveland; the Department of Psychiatry, University of Pennsylvania, Philadelphia, and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia; the Department of Psychiatry, Baylor College of Medicine, and the Michael E. DeBakey VA Medical Center, Houston; the Department of Psychiatry, Duke University Medical College, Durham, N.C.; and NIMH, Bethesda, Md.
NewYork–Presbyterian Hospital · US

Funding

CTSA INFRASTRUCTURE FOR PEDIATRIC RESEARCHUL1RR024989 · NCRR · CASE WESTERN RESERVE UNIVERSITY · PI DAVIS, PAMELA B · 2007 to 2011
$53.7M
CTSA INFRASTRUCTURE FOR PEDIATRIC RESEARCHUL1RR024996 · NCRR · WEILL MEDICAL COLL OF CORNELL UNIV · PI IMPERATO-MCGINLEY, JULIANNE L · 2007 to 2011
$49.6M
Research Methods CoreP30MH085943 · NIMH · WEILL MEDICAL COLL OF CORNELL UNIV · PI ALEXOPOULOS, GEORGE S · 2009 to 2013
$9.2M
RESEARCH METHODS COREP30MH090333 · NIMH · UNIVERSITY OF PITTSBURGH AT PITTSBURGH · PI DEW, MARY AMANDA · 2011 to 2015
$8.3M
Research Network Development Core (pages 329-374)P30MH071944 · NIMH · UNIVERSITY OF PITTSBURGH AT PITTSBURGH · PI REYNOLDS, CHARLES F. · 2005 to 2009
$6.7M
The Effects of Bipolar Disorder and its Comorbidities on Cognition in Older AdultR01MH084921 · NIMH · UNIVERSITY OF PITTSBURGH AT PITTSBURGH · PI GILDENGERS, ARIEL GERARD · 2010 to 2014
$1.8M
Acute Pharmacotherapy of Late-Life Mania-Study Coordinating CenterU01MH074511 · NIMH · WEILL MEDICAL COLL OF CORNELL UNIV · PI YOUNG, ROBERT C. · 2005 to 2009
$1.3M
Treatment of Bipolar Disorder in Old AgeK02MH067028 · NIMH · WEILL MEDICAL COLL OF CORNELL UNIV · PI YOUNG, ROBERT C. · 2003 to 2013
$1.2M
Acute Pharmacotherapy of Late-Life ManiaU01MH068846 · NIMH · UNIVERSITY OF PITTSBURGH AT PITTSBURGH · PI MULSANT, BENOIT H · 2005 to 2009
$1.2M
Acute Pharmacotherapy of Late-Life ManiaU01MH068847 · NIMH · WEILL MEDICAL COLL OF CORNELL UNIV · PI YOUNG, ROBERT C. · 2005 to 2009
$650k
Complex Trials for Severe Geriatric Mood DisordersK24MH069430 · NIMH · UNIVERSITY OF PITTSBURGH AT PITTSBURGH · PI MULSANT, BENOIT H · 2004 to 2008
$601k
NCRR NIH HHS UL1 RR024989NCRR NIH HHS UL1 RR024996NIMH NIH HHS K02 MH067028NIMH NIH HHS K24 MH069430NIMH NIH HHS P30 MH071944NIMH NIH HHS P30 MH085943NIMH NIH HHS P30 MH090333NIMH NIH HHS R01 MH084921NIMH NIH HHS U01 MH068846NIMH NIH HHS U01 MH068847NIMH NIH HHS U01 MH074511
6 · The paper itself

Abstract

objectiveClinicians treating older patients with bipolar disorder with mood stabilizers need evidence from age-specific randomized controlled trials. The authors describe findings from a first such study of late-life mania.

methodThe authors compared the tolerability and efficacy of lithium carbonate and divalproex in 224 inpatients and outpatients age 60 or older with bipolar I disorder who presented with a manic, hypomanic, or mixed episode. Participants were randomly assigned, under double-blind conditions, to treatment with lithium (target serum concentration, 0.80-0.99 mEq/L) or divalproex (target serum valproate concentration, 80-99 μg/mL) for 9 weeks. Participants with an inadequate response after 3 weeks received open adjunctive risperidone. The authors hypothesized that divalproex would be better tolerated and more efficacious than lithium. Tolerability was assessed based on a measure of sedation and on the proportions of participants achieving target concentrations. Efficacy was assessed with the Young Mania Rating Scale (YMRS).

resultsAttrition rates were similar for lithium and divalproex (14% and 18% at week 3 and 51% and 44% at week 9, respectively). The groups did not differ significantly in sedation. Participants in the lithium group tended to experience more tremor. Similar proportions of participants in the lithium and divalproex groups achieved target concentrations (57% and 56%, respectively). A longitudinal mixed model of improvement (change from baseline in YMRS score) favored lithium (change in score, 3.90; 97.5% CI=1.71, 6.09). Nine-week response rates did not differ significantly between the lithium and divalproex groups (79% and 73%, respectively). The need for adjunctive risperidone was low and similar between groups (17% and 14%, respectively).

conclusionsBoth lithium and divalproex were adequately tolerated and efficacious; lithium was associated with a greater reduction in mania scores over 9 weeks.

Indexed as

AgedAntimanic AgentsAntipsychotic AgentsBipolar DisorderDouble-Blind MethodDrug Therapy, CombinationFemaleHumansLithium CarbonateMaleMiddle AgedRisperidoneTreatment OutcomeValproic AcidAntimanic AgentsAntipsychotic AgentsLithium CarbonateRisperidoneValproic AcidBipolarDivalproexLate-lifeLithiumMania

Identifiers

PMID29088928
PMCPMC6214451
OpenAlexW2744819261

What OpenQuestion holds

Textmetadata
LicenceTDM
Read underepoch 390

Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.