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Florence Nightingale Journal of Nursing logoLink to Florence Nightingale Journal of Nursing
. 2020 Jun 1;28(2):124–132. doi: 10.5152/FNJN.2020.19073

Determination of Independence and Life Satisfaction Level of Individuals with Mental Disorder

Ayşegül Bilge 1,✉, Nezihe Bulut-Uğurlu 2, Cansu Güler 1
PMCID: PMC8152157  PMID: 34263191

Abstract

Aim

The study aimed to determine the level of independence and life satisfaction of individuals with diagnosed mental disorder.

Method

The descriptive study was conducted with 108 inpatients in two public universities, medical faculty hospitals mental health and psychiatric clinics. Personal information form, Life Satisfaction Scale, and Psychiatric Patient Independence Level Scale were used for data collection tool.

Results

Mean age of the participants was 41.8±14.1 years. 60.2% (n=65) were male, 57.4% (n=62) were 34 years and older, 58.3% (n=63) were single, and 33.3% (n=36) were diagnosed with depression. When the distribution of the mean score of the independence level was analyzed according to the individuals’ characteristics, a statistically significant difference was found in terms of age, marital status, education status, medical diagnosis, and duration of treatment (p<0.05). When the distribution of life satisfaction score averages of the individuals diagnosed with mental disorder were examined according to the individuals’ characteristics, there was a statistically significant difference according to the variables of medical diagnosis (p<0.05). Thus, patients with mental disorders, had moderate dependency, had a moderate level of life satisfaction, and a negative and poor correlation was found between life satisfaction and dependence (rho=−0.306; p<0.01). As a result of the regression analysis, 10.5% of the increase in life satisfaction was determined by the independence level (R=0.324; R2=0.105; p<0.01).

Conclusion

It was concluded that the participating individuals had moderate independent and life satisfaction. The variables such as diagnosis, age, life satisfaction, and independence levels increased, and the level of dependence decreased.

Keywords: Life satisfaction, independence level, mental disorder

INTRODUCTION

In the first months of life, attachment with the parent is influential and can continue throughout life affecting relationships in the adult period (Bowlby,1988; Karakuş, 2012). In case of the foundation of trust in an individual with healthy attachment, personal competence and positive self-value are formed; otherwise, the independence and individualization of the individual can be prevented (Karakuş, 2012; Öz, 2004). In the case of insecure attachment, individuals need approval from someone else in the decision-making process, see themselves inadequate to meet their needs, avoid problems or assume responsibility, and seek happiness and self-esteem in the dependent person or object (Öz, 2004; Terzi & Çankaya, 2009). In fact, in the absence of the person or object on which an individual is dependent in a dependency relationship, life may become challenging or restricted (Öz, 2004).

Life satisfaction includes subjective judgments that include qualities such as the desire to change life, satisfaction with the past, present, and future, and the importance of others in the life of the individual (Diener, Suh, Lukas, & Smith, 1999; Dost, 2007). In short, it can be defined as the feeling of satisfaction as a result of the general judgments and evaluations of the individual about his/her own life (Çivitçi, 2012; Yılmaz & Altıok, 2009). Satisfaction obtained from life through the realization of expectations and desires results in happiness, while the other problems, difficulties, obstacles, and conflicts encountered in the opposite way may negatively affect life satisfaction (Keser, 2005).

The World Health Organization’s emphasis on “complete well-being” in defining health is directly related to the concept of quality of life. The concept of quality of life, which consists of a subjective dimension such as life satisfaction and an objective dimension such as maintaining an independent life, is affected by the deterioration of health. Therefore, although every threat to health depends on various causal factors, it can negatively affect both the level of independence and life satisfaction (Soygür, 2003).

Individuals may need help from someone else in order to meet their needs in cases of reduced functionality of old age, emotional loss, and chronic physical and mental illness (Korhan, Yönt, Tokem, Karadağ, Sarıoğlu, & Yıldız, 2013; Öz, 2004). It is natural and expected that individuals need help to meet their needs in cases of reduced functionality, but it is not a healthy behavior for an individual to constantly need someone else to maintain his or her life. These individuals can become dependent on the care of someone else to meet their needs (Öz, 2004). According to Orem, one of the nursing theorists, self-care is the use of the necessary skills at the right time to protect an individual’s health, life, and well-being (Arı, Saraçlı, & Karacan, 2015). According to Orem, it is essential to support the individual who is dependent on someone else to meet his/her needs until he/she meets his/her basic needs (Korhan et al., 2013; Öz, 2004). The main purpose of self-care is to fulfill all the responsibilities of the individual regarding his/her health independently. When self-care is fulfilled, it contributes to a healthy and happy life. In other words, as individuals become independent in self-care, positive emotions increase (Parissopoulos & Kotzabassaki, 2004). In a study conducted by Ergin, Hatipoglu, Bozkurt, & Bostancı (2011) with university students on this subject, it was concluded that there was a significant relationship between life satisfaction and self-care power.

Individuals with a diagnosed mental illness may experience addiction and insatiability to life as a symptom of the disease and sometimes as a secondary symptom due to the continuity of the disease (Fergusson McLeod, Horwood, Swain, Chapple, & Poulton, 2015). The aim of the psychiatric nurse is to support the individual to be a self-sufficient, high-functioning, happy, and independent individual with the principle of uniqueness. In order for the psychiatric nurse to achieve this goal, planning and providing care by focusing on life satisfaction and independence levels directly related to the well-being of the individual will have a positive effect on the health outcomes of the individuals (Çam, 2014). On the basis of this need, the aim of this study was to determine the factors affecting the independence and life satisfaction of individuals diagnosed with mental illness and the relationship between life satisfaction and independence. Thus, we aimed to answer the following research questions:

  1. What are life satisfaction and independence levels of individuals diagnosed with mental illness?

  2. Is there a relationship between life satisfaction and independence levels of individuals diagnosed with mental illness?

  3. Is there any difference between the levels of life satisfaction and independence according to the descriptive characteristics of individuals diagnosed with mental illness?

METHOD

Study Design

This is a descriptive study.

Sample

This study was conducted between April 01, 2016 and May 15, 2016 with inpatients who were hospitalized in two public universities, medical faculty hospital, psychiatric clinic. A methodological approach was not used to determine the sample of the study. The inclusion criteria included volunteering to participate in the study and being present in the psychiatric clinics for treatment, while exclusion criteria included the criteria for having physical and mental illness that would prevent them from understanding the questions (n=108).

Data Collection

As a data collection tool, personal information form, Life Satisfaction Scale (LSS), and Psychiatric Patient Independence Level Scale (PPILS) were used.

Personal Information Form

The form which was prepared by the researchers included general information about the sociodemographic characteristics and sample profile of the participants such as diagnosis, duration of disease, age, gender, marital status, educational status, working status, and duration of hospitalization.

Life Satisfaction Scale (LSS)

The scale developed by Diener, Emmons, Larsen & Griffin, (1985) and which conducted validity and reliability according to methods by Köker (1991) in Turkish, consists of five items. The scale consists of a single sub-dimension and is a 7-point Likert type and is scored between 1 and 7 points. The increase in the scores obtained from the scale that measures the cognitive dimension of subjective well-being indicates that perceived life satisfaction is high. The Cronbach’s alpha reliability coefficient was not examined by Köker (1991) for the reliability of the Turkish version of the scale, and the Cronbach’s alpha reliability coefficient was 0.92 for this study.

Psychiatric Patient Independence Level Scale (PPILS)

The scale developed by Acele, Kert, Siviloğlu, Özaydın, Bilge & Çam, (2014) consists of 45 items in 1 dimension. The scoring of the scale varies between 0 and 2, which means that as the scores obtained from the scale increase, the dependency level of the individual increases and a caregiver needs to be cared for. Low scores from the scale mean that the individual can do his/her own care and does not need care or support. In the evaluation of the total score of the scale, the patients who scored between 0 and 44 were “Independent,” the ones between 45 and 60 were “Mild Dependent,” those between 61 and 75 were “Intermediate Dependent” and those who were scored between 76 and 90 were “High dependent”. Each item of the scale should be scored by the observer researcher. Acele et al. (2014) found the Cronbach’s alpha reliability coefficient to be 0.97 in the validity and reliability study; the Cronbach’s alpha reliability coefficient was 0.97 for this study.

The data of the study were collected using the face-to-face interview technique by the researchers in a suitable range for individuals diagnosed as inpatient psychiatric illnesses during the institutional permits, and the data of the PPILS evaluating behaviors and attitudes were collected by the researcher.

Statistical Analysis

Statistical Package for Social Sciences 25.0 (IBM SPSS Corp.; Armonk, NY, USA) package program was used for statistical analysis of the data. Non-parametric tests were used to evaluate the data of the sample, which did not fit the normal distribution. The Mann–Whitney U test was used for two independent groups to compare continuous variables with sociodemographic variables and the Kruskal Wallis test was used to compare more than two independent groups. The Spearman’s rank correlation coefficient (rho value) was examined in order to evaluate the relationship between LSS and PPILS in non-normal sample. In addition, simple linear regression analysis was performed to determine the extent to which life satisfaction scores were predicted by independence scores. Results were expressed as number-percentage distribution, mean and ± standard deviation, and min-max values. It was considered statistically significant that the obtained p value was less than 0.05.

Ethical Considerations

The ethics committee permission was obtained from the Ege University Faculty of Nursing Scientific Ethics Committee (Date and Number: March 18, 2016/2016-112) in order to conduct the research and written institution permission (Date and Number: March 28, 2016/33623) was obtained from hospitals for the application of the questionnaire forms. At the same time, verbal consent was obtained from the individuals who participated in the study during the filling of the data collection forms.

RESULTS

The mean age of the participants was 41.8±14.1 years. Of the participants, 60.2% (n=65) were male, 57.4% (n=62) were 34 years and older, 58.3% (n=63) were single, 37% (n=40) were secondary school graduates, 60.2% (n=65) were unemployed, 33.3% (n=36) were admitted to the clinic with the diagnosis of major depression, 26.9% (n=29) were treated for more than nine years, and 38% (n=41) were hospitalized for 1–7 days (Table 1).

Table 1.

Distribution of LSS and PPILS mean scores of individuals diagnosed with mental illness according to the characteristics (n=108)

Variable Life Satisfaction Scale (LSS) Psychiatric Patient Independence Level Scale (PPILS)
Total Score Mean±SD Total Score Mean±SD
Year 18 and under year (n=4) 19.75±7.04 53.75±13.33
19–25 years (n=20) 20.25±8.50 53.50±13.51
26–33 years (n=22) 19.82±5.47 54.41±14.19
34 years and older (n=62) 16.90±7.36 65.68±14.54
KW/p 4.15/0.25 13.75/0.03*
Gender Female (n=43) 17.16±6.49 63.86±15.73
Male (n=65) 18.92±7.76 58.58±14.61
U/p −1.05/0.29 −1.76/0.08
Marital Status Married (n=45) 16.98±7.10 66.69±14.86
Single (n= 63) 19.11±7.38 56.40±14.07
U/p −1.23/0.22 −3.18/0.01*
Education Primary school (n=27) 16.93±7.55 71.48±10.68
Secondary school (n=40) 17.38±7.71 60.58±15.58
High school (n=19) 18.47±6.01 53.21±14.14
University (n=22) 21.13±6.89 54.09±13.06
KW/p 5.08/0.17 19.98/0.00**
Occupational Status Yes (n=43) 17.98±8.04 59.60±15.75
No (n=65) 18.38±6.83 61.40±14.93
U/p −0.45±0.65 −0.86±0.39
Medical Diagnosis Major depression (n=36) 15.72±6.50 70.69±10.88
Bipolar disorder (n=35) 18.48±7.19 57.91±15.33
Schizophrenic disorder (n=18) 18.17±7.97 60.16±14.77
Alcohol and substance addiction (n=14) 22.43±7.65 48.78±10.84
Other (n=5) 22.80±5.00 43.20±1.73
KW/p 5.88/0.05* 26.17/0.00**
Duration of Treatment 0–2 year (n=43) 17.98±7.40 65.51±14.77
3–5 year (n=22) 19.27±7.44 56.50±15.88
6–8 year (n=14) 16.85±6.70 59.71±13.29
9 and more years (n=29) 18.45±7.59 57.17±14.95
KW/p 0.81/0.85 5.88/0.12
Treatment Time 1–7 days (n=41) 18.62±6.67 63.33±15.98
8–14 days (n=28) 16.87±7.94 62.07±13.89
15 and more days (n=39) 18.87±7.45 56.97±15.05
KW/p 1.32/0.52 3.326/0.19
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LSS: Life Satisfaction Scale; PPILS: Psychiatric Patient Independence Level Scale, KW: Kruskal Wallis test; SD: Standard deviation; Min: Minimum; Max: Maximum

*

p<0.05,

**

p<0.01

In the study, when the distribution of mean PPILS scores according to the descriptive characteristics of individuals diagnosed with mental illness was examined, a statistically significant difference (p<0.05) was found in the mean PPILS scores according to the variables of age, marital status, educational status, and medical diagnosis; there were no significant differences according to gender, working status, duration of treatment, and duration of clinical findings (p>0.05; Table 2). When the distribution of the mean LSS score of the individuals diagnosed with mental illness was examined according to the descriptive characteristics of the individuals, a statistically significant difference was found according to the medical diagnosis variable (p<0.05); on the contrary, no significant difference was found according to the variables of disease duration, age, gender, marital status, educational status, working status, and duration of hospitalization (p>0.05; Table 1).

Table 2.

Mean level of independence and satisfaction of individuals diagnosed with mental illness (n=108)

Scales Mean±SD Min–Max Score range
LSS 18.22±7.30 7–35 7–35
PPILS 60.69±15.21 35–84 0–90
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LSS: Life Satisfaction Scale; PPILS: Psychiatric Patient Independence Level Scale; SD: Standard deviation; Min: Minimum; Max: Maximum

It was determined that the mean PPILS scores of the participants with mental illness were 60.69±15.21 and the individuals were moderately dependent. The mean LSS score of the individuals was found to be 18.22±7.30 with moderate life satisfaction (Table 2).

Correlation coefficient (rho) was found to be −0.306 (p<0.01) as a result of the correlation analysis conducted to investigate the relationship between the total score obtained from the LSS and the PPILS (p<0.01). Accordingly, a significant negative correlation was found between the total scores of the LSS and PPILS (Table 3). As a result of linear regression analysis, it was examined whether independence scores predicted life satisfaction scores and as a result regression coefficient was found as R=0.324, R2=0.105, (Corrected R2=0.097, Predicted Std. Error=6.942). Thus, it was concluded that 10.5% of the total variance in life satisfaction scores were explained by independence level scores.

Table 3.

The relationship between the Life Satisfaction Scale and the Psychiatric Patient Independence Level Scale (n=108).

LSS PPILS
LSS 1 rho=−0.306** (0.001)
PPILS rho=−0.306** (0.001) 1
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LSS: Life Satisfaction Scale; PPILS: Psychiatric Patient Independence Level Scale

**

p<0.01

DISCUSSION

Determining the level of life satisfaction and independence, which is an important indicator of well-being, provides important data for meeting the care needs of individuals diagnosed with mental illness in order to lead a quality life (Korhan et al., 2013; Soygür, 2003). In this study conducted with this reason, the life satisfaction and independence level of the individuals diagnosed with mental illness and the relationship between the factors affecting life satisfaction and independence level were investigated.

More than half of the participants were older than 34 years old, and more than half were male and single, one third of them were secondary school graduates, and more than half were not professionally employed. When the disease history of the participants was examined, one-third of them were treated with the diagnosis of major depression, about half of them had been treated for two or less years, and about half of them had been treated in the clinic for one to seven days.

In the study, it was concluded that the level of independence of individuals diagnosed with mental illness was affected by sociodemographic variables such as age, marital status, and educational level. In the study, it was concluded that individuals aged 34 years and over, married, and primary school graduates were significantly more dependent. There are contradictory results in the literature regarding the relationship between age and independence. In some of the studies, there was an inverse relationship between independence and age (Çakmak, Süt, Öztürk, Tamam, & Bal, 2016) and in some others, it was found that independence was independent of age (Rymaszewska & Mazurek, 2012). In this study, it was concluded that the singles were significantly more independent. Rymaszewska and Mazurek (2012) in their study with schizophrenia patients, and Çakmak et al. (2016) in their study with psychiatric diagnosis, found that single individuals were more dependent compared to those assessed in the present study. Although the severity of psychopathological symptoms increases and functionality decreases, it is thought that this difference in research results cannot be explained solely by sociodemographic variables, but it is considered that disease history should be taken into consideration.

In the study, it is concluded that women, unemployed individuals, and new hospital admissions are more dependent, although not statistically significant. It is stated in the literature that education level positively affects self-care power, which has a direct relationship with the level of independence of individuals (Altay & Aydın-Avcı, 2009; Bakış & Çınar, 2007; Rymaszewska & Mazurek, 2012). Although there was no statistically significant difference in the study, it was concluded that women were more dependent (p>0.05). In the literature, when the effect of gender on the independence levels of individuals diagnosed with mental illness was examined, inconsistent results were reached (Çakmak et al., 2016; Melle, Friis, Hauff, & Vagium, 2000; Sanderson & Andrews, 2002). Although no statistically significant difference was found in the study, it was concluded that unemployed individuals were more dependent, but Rymaszewska and Mazurek (2012) found no significant relationship between unemployment and independence in a study conducted with a similar sample group. It is thought that the interpretation of factors such as stigmatization, discrimination, psychosocial skill interventions, and employment policies, which are known to have an effect on unemployment, may provide richer findings in predicting the resulting difference. In this study, it was observed that individuals diagnosed with mental illness were moderately dependent during the first week of admission to the clinic, and that as the therapeutic process prolonged, dependence levels decreased toward the mild level (Table 1). Disability associated with psychopathological symptoms during exacerbation of symptoms for which hospitalization is envisaged adversely affects the independence of individuals (Dikeç & Kutlu, 2015; Söğütlü, Özen, Varlık, & Güler, 2017). It is known that psychopharmacological therapies and attempts to improve various functionalities in the therapeutic process starting with the application of individuals to a health institution are effective in increasing the independence of individuals by increasing their functionality (Dikeç & Kutlu, 2015; Çelikbaş & Ergün, 2018; Söğütlü et al., 2017). Accordingly, it is thought that the independence of individuals from day to day may be related to the therapeutic process.

When the independence levels of the individuals diagnosed with mental illness were examined, it was seen that they were moderately dependent (Table 2). When the available national and international literature is examined, there are no studies examining the independence levels of individuals diagnosed with mental illness. Although mentally healthy individuals live independently (Bayındır & Ünsal, 2016), individuals suffering from mental illness experience a decrease in functionality that cannot meet their needs independently (Kaya & Öz, 2019). Neurocognitive losses in each of the mental illnesses may affect the functionality of individuals negatively and thus increase their dependence on another (De Silva, Cooper, Li, Lund, & Patel, 2013; Koc-Apaydin & Atagün, 2018; Kupferberg, Bicks, & Hasler, 2016; Özyüksel & Uluğ, 2007). In the study, when compared with other psychiatric diagnosis groups, it is seen that individuals diagnosed with major depression and schizophrenia are moderately dependent and individuals with bipolar disorder are low dependent. Kaya and Öz (2019) and Maglinao, Fiorillo, Malangone, De Rosa, & Maj (2006) conducted with patients with schizophrenia, Doğanavşargil-Baysal, Gökmen, Akbaş, Cinemre, Metin, & Karaman. (2013) with patients diagnosed with bipolar disorder, and Vikas, Avasthi, & Sharan (2009) with individuals with major depression found similar results. It is known that almost all mental illnesses cause functional impairment at various levels (Erol, Kılıç, Ulusoy, Keçeci, & Şimşek, 1998). It is thought that many variables such as the level of destruction caused by the disease and the level of benefiting from psychosocial skills training may affect the functioning of individuals diagnosed with mental illness and affect their independence negatively. Although the duration of treatment was not found to be significantly effective in the independence of individuals diagnosed with mental illness, it was seen that individuals suffering from the disease for more than two years were higher and moderate dependent than the other groups, and there was no direct and continuous relationship between the time they were diagnosed and their independence levels (Table 1). It is thought that the low independence of individuals diagnosed for less than two years may be affected by the diagnosed disease variable.

In this study, it was concluded that the level of life satisfaction of individuals diagnosed with mental illness was moderate and that the medical diagnosis had a significant effect on life satisfaction. In this study, it was observed that the individuals with the diagnosis of major depression had a statistically significant level of life satisfaction and that the life satisfaction of the individuals diagnosed with the disease in the other group such as alcohol and substance dependence and anxiety disorders was better than the moderate level (Table 1). Fergusson et al. (2015), in a longitudinal study conducted in a large sample group, stated that there was a mutual relationship between mental health and life satisfaction, and that individuals who were diagnosed with mental illness had moderate life satisfaction levels. In the same study, the effect of the diagnosis of mental illness on life satisfaction was examined and it was concluded that there was a negative relationship between the presence of major depression and suicidal ideation or attempts, and life satisfaction, whereas there was no statistically significant relationship between alcohol dependence and life satisfaction (Fergusson et al., 2015). In this study, it is predicted that the difference in favor of individuals with alcohol and substance dependence may be related to high level of independence.

Although no statistically significant difference was found in the study, it was seen that life satisfaction of individuals in the age group of 19–25 years, males, singles, university graduates, and non-working people was higher than that in other groups (Table 1). It is reported that sociodemographic factors such as age, gender, marital status, working status, and education are effective in determining life satisfaction (Altay & Aydın-Avcı, 2009; Bakış & Çınar 2007). Self-care is to fulfill the responsibilities of individuals for their well-being (Altay & Aydın-Avcı, 2009). To maintaining self-care, the continuity of the balance between the skills and needs of individuals to act is essential (Balcı, 2003). By nature, chronic physical or mental illness can adversely affect the ability of individuals experiencing action to meet their needs. If self-care is not fulfilled, life satisfaction is reported to be negatively affected if individuals become dependent on someone else (Altay & Aydın-Avcı, 2009).

In the study, a negative and weak correlation was found between life satisfaction and addiction level of individuals diagnosed with mental illness (rho=−0.306, p<0.01; Table 3). As a result of linear regression analysis, results of R=0.324, R2=0.105 were found (Corrected R2=0.097; Predicted Std. Error=6.942; p<0.01). According to this finding, although independence scores can predict statistically significant life satisfaction (p<0.01), it is responsible for only 10.5% of the increase in life satisfaction scores. The concept of life satisfaction is influenced by subjective experiences and changes in psychosocial skills (Edmondson, Pahwa, Lee, & Brekke, 2012; Kaya and Öz, 2019). In this study, a weak significant relationship and a 10.5% coefficient of explanatory value indicate that life satisfaction increases together with independent individuals diagnosed with mental illness, but life satisfaction is not only related to individual independence. However, the level of independence is not only related to life satisfaction. Yanos and Moos (2007) stated that the level of independence is affected by changing environmental factors, personal resources, psychiatric symptoms, cognitive assessment, and coping skills. In the literature, Altay and Aydın-Avcı (2009) and Bakış and Çinar (2007) with the elderly living in nursing homes, Ergin et al. (2011) with university students, Bradshaw and Brekke (1999) and Edmondson et al. (2012) with individuals diagnosed with schizophrenia found similar results with current research.

Study Limitations

The limitation of the sample size in the study can be highlighted by the inclusion of only inpatients in two university hospitals and with the participation of 108 individuals in the study. The completion of the PPILS by the researcher based on observations caused limitations on the objectivity of the researcher.

CONCLUSION AND RECOMMENDATIONS

According to the findings of the study, it was found that the individuals who participated in the research were moderately dependent and their life satisfaction was moderate. It was concluded that variables such as age, marital status, education level, medical diagnosis, and duration of treatment of the participants affected the levels of life satisfaction and independence and life satisfaction increased as the dependency levels of the patients increased. In addition, it can be said that males, in the age group of 19–25 years, singles, high education level, employees, alcohol dependence diagnosis, 3–5 years of treatment, 15 days inpatient treatment, and others have higher life satisfaction.

This study provides valuable results in terms of planning psychosocial interventions that may increase the life satisfaction and independence of the patients by taking these variables into consideration while regulating the therapeutic environment of psychiatric nurses. In line with these results, it is recommended that similar studies be conducted in larger sample groups, further statistical analyzes are conducted in order to investigate in depth the factors that predict life satisfaction other than independence variable and subjective concepts such as life satisfaction are reevaluated with qualitative research methods.

Footnotes

Ethics Committee Approval: Ethics committee approval was received for this study from the ethics committee of Scientific Ethics Committee of Ege University Nursing Faculty (Approval date: 18.03.2016, protocol no: 2016-112).

Informed Consent: Verbal informed consent was obtained from the parents of the children who participated in this study.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept – A.B., N.B.U, C.G.; Design – A.B., N.B.U, C.G.; Supervision – A.B., N.B.U, C.G.; Resources – A.B., N.B.U, C.G.; Materials – A.B., N.B.U, C.G.; Data Collection and/or Processing – N.B.U, C.G.; Analysis and/or Interpretation – A.B., C.G.; Literature Search – A.B., C.G.; Writing Manuscript – A.B., C.G.; Critical Review – A.B., C.G.; Other – A.B., N.B.U, C.G.

Conflict of Interest: The authors have no conflicts of interest to declare.

Financial Disclosure: The authors declared that this study has received no financial support.

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