ABSTRACT

The Turkish Republic of Northern Cyprus (TRNC), which is located in the northern part of the island of Cyprus, has a complex history and was established with great difficulties. Like many other domains, the field of psychiatry was rebuilt after the wars in the TRNC. Hospital-based mental health services have continued in the TRNC since the first hospital was established after the war of 1974. The current mental health law was created during the period of British administration and anew draft law is now being considered in the parliament. Rates of suicide increased in the TRNC from 1992 to 2012, and domestic violence, homophobia, transphobia, and psychoactive substance abuse are also important problems. However, many institutions now carry out preventive and rehabilitative studies in the field of mental health and this is a promising and significant development. Conducting a study which determines the mental health profile of the TRNC is important for shaping future studies in the field of mental health. In addition, it is important in terms of designing initiatives to make mental health services more community-based. Creating a database for scientific studies will also contribute to a better and more systematic organization of the information. This will also help nurses receiving postgraduate education in the field of mental health and psychiatric nursing to improve the care given to individuals/patients in institutions providing mental health services. The number of nurses working in psychiatry should be increased and programs given in order to allow them to become more properly qualified.

INTRODUCTION

“Awareness” is an important concept for all mental health professionals in general. With regard to specific mental health policies and practices, it is necessary that professionals are aware of what has happened in the past and the stages which have occurred up to the present day. Past, present, and future are not separate from each other. Having an awareness of past and present developments may determine the direction of future plans.

Wars are negative experiences for public mental health, but they contribute to developments and changes in the field of healthcare.¹ In 1963 and 1974, two major wars took place between Turkish Cypriots and Greek Cypriots, causing great suffering for the individuals who lived through them.^2,3 After the 1963 war, the residential areas of the Turkish Cypriots and Greek Cypriots were divided along a ceasefire line called  the “green line”. After the 1974 war, Cyprus was separated into a northern and a southern area, divided by a buffer zone. Turkish Cypriots began to live in the north of the island and Greek Cypriots in the south. Later, two different republics, the Turkish Republic of Northern Cyprus (TRNC) and the Republic of Cyprus were established.^1,4 Turkish Cypriots experienced many rapid changes as a result of these wars. Economic and social structures were upended, living spaces were bombed or abandoned, day-to-day social life was profoundly altered, many deaths were witnessed, and great pain and suffering were experienced. These negative changes caused deep psychological strains.^3,4 The number of suicide attempts and completed suicides increased in Northern Cyprus between 1970 and 1990. While five people attempted suicide in 1970, 34 people attempted suicide in 1990.⁵ The changes that Turkish Cypriots experienced in the field of mental health started with the war of 1974: the island’s sole psychiatric hospital remained in the south, while there was an emerging need for mental health services in the north.^2,6,7 Today, there are two mental health hospitals (one private hospital and one state hospital) in the TRNC.^8,9

Examining specific studies on mental health in Northern Cyprus, according to the study conducted by Yağlı et al.⁵ to determine suicide attempts and prevalence, five people attempted suicide in 1970 and this number increased to 34 in 1990. According to their study, there was an increase in suicide attempts and completed suicides in Northern Cyprus between 1970-1990. The study by Sönmez et al.¹⁰ investigating the rate of suicides with drugs reported that suicides had continued increasing from 1992 until 2012. Although there is no study indicating the general mental health profile of TRNC, studies have reported that suicide rates continued to increase from 1992 to 2012,^5,10 and that psychoactive substance abuse is an increasing problem in TRNC.^11-16 In addition, problems such as domestic violence,^17-19 and homophobia and transphobia against LGBTI individuals²⁰ have been observed. These issues indicate there is a gradually increasing need for psychological care in the Northern Cypriot population. It is thus important to examine the mental health services being provided today and to conduct studies on how best to promote and maintain mental health.

No literature has been compiled about psychiatry in the TRNC. When history is not written, it disappears from view over time. Knowing about and understanding the developments in the field of psychiatry from the past to the present is important in helping to develop policies for the future. To this end, this study aimed to explain the history of psychiatry in Northern Cyprus, and this study may provide a basis for new studies in the field of mental health.

CYPRUS

In order to better understand the issue of psychiatry in Northern Cyprus, it is important to first examine the features of the island. Cyprus is located in the eastern Mediterranean and is the third-largest island in this region. It consists of two different states, the TRNC and the Republic of Cyprus. Due to its geographical location, the island of Cyprus has historically been able to control trade routes through the Eastern Mediterranean and to and from the Middle East. For this reason, many civilizations have tried to establish sovereignty over Cyprus, which has led to it being the focal point of many international conflicts.^21,22

Cyprus was part of the Ottoman Empire between 1571 and 1878. During this period, Turks and Greeks lived on the island together. In 1878, in exchange for various promises, Cyprus was leased to the British Empire and placed under the administration of the United Kingdom. Under the Treaty of Lausanne, the free migration of Turks was allowed, and many Turks emigrated. During this period, the population of Turkish Cypriots decreased compared to Greek Cypriots due to emigration.²¹ In a decree of 1917, those people living on the island were asked to become British citizens within two years. A large number of Turks, who did not accept this decree, emigrated from Cyprus to various parts of Anatolia. The United Kingdom proclaimed Cyprus a “Crown Colony” of the British Empire in 1925.^4,23 Between 1955 and 1959, the Ethniki Organosis Kyprion Agoniston (EOKA) (in English: the National Organization of Cypriot Fighters), established by Greek Cypriots and led by George Grivas, demanded “enosis” (the union of the island with Greece). Turkish Cypriots, on the other hand, established the Turkish Resistance Organization. Turkish and Greek leaders reached a consensus and established the Republic of Cyprus in 1959. However, this republic could not bring peace and harmony to the island. In 1963 internal conflicts degenerated into fully-fledged armed fighting between the two communities on the island. The loss of life in this war caused great suffering. After the war, a ceasefire line known as the “Green Line” was established. Henceforth, Turks and Greeks lived in different areas. In 1974, the EOKA leader Nikos Sampson carried out a military coup with the support of the Greek National Guard Forces to overthrow President Makarios and to declare a Greek Republic in Cyprus.⁴ At the same time, attacks against Turks began on the island. The 1960 Treaty of Guarantee allowed Greece, Turkey, and the United Kingdom to unilaterally intervene to restore democracy in Cyprus in the event of a coup if attempts to garner multilateral support failed. On the basis of Article 4 of the Treaty of Guarantee, Turkey carried out two peace-keeping military operations (Operation Peace) to counter the EOKA in 1974. The first Operation Peace was implemented on July 20^th, 1974. Turkish troops took control of Kyrenia on July 22^nd and stopped advancing after a ceasefire. Meanwhile, Nikos Sampson’s leadership ended and he was replaced by Klerides. The three guarantor powers, Britain, Greece, and Turkey, as required by the treaty, met for discussions in Geneva between the 25^th July and 30^th July.

At the 1^st Geneva Conference, Operation Peace was found to be legitimate under Article 4 of the Treaty of Guarantee. Turkish administration of some of the island and the presence of the Turkish Armed Forces were accepted. As a result of the conference, a protocol was signed in which two different administrations were accepted, Turkish and Greek. It was decided that the security of mixed villages would be protected by a United Nations Peacekeeping Force. However, the implementation of these decisions was not successful.

Turkey conducted a second operation on August 14^th, 1974. Since then, the northern part of the island has been under the control of Turkish Cypriots. As a result of these operations, aimed at maintaining peace and stability on the island, many Turkish Cypriots were saved and a stable, peaceful environment was established. The efforts to connect Cyprus to Greece, which had carried on for many years, were prevented. The “Green Line” borders were determined after the second Operation Peace, and Turkish Cypriots gathered in the north of the island, and Greek Cypriots in the south. The TRNC was established in 1983. The Greek Cypriot administration in the south of Cyprus established the Republic of Cyprus in 2004. This republic became a member of the European Union as the official and legitimate state of the island.^24,25

Psychiatry in Cyprus

Treatment relating to mental illness in Cyprus began with the establishment of sanatoriums in the Ottoman Period.^21,26 In this period, the treatment of mental illness was the domain of mystics and shaman-like figures.²⁷ During the Ottoman rule, these sanatoriums became highly developed institutions in terms of the therapeutic practices used compared to other places in the world. Islamic communities were generally tolerant of individuals with mental health problems, and treatments included the use of music. Individual patients were not isolated from society and an attempt was made to treat them humanely.^28-30

With the leasing of Cyprus to the British Empire, the period of British administration began.²¹ The Mental Illness Law enacted during the British rule provides information about that period. Individuals with deteriorating mental health were hospitalized in a hospital known as the “madhouse”, located near Nicosia. Although there was training in the field of mental health for nurses in England in the 1940s,^2,6 nurses were not specifically mentioned in the law.³¹ Before 1974, there was a 653-bed hospital, known as the “Mental Hospital”, serving all of Cyprus during this period. In the Mental Hospital, activities such as basket-weaving were conducted for therapeutic purposes. Patients who were able to work were paid a little. However, no emphasis was placed on the privacy of the hospitalized patients, and there was no distinction in terms of room accommodation according to the type of patient.⁷

With the wars, the lifestyle of Turkish Cypriots changed, and many areas, including mental health, needed to be rebuilt. Living spaces were bombed, there was extensive loss of life, families were torn apart and suffered great losses, and economic structures and day-to-day social life changed. After all these changes, it was inevitable that mental difficulties would be experienced.^3,4 A study conducted by Yağlı et al.⁵ to determine suicide attempts and prevalence in 1992 found that five people had attempted suicide in 1970 and this number increased to 34 in 1990. Also, their study determined that suicide rates were at a minimum in 1974 and at a maximum in 1985 and were encountered more frequently in women than men. However, completed suicides were more common among men. These results show that there was an increase in suicide attempts and completed suicides in Northern Cyprus between 1970 and 1990.⁵ Although the need for mental health services in Northern Cyprus increased after 1974, the only hospital remained in the southern part of the island. Thus, an effort began to establish a hospital in Northern Cyprus and re-establish psychiatric health care.²

Development of Psychiatry in Northern Cyprus

The mental health field in the north of Cyprus was born from a huge gap and profound need. After the war of 1974, the island was divided and in a state of disorder. The Mental Hospital that had previously served both Turks and Greeks remained in Southern Cyprus, and there was no hospital in the north capable of meeting its mental health needs.² The first stage in establishing mental health services in the TRNC thus began. Married couple Baykal and Hüseyin Sarper, who were the first qualified Turkish psychiatric nurses in Cyprus, had trained in Psychiatric Nursing in England in 1947. After completing their education, they started working at the Mental Hospital. Baykal Sarper was the nurse in charge of the women’s ward, while Hüseyin Sarper was the nurse in charge of the men’s ward. They worked with the Greek doctor, Migelidis, the chief physician of the hospital.^2,6 During the 1974 war, the Sarpers, in cooperation with Turkish psychiatrist Dr. Sezai Sezgin, converted the Victoria Girls High School into a mental health clinic,² later known as the Nicosia Mental Health and Neurological Diseases Hospital.³² Mentally ill individuals were provided with care in this clinic during the war,² and a total of 77 individuals (52 soldiers, 20 mujahedeen, and five civilians) were hospitalized in this clinic during the 1974 conflict.³² As a result of the fighting, the Turkish patients hospitalized in the southern part of the island could not leave the hospital, and although the psychiatric nurses wanted to transfer these individuals to the Turkish region, they were unable to do so. However, various activities, such as a volleyball tournament, were conducted in the mental health clinic to reduce the trauma caused by the war.²

During the course of the 1970s, in various conferences and meetings attended by physicians, it was stated that relations with other medical fields should be maintained, that the Open Door method should be used and that individuals should be treated in the community where possible to make them less isolated from society at large. Polyclinic services relating to mental health were provided in the Famagusta region in Cyprus, while those individuals being treated at the Nicosia Mental Health and Neurological Diseases Hospital were treated with menstrual training, occupational therapy, ECT, electro-chemical shock therapy, Galvano-Faradi therapy, and tranquilizers.³² An additional mental health clinic was subsequently established in the former Selimiye Primary School. This building had three male wards, four single-patient rooms, a kitchen, dining hall, occupational therapy workshop, as well as an administrative section with a polyclinic. On the 25^th June, 1981, a new hospital, the Barış Mental and Neurological Diseases Hospital, came into service. This hospital still provides service as a state hospital, and polyclinic services are provided in many regions. The Barış Mental and Neurological Diseases Hospital has a capacity of 180 beds. However, no information is available on the numbers of specialized mental health and psychiatric nurses in the hospital at its founding.⁸

Even today, the number of institutions providing inpatient psychiatric services in North Cyprus is very limited. “Pembe Köşk” was the first addiction and rehabilitation center in the TRNC, operating between 2002 and 2010. After a nine-year break, it reopened in 2019 and now serves as the first private psychiatric hospital in the TRNC.³³ Therefore, there are now two in-patient psychiatric hospitals in the TRNC, one private and one public-sector hospital. In addition, polyclinic services are provided in a number of private hospitals, state hospitals, and health centers.

In terms of psychiatric education, The Mental Health Institute was established in 2005. This institute provides certificated programs in “psychoactive substance addiction counseling” for mental health professionals. Several other educational programs are also provided within the institute, including training in psychodrama, sports psychology, clinical therapy interview techniques, forensic psychology, child attention tests, life skills, management skills, body language, and motivational interview techniques.³⁴

The current law regarding mental health in Northern Cyprus was established during the period of British rule in 1931 as the “Mental Illness Law”.³¹ Studies are currently underway with the aim of passing a new law. On the 25^th September, 2018, the draft Mental Health Law was submitted to the parliament.³⁵ As of the time of writing, there is no study investigating the mental health profile of the Northern Cyprus society. However, a study conducted to determine suicides with drugs in Northern Cyprus between 2002-2012 found the mean age of women attempting suicide to be 25.80±11.36 years and the mean age of men to be 27.94±12.44 years. Also, that study found that suicide attempts were encountered most in spring at a rate of 27.6% and least in winter at a rate of 20.4%. Examining suicide attempts in terms of the year; 158 people attempted suicide in 2002, 223 people in 2004, 193 people in 2005, 251 people in 2006, 231 people in 2007, 208 people in 2008, 238 people in 2009, 237 people in 2010, 216 people in 2011 and 196 people in 2012.¹⁰

A study conducted by Çakıcı et al.¹⁵ investigating the prevalence of drug abuse in the TRNC found the rate of illegal drug abuse to be 3.0%. Another study conducted by Çakıcı et al.¹³ in 2008 found that this rate had increased to 7.7%. Another study determined that the lifelong rate of smoking among primary school students was 10% in female students, 11.8% in male students and the lifelong rate of drinking alcohol among primary school students overall was 23.5%.¹¹ In addition, the rate of illegal drug abuse among high school students increased from 2% in 1996 to 5.2% in 2015. Also, the rate of taking tranquilizers, which are classified as other psychoactive substances, was 3.2% and the rate of taking volatile substances was 2.9%. When examining the reasons for taking other psychoactive substances, high school students took these substances mainly for soothing their nervousness (13%) and secondly for relaxing (6.5%).¹⁶ In Northern Cyprus, psychoactive substance abuse has become an important problem from primary school until adulthood.

In a study conducted on the levels of aggression in children, 5^th-grade students in primary school were found to be moderately aggressive.³⁶ This shows that violent behavior in the TRNC begins in childhood. Violence against LGBTI individuals is also common. Under the aegis of the “Unspoken Project”, a two-stage study of homophobia and transphobia in the TRNC population was conducted, and violence against LGBTI individuals was found in the results of the first stage. As a result of this, attempts were made to increase societal awareness of these issues, and a second study was conducted. However, in the second study, it was observed that homophobia and transphobia had continued.²⁰

A study conducted by Masaroğulları and Uzunboylu¹⁹ to investigate the reasons of violence against women found that the province with the highest rate of violence was Gazimagusa. Partner jealousy was considered the most frequent reason among violence types at a rate of 74% and women were forced into sexual intercourse by their partners at a rate of 14%. A study conducted by Mammadov¹⁸ to examine the state of pregnant women being subjected to domestic violence in Northern Cyprus determined that 74.9% of women were subjected to economic violence, this rate increased to 76.6% during pregnancy, 48.9% were subjected to verbal violence, this rate dropped to 41.1% during pregnancy, 35.6% were subjected to emotional violence, this rate dropped to 27.9% during pregnancy, 21% were subjected to sexual violence, this rate dropped to 19.2% during pregnancy, 2.7% were subjected to physical violence and this rate dropped to 0.9% during pregnancy. In Northern Cyprus, violence against women and LGBTI individuals and psychoactive substance abuse are important problems. Interventions aimed at protecting the mental health of women and LGBTI individuals who are members of at-risk groups and the prevention of psychoactive substance abuse are considered to be important.

In considering mental health issues, the safeguarding and improvement of the mental health of healthcare professionals themselves can also be addressed. In a study conducted with 350 nurses working in a state hospital in TRNC, general symptoms of mental disorder were found in 50.3% of nurses. 65.7% experienced somatization, 57.2% experienced obsessive-compulsive symptoms, 50% experienced anxiety, 53.3% experienced hostile thoughts, 60% paranoid thoughts, and 47.2% psychotic thoughts.³⁷ These data are not sufficient to determine the mental health of healthcare professionals, but it is important to improve the quality of service, to protect and improve the mental health of healthcare professionals, to conduct further research, and to implement initiatives in this regard. In a study conducted on the mental state of 553 university students studying in the field of health in the TRNC, individuals from broken homes, those with less income than their expenditure, those who were in their final year of study, and those who had a family history of mental illness were found to be at risk of developing psychiatric symptoms.³⁸ It is important that the number of studies on the mental state of healthcare professionals during their student years be increased, and that preventive interventions be planned in this period to protect and improve the mental health of the individuals in at-risk groups. A study conducted with 560 students studying in the field of health at a private university in the TRNC found that students see individuals with mental health problems as dangerous, experience frustration and desperation in their interpersonal relationships with them, and have negative attitudes towards these individuals.³⁹ Healthcare professionals have an important role both in the delivery of services and in the shaping of mental health policies. Providing training to combat their negative attitudes while they are still studying may help them to change their outlooks.

In the TRNC, statistical studies are carried out by the Ministry of Health, Inpatient Treatment Institutions, and the Primary Health Services Department. According to the most recent data published by these institutions in 2018, the total number of patients in the state psychiatric hospital was 1,694, the average number of patients in one day was 57, and the total number of physicians was 13. In these published data, it was considered important to include statistics such as specific diseases, the total number of nurses, the total number of patients per nurse, the total number of psychiatrists, and the total number of patients seen per day.⁴⁰ These data suggest that mental health needs are increasing, and that the entire society, including healthcare workers, needs better and more extensive preventive and rehabilitative mental health services.

Preventive and Rehabilitative Health Services in Northern Cyprus

As in all health services, the implementation of a preventive health policy in mental health services is important. When a preventive health policy is implemented, factors which may lead to the illness are revealed and the illness can be prevented with early intervention. Some mental illnesses may continue longer, and at that point, there will be a need for the support of rehabilitation centers.

A variety of different preventive healthcare and rehabilitation services are provided in Northern Cyprus, including Social Work Centers, the Lapta Rest Home, the Nicosia Kindergarten, Counseling Support for Families, Rehabilitation Centers for Disabled People over 18, the Social Aid Unit, the Martyrs and Veterans Unit, the Women’s Shelter, Family Education programs, the Kalkanlı Living House, and the Accessible Living House. With regard to domestic violence, the “Domestic Violence and Violence against Women Form” was designed as a result of the efforts of the Youth, Family Support, and Education Center (YFSEC) to create a domestic violence database in TRNC. This form was introduced to police officers and healthcare workers in 2012.⁴¹ In addition, the “Combating Domestic Violence Coordination Mechanism” was established in 2018: the Ministry of Labor and Social Security, the Ministry of National Education and Culture, the Ministry of Health, the Turkish Municipality of Nicosia and the SOS Children’s Village Association signed a protocol to work cooperatively to prevent violence against women by collecting data and providing training.⁴² The Department of Gender Equality was established in December 2018. At the same time the “ALO 183” helpline was set up to report child neglect and abuse, and violence against women. Free legal aid was also provided.⁴³

To combat drug abuse, an Anti-Drug Commission was established within the Prime Ministry on the 3^rd September, 2014. This Commission has pioneered, planned and implemented initiatives to prevent psychoactive substance abuse. The “ALO 1191” Addiction Counseling and Support Line, a 24-hour, seven-day-a-week helpline was opened on the 26^th June, 2019. In addition, awareness-raising training is frequently conducted.⁴⁴

In Northern Cyprus, preventive and rehabilitative studies are conducted in most areas. However, we have encountered no study regarding the effectiveness of these studies. It is believed to be important to reveal data regarding the effectiveness of studies through scientific studies and to shape future studies with the results acquired. In Turkey, studies are conducted regarding domestic violence, violence against LGBTI individuals, suicides and psychoactive substance abuse. The results of these studies are very important, but mental health needs are not limited to them. In order to provide mental health services in line with the needs of the people, it is necessary to conduct a study containing the mental health profile and to shape policies according to these needs. Shaping policies in terms of institutions and interventions protecting mental health is important in decreasing the prevalence of mental illnesses and increasing the quality of services.

CONCLUSION

Northern Cyprus has a hospital-based mental health service. Many developed countries adopt preventive health services and have community-based mental health systems.⁴⁵ When a hospital-based system is used, it tends to focus on the individual’s disorder rather than the individual themselves, and especially on periods of exacerbation or crisis. The factors which lead to the disease are overlooked and untreated, more frequent periods of acute crisis may occur and social stigma may increase as a result. In addition, biopsychosocial care is not provided, and how an individual functions holistically is not focused on. Individuals may thus remain hospitalized for many years, and, when they are discharged from the hospital, they may be left to deal with their illnesses alone, leading to re-hospitalizations. These repeated hospitalizations are known as the “revolving door phenomenon”. They harm the individual and increase the need for beds, personnel, and thus also give rise to increased costs.⁴⁶ In environments where the individual’s ability to function is disturbed for many years, the individual cannot be healed.

The mental health profile of the TRNC can be revealed through studies, and initiatives should be designed to make mental health services more community-based. In this context, it is important to design a mental health action plan and work on a new mental health law. Since the current mental health law was created during the period of British administration, occupational groups working in the field of mental health should come together to prepare a new mental health law that will be community-based and that will decide on which service areas need to be prioritized.

Preventive and rehabilitative studies have been conducted in many fields but there are difficulties in accessing the data of some studies. It is important that the studies be followed up at regular intervals in order to be aware of and to understand any developments which may have occurred. Creating a database of these scientific studies will contribute to the systematic organization of information.

There has been no study revealing the mental health profile of the TRNC to date. Carrying out such a study is important in terms of designing future studies on mental health in the TRNC. It is essential to ensure accessibility to data, such as disease-specific statistics, the number of personnel working in mental health, the number of patients per staff member, the number of beds, etc. It is also important that activities be conducted to raise the awareness of healthcare professionals and to combat any negative attitudes towards people with mental health issues. These activities should begin while they are students and continue throughout their professional lives. Further research is also needed to determine the mental health status of healthcare professionals, and interventions for at-risk groups should begin during their period as students.

Another problem in the mental health field in the TRNC is that specialization in nursing has not yet been established. Currently, there are psychiatric nursing graduate programs at many universities in the TRNC. The contribution of the academic studies of psychiatric nurses who graduated from these programs, especially thesis research in mental health issues is important. However, the number and quality of nurses who receive postgraduate education in psychiatric nursing needs to be increased.

There are several specialist psychiatric nurses doing master’s degrees; however, most of them directly provide care to psychiatric patients, carry out their duties in other clinics or work in the academic field in educational institutions. Having nurses with a postgraduate education in the field of mental health and psychiatric nursing may improve the care given to individuals in those institutions providing mental health services. Nurses working in psychiatry should be able to gain further qualifications through certificated programs.

It is important and promising that there are many organizations in the TRNC offering preventive and rehabilitative activities in the field of mental health. Psychiatric nurses can contribute their experience to institutions such as the Department of Gender Equality, the Drug Enforcement Commission, the YFSEC, and the Rehabilitation Center for Disabled People over 18.

MAIN POINTS

-    There is no updated mental health law, policy text or action plan in Northern Cyprus.

-    Psychoactive substance abuse, domestic violence, suicide, homophobia and transphobia are important problems.

-    A hospital-based system is currently used. It is important to design initiatives to make mental health services community-based.

-    Research on mental health is limited.

ETHICS

Peer-review: Externally peer-reviewed.

Author contributions: Concept: A.A., Design: A.A., Supervision: M.M., Resource: A.A, Materials: A.A., Data Collection and/or Processing: A.A., Analysis and/or Interpretation: A.A., M.M., Literature Search: A.A., Writing: A.A., Critical Reviews: M.M.

DISCLOSURES

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

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