Authors: Adele Adelle (Department of Allied Health, Swinburne University of Technology, Melbourne, Victoria, Australia), Kris Bedford (Department of Allied Health, Swinburne University of Technology, Melbourne, Victoria, Australia), Sabrina McMahon (Department of Allied Health, Swinburne University of Technology, Melbourne, Victoria, Australia), Carolyn Dun (Northern Area Mental Health Service, Mental Health Division, Northern Health, Melbourne, Victoria, Australia), Rachael Starbuck (Mental Health and Wellbeing Program, Eastern Health, Melbourne, Victoria, Australia), Nastaran Doroud (Department of Allied Health, Swinburne University of Technology, Melbourne, Victoria, Australia)
Categories: Review Article, acute, inpatient, mental health, occupational therapy, recovery
Source: Australian Occupational Therapy Journal
The role of occupational therapists in acute mental health inpatient A systematic scoping review
Authors: Adele Adelle, Kris Bedford, Sabrina McMahon, Carolyn Dun, Rachael Starbuck, Nastaran Doroud
Abstract
Introduction
Occupational therapists play an important role in offering interventions in acute mental health inpatient settings through use of individualised, activity‐based, sensory, and group approaches. They may face challenges, however, to implement evidence‐based interventions due to high caseload, consumers' short duration of stay, and general limited understanding of the value of occupational therapy interventions. This scoping review aimed to address this gap by answering the following ‘What evidence is available for occupational therapy interventions within acute mental health inpatient settings?’
Methods
This review used Arksey and O′Malley's (2005) scoping review framework. The review question was identified by occupational therapists from two leading mental health settings in Melbourne, Victoria. Three electronic databases, citation searches, and hand searching were used to locate studies that were independently screened by authors. Studies within adult acute inpatient mental health units that examined interventions designed or delivered by occupational therapists were selected. These studies were data extracted, and findings were thematically synthesised.
Consumer and community involvement
There was no consumer and community involvement.
Findings
Twenty‐one studies relevant to the review question were identified. The findings from these studies were synthesised into five (a) consumers' experiences of occupational therapy interventions; (b) enabling activity engagement and choice; (c) restoring function; (d) reduced need for restrictive practices; and (e) sensory modulation. These themes are discussed in relation to environmental and occupational factors, occupational therapy approaches, and contributions to consumers' recovery.
Conclusion
The findings from this review highlighted the pivotal role of occupational therapists in acute inpatient mental health settings in addressing occupational deprivation and functional decline; reducing the need for restrictive practices; enabling self‐management strategies to reduce distress; and fostering personal recovery. Understanding of and promoting the unique value of occupational therapy interventions is essential to ensure effective multidisciplinary care within acute mental health settings. Future research is recommended to further explore and investigate effectiveness of occupational therapy interventions, barriers to evidence‐based practices, and consumers' experiences.
INTRODUCTION
Inpatient settings are integral to mental health care (Hopkins et al., 2009). Interventions delivered in inpatient settings are crucial to maximising outcomes, enabling recovery, and community transition (Paterson et al., 2018; Tyler et al., 2019; Waldemar et al., 2016). Inpatient settings can, however, be challenging due to high number and rapid turnover of consumers, limited staff and opportunity for collaboration, presentation of acute symptoms, and consequently, use of restrictive management approaches (Waldemar et al., 2016). Such approaches may include physical or chemical restraint and seclusion (Baker et al., 2021; Lawrence et al., 2022). Changes in mental health care and the emergence of the recovery paradigm (Nugent et al., 2017) over the past three decades led to a deeper understanding of mental health care as being more than symptom reduction (van Weeghel et al., 2019; Winsper et al., 2020). Recovery for people with mental illness is understood as a journey of establishing a meaningful life and moving beyond the limitations caused by mental illness (Slade & Wallace, 2017; van Weeghel et al., 2019). The Royal Commission into Victoria's Mental Health System (State of Victoria, 2021) highlighted the negative consequences of excessive medical treatment and restrictive practices and the need for further development and implementation of interventions improving personal recovery. Additionally, there has been a global effort in mental health service and policy reform to diminish reliance on inpatient services, placing a greater emphasis on community‐based care (Foye et al., 2020).
Occupational therapy, with an emphasis on meaningful activity engagement and client‐centred practices, is known to promote recovery and participation (Höhl et al., 2017; Krupa et al., 2009; Lloyd & Lee Williams, 2010; Synovec, 2015). Occupation‐based interventions (e.g., with a focus on skills or functioning) are known to enhance functioning, foster social inclusion, and prevent further relapse (Fieldhouse & Bannigan, 2014). Skaltsi et al. (2021) underlined the value of purposeful activities and occupational therapy interventions, designed in collaboration with the multidisciplinary team and the consumers, to enhancing functional performance and wellbeing for consumers in acute inpatient units. A qualitative synthesis of studies exploring consumers' experiences further highlighted the unique contribution of occupational therapy interventions to acute mental health settings, highly valued by consumers (Steede & Gough, 2022). In particular, consumers reflected on the role of occupational therapy in offering choice, a sense of normality and belonging, and opportunities to participate in meaningful activities. Nonetheless, occupational therapists may encounter challenges in individualised service planning and interventions and restrictions within the acute settings (Sims, 2014).
Lloyd and Lee Williams (2010) highlighted the importance of advocating for better recognition of occupational therapy within acute mental health care; particularly in relation to individual assessments and interventions, group approaches, and discharge planning. Over a decade since this publication, evidence on the role of occupational therapy in acute inpatient mental health remains scarce. Kirsh et al. (2019) and D'Amico et al. (2018) summarised occupational therapy interventions in key areas including psychoeducation, activity‐based or time‐use approaches, supported employment or education, group work, and skill training. Gibson et al. (2011) also reported positive, yet limited, evidence on the role of occupational therapy in mental health practice; particularly interventions within real‐life contexts. None of these studies, however, were specific to inpatient settings.
Inpatient mental health settings are often associated with high levels of consumer distress that makes these settings particularly challenging (Hopkins et al., 2009; Waldemar et al., 2016). Involuntary admissions of increasing frequency with accompanying restrictive practices pose challenges to the provision of occupation‐based interventions that are known to promote consumer recovery and wellbeing (Foye et al., 2020; Lawrence et al., 2022). Moreover, a qualitative synthesis by Sugiura et al. (2020) demonstrated that consumers felt dismissed due to power imbalance, lack of choice, and limited communication.
Boredom and lack of engagement in meaningful activities has been reported across a number of studies as a pervasive challenge within inpatient settings (Marshall et al., 2020; Steele et al., 2013). Lack of routine and choice and limited opportunities for engagement in meaningful activities can exacerbate smoking, abscondment, psychiatric symptoms, and the likelihood of violent behaviour in inpatient mental health units (Marshall et al., 2020). Occupational therapy interventions are specifically designed to engage consumers in meaningful and everyday life activities, which are pivotal in facilitating choice and providing consumers with a sense of control (Lim et al., 2007; Marshall et al., 2020). Occupational therapy interventions can enhance a sense of identity, routine, choice, and meaningful connections (Knight et al., 2023).
Occupational therapy can offer a unique contribution to inpatient mental health services through the use of person‐centred approaches enabling engagement in meaningful activities (Lloyd & Lee Williams, 2010; Sims, 2014). Despite its potential significance, however, there is no recent review of occupational therapy interventions within these settings. This scoping review addressed this gap by synthesising evidence for occupational therapy interventions delivered within acute adult mental health inpatient units.
METHODS
Arksey and O'Malley's (2005) methodological framework, updated by Peters et al. (2020), was used to guide this review. This framework provides a systematic approach to identify and summarise current evidence through the following six
Step Formulate the review question
Step 1 includes identifying a review question and its elements (Arksey & O'Malley, 2005; Peters et al., 2020). The initial review question was identified by occupational therapists from two major mental health services in Victoria, Australia, and further refined based on population, concept, and context elements (Peters et al., 2020) as ‘What evidence is available for occupational therapy interventions within acute mental health inpatient settings?’
Step Search for and identify relevant studies
Scoping reviews aim to adopt a comprehensive search strategy (Arksey & O'Malley, 2005; Peters et al., 2020). We developed a search strategy guided by the facets of the review question to search three electronic CINAHL, Web of Science, and PsycNet. Examples of search terms were ‘Adult*’, ‘mental health’ or ‘mental illness*’ or ‘mental disorder*’ or psychiatric or psychosis or psychotic or depression, inpatient or acute or hospital or ward or ‘high dependency’ or forensic or secure, and ‘occupational therap*’ or ‘occupational therapist*’. Database searches were limited to peer‐reviewed articles published between 2010 and 2023. Citation tracking, hand searching of reference lists, and manual searching of key journals (e.g., occupational therapy journals) to find relevant studies not yielded in electronic databases (Kable et al., 2012).
Step Select relevant studies
Study selection was completed in two abstract and title screening and full‐text review (Peters et al., 2020). First, all studies yielded in electronic database results and manual searches were imported to Covidence to complete title and abstract screening. Articles that did not address key concepts such as acute or inpatient settings or occupational therapy interventions were excluded. Study selection in both phases was based on the following inclusion (1) adults aged 18–65 years who have a mental illness (including co‐occurring alcohol and substance use); (2) interventions designed or delivered by occupational therapists within acute inpatient mental health units with a maximum admission time of 3 months (i.e., while the person is in an inpatient unit). The focus of this review was to better understand the design and delivery of the interventions in acute inpatient mental health settings. Hence, we excluded occupational therapy assessments (e.g., cognitive and functional capacity assessments), multidisciplinary interventions (without explicit mention of occupational therapy interventions), and discharge planning. Private acute inpatient mental health units were also excluded due to differences in illness severity, admission procedures, and length of stay. Title and abstract screenings, and full text reviews were completed independently by two authors (Page et al., 2021). Any conflicts between the two authors were discussed and agreed upon and/or reviewed by another author (Figure 1).
Step Extract and chart data
Data extraction fields were guided by the scoping review methodological framework (Arksey & O'Malley, 2005; Peters et al., 2020) and agreed upon by all authors. As suggested by Levac et al. (2010), a quality appraisal was undertaken to assess the methodological rigour of each study reviewed using the Critical Appraisal Skills Program (CASP). The authors completed the appraisals independently and met to discuss the results.
Steps 5 and Organise, summarise and report results, and consultation
Findings from each study were coded by authors to identify similarities and differences and grouped into categories from which five main themes emerged that embody the occupational therapy role in acute mental health inpatient units. The synthesis process was discussed and agreed upon by all authors. Two occupational therapists from the leading mental health settings were consulted regularly throughout the review process.
Positionality statement
Three authors were final‐year occupational therapy master's students when this review was conducted. Two of the three had prior experience working in forensic and acute mental health settings in other capacities. The other three authors have research and clinical experience in various mental health settings including acute inpatient units. These authors provided guidance and mentorship to the student authors during the research and writing of the manuscript. All authors approached the topic based on their understanding of the current roles of occupational therapists in acute inpatient mental health settings.
FINDINGS
Twenty‐one studies were included in the review comprising of 10 qualitative, nine quantitative, one mixed method designs, and one scoping review (Table 1). Studies were conducted in Australia (n = 4), United Kingdom (n = 3), Israel (n = 2), North America (n = 2), and multiple countries (n = 5), with one each in Denmark, Singapore, Hong Kong, Greece, and Japan. Five themes were identified through synthesis of the findings including (a) consumers' experiences of occupational therapy interventions; (b) enabling activity engagement; (c) restoring functioning; (d) reduced need for restrictive practices; and (e) sensory modulation. Thematic findings are presented in relation to environmental and occupational factors, occupational therapy approaches, and contributions to consumers' recovery.
Consumers' experiences of occupational therapy interventions
Five studies examined experiences of consumers engaged with occupational therapy services on acute inpatient units (Table 1), including experiences related to occupational therapy setting, opportunities for engaging in activities, personal recovery, and occupational therapy approaches.
Studies suggested inpatient environments are not conducive to occupational engagement, negatively impacting sense of autonomy and personal recovery (Steede & Gough, 2022; Bryant et al., 2016), and ultimately consumers' experiences of occupational therapy services. Birken and Bryant (2019) conducted a photovoice study to explore consumers' experiences of an occupational therapy department, which was located away from the inpatient units (i.e., in a separate building). They found that occupational therapy provided a supportive environment that can enable choice, engagement, and personal recovery. In contrast, Steede and Gough (2022) suggested occupational therapy inpatient departments delivering services outside of the unit that required consumers pass through the security doors can be a barrier to engagement due to limited accessibility. Both studies, however, concur that occupational therapy staff are pivotal in providing access to spaces conducive to activity engagement (Birken & Bryant, 2019; Steede & Gough, 2022). Lloyd and Lee Williams (2010) also discussed the role of occupational therapy in providing opportunities to overcome limited occupational choices in restrictive environments. The positive experiences of occupational engagement for consumers in acute mental health inpatient units were strongly presented in the reviewed studies. Studies suggest that choice and opportunities for meaningful activities are important to overcome barriers to engagement and occupational deprivation (Birken & Bryant, 2019; Lloyd & Lee Williams, 2010).
The role of occupational therapy in promoting personal recovery was highlighted in three studies (Ng et al., 2020;Bryant et al., 2016; Steede & Gough, 2022). In a prospective cohort study, Ng et al. (2020) found that occupational therapy interventions helped improve symptoms. Steede and Gough (2022) completed a qualitative evidence synthesis that found the importance of skill development for sustained recovery following discharge. Bryant et al. (2016) demonstrated consumers' positive experiences of occupational therapy in addressing barriers impeding wellbeing. Occupational therapists use consumer‐centred approaches that are often less formal which helps build trust, encourage engagement in meaningful activities, and promote choice and recovery (Birken & Bryant, 2019; Steede & Gough, 2022).
Enabling activity engagement and choice
Six studies focussed on the role of occupational therapy in enabling activity engagement within acute mental health inpatient units (Table 1). This included consumers' experience of restrictive environments, improving therapeutic milieu, building insight into the benefits of occupation, and facilitating personal recovery. Studies identified acute mental health inpatient units may pose barriers to activity engagement. Impoverished social environments that offer limited interactions, medication side effects, and organisational restrictions were examples of barriers impacting consumers' engagement and satisfaction (Levick et al., 2023).
Limited opportunities for activity engagement can impact personal recovery; leading to psychological distress, aggression, and decreased functional capacity (Marshall et al., 2020). Ngooi et al. (2022) suggested occupational therapy group‐based activities delivered in acute inpatient units can promote activity engagement, personal recovery, and peer support; leading to consumers' satisfaction and sense of efficacy. Lipskaya‐Velikovsky et al. (2020) similarly suggested enabling occupational engagement in acute inpatient units can provide a sense of enjoyment that can help emotional regulation.
A phenomenological approach adopted by Bailliard et al. (2021) identified consumers' experience of using a structured reflection to assist identify the links between occupational patterns and routines on health and wellbeing. The authors suggested that the reflective process promoted awareness and encouraged consumers to identify strategies to engage in meaningful occupations that supported personal recovery and participation after discharge (Bailliard et al., 2021).
Restoring function
Acute settings may be associated with decline in consumers' functional capacity due to limited activity engagement and opportunities (Lipskaya‐Velikovsky et al., 2016; Skaltsi et al., 2021). Four studies focussed on the role of occupational therapy in restoring functional capacity and independence in acute mental health inpatient settings (Table 1). Evatt et al. (2016), for example, discussed effectiveness of graded task analysis in improving consumers' functioning. Lipskaya‐Velikovsky et al. (2016) described preliminary findings from a manualised short‐term group program, named ‘occupational connections (OC)’. The authors explained the benefits of the OC program in enabling engagement and functioning that can facilitate reintegration into the community after discharge.
Reduced need for restrictive practices
Five studies explored occupational therapy's role in restrictive environments, including seclusion and Intensive Care Areas (ICAs). Key areas addressed in these studies were occupational deprivation, the impact on personal recovery and occupational engagement. Whiteford (2000) defined occupational deprivation as ‘a state of preclusion from engagement in occupations of necessity and/or meaning due to factors that stand outside the immediate control of the individual’ (p. 201). Knight et al. (2023) found that seclusion negatively impacts mental wellbeing due to occupational deprivation, high levels of distress, and limited opportunities to participate in activities. Seclusion and ICAs embody a punitive rather than a therapeutic approach which negatively impacts personal recovery (Knight et al., 2023). Knight et al. (2023), for instance, explained that the negative experiences of seclusion and restrictive environments can be mitigated by incorporating connection through activity engagement. Several authors discussed the unique role of occupational therapists in enabling safe activity engagement in restrictive settings (Lloyd et al., 2014; Lloyd & Lee Williams, 2010). Evatt et al. (2016) also explained the contribution of occupational therapy interventions in facilitating transition from restrictive settings through the use of graded activities and skills training.
Sensory modulation
Four studies examined the role of occupational therapy in providing interventions to support sensory modulation within acute adult inpatient settings (Table 1). Sensory modulation interventions hold potential to empower consumers to self‐manage emotions (Barbic et al., 2019). Lloyd et al. (2014) reported significant reduction of distress through the utilisation of sensory rooms. Barbic et al. (2019) and Machingura et al. (2021) reported positive consumer experiences of sensory modalities and sensory rooms in acute inpatient settings. These studies also reported staff's positive experience in using sensory modalities or sensory rooms as an alternative to restrictive practices that helps to enable choice and promote personal recovery (Andersen et al. (2017) suggested occupational therapists have a role in offering training to multidisciplinary staff on sensory modulation strategies as alternatives to restrictive practices. Machingura et al. (2021) discussed that risk management and safe use of sensory strategies should also be considered.
DISCUSSION
Findings suggest that occupational therapy has a pivotal role in enabling activity engagement, addressing lack of occupational choices and promoting recovery within acute inpatient mental health units. There needs to be better recognition of the role of occupational therapists in these settings. Occupational therapists can meaningfully contribute to consumers' wellbeing and recovery using task analysis, activity grading and adaptation, and sensory modulation strategies. These approaches help to reduce distress, promote choice, enable self‐management, and prevent the use of restrictive practices (e.g., seclusion, physical, or chemical restraint, Baker et al., 2021; Lawrence et al., 2022).
Inpatient acute settings are often associated with boredom and social isolation due to limited opportunity to engage in meaningful activities (Marshall et al., 2020; Steele et al., 2013) that is negatively influencing wellbeing (Stewart & Craik, 2007; Whiteford et al., 2020). Consumers in inpatient mental health setting may be spending time ‘doing nothing’, resting or in passive activities (such as watching TV) that have limited contribution to wellbeing and recovery (Jonsson, 2008) and can lead to higher levels of distress, depressive symptoms, dysfunctional behaviour, and ultimately likelihood of readmission (Folke et al., 2018; Marshall et al., 2020; Phillips et al., 2022). This can be primarily due to lack of choice and opportunities to engage in meaningful activities. Findings from our review underlined the role of occupational therapists in addressing lack of occupational choice and occupational deprivation, through offering opportunities for meaningful activity engagement, establishing trusting relationships, and creating supportive environments. It is noteworthy that in this context, the critical role of occupational therapists extends beyond merely ‘engaging’ consumers in an activity to address boredom; rather, it involves integrating evidence into designing, adapting, and tailoring meaningful activities to consumers' needs, interests, and functional capacities. Using task analysis, activity grading, and environmental adaptations, occupational therapists design meaningful individual or group activities within the restrictions of acute settings to offer choice, prevent functional decline, enable skills, and reconnect consumers with real‐life activities, which can assist with community reintegration after discharge. Staniszewska et al. (2019) identified the importance of respectful relationships, approaches to minimise use of restrictive practices, and creating supportive environments to improve consumers' experiences of inpatient settings. Consistently, our scoping review reinforced the value of occupational therapy in contributing to consumers' experiences, wellbeing, and recovery.
Another key finding from our review was the role of occupational therapy interventions in reducing the impacts of restrictive practices. Restrictive practices refer to coercive interventions such as chemical or physical restraints (e.g., forced medication or sedation) or seclusion that can have a detrimental effect on consumers' experiences and wellbeing (Baker et al., 2021; Staniszewska et al., 2019). Lawrence et al. (2022), for instance, reported that although some consumers may acknowledge the necessity of restrictive practices these are often experienced as a ‘violation of their rights’ (p.333) and disempowering. Occupational therapists offer opportunities for safe and meaningful engagement in activities within restrictive settings that can contribute to de‐escalation and addressing distress (Knight et al., 2023; Lawrence et al., 2022). Occupational therapists build upon the knowledge and evidence on sensory modulations to enable self‐management of distress, such as use of calming strategies or sensory rooms (Machingura et al., 2021). The findings from our scoping review suggest that occupational therapists can help develop training materials or accessible packages for staff and consumers to ensure safe and appropriate use of sensory rooms (Doroud et al., 2024).
Implications for practice and future research
The findings from this scoping review highlight the value of occupational therapy interventions within acute inpatient mental health settings, particularly in addressing distress, lack of occupational choice, and absence of a sense of control, creating a positive experience for consumers and promoting recovery (Nugent et al., 2017; Staniszewska et al., 2019). This has several implications for practice and research.
First, this review suggests a need for better recognition of the contribution and unique role of occupational therapists in acute inpatient mental health settings (Lawrence et al., 2022; Lloyd & Lee Williams, 2010). For example, it would be valuable for occupational therapists to unpack their clinical reasoning and evidence‐base when collaborating with other disciplines. Occupational therapists may also be able to contribute to professional development workshops or training materials representing occupational therapy interventions such as activity analysis, task grading, and sensory modulation. This review also suggests that occupational therapists should be actively involved in interdisciplinary care planning (e.g., through case conferences) to enhance consumers' experiences, enable choice, and reduce the need for restrictive practices.
Second, the findings from our review highlighted the unique contribution of occupational therapy in offering recovery‐oriented practice in acute mental health inpatient units. Several studies highlighted the pertinent fit between the principles of recovery‐oriented practice and occupational therapy frameworks (Krupa et al., 2009; Nugent et al., 2017). Therefore, it is important for occupational therapists to enhance their knowledge and skills in recovery‐oriented practice, occupational therapy frameworks, and occupation‐based interventions.
Third, this review highlighted the need for strengthening the evidence base of occupational therapy interventions in acute inpatient mental health settings. Most studies included in this review have limited external validity due to small sample size, single‐site studies, and substantial variations in the inpatient units. Most studies recruited participants through the treating clinicians, which can introduce potential selection bias. Moreover, only four studies were conducted in Australia, which can impact application of the findings to the Australian context. Except for a quasi‐experimental study (Tanaka et al., 2014), no randomised controlled trials were located in our review which can be explained due to the challenging nature of acute inpatient mental health units. A systematic review by Wall et al. (2023) explored occupation‐based interventions in hospital settings, which also suggested the need for rigorous studies to better understand application of occupational therapy interventions in acute mental health settings.
Finally, there is a need for strengthening evidence‐based and recovery‐oriented practice in acute mental health care. High number and rapid turnover of consumers, limited numbers of occupational therapists and opportunity for collaboration, presentation of acute symptoms, and use of restrictive management approaches may pose a challenge in delivering consumer‐centred evidence‐based approaches (Waldemar et al., 2016). Occupational therapists can contribute to emerging evidence through collaborative research and evaluation, for example, through involvement of consumers in co‐production of research (Spencer et al., 2013, as cited in Roper et al., 2018) and by enhancing knowledge translation in acute settings (e.g., streamlining access to evidence and practice resources).
Limitations
This review consulted with experienced occupational therapists throughout the process, which added to the depth of understanding, specific challenges, and needs within the acute inpatient mental health settings, additional sources of evidence (see Prisma diagram Figure 1) and ensuring results and recommendations were fit for purpose (Arksey & O'Malley, 2005). Several limitations may impact the findings of this review. The scoping review only included three databases that may have limited the extensiveness of the search. This review focussed on interventions designed or delivered by occupational therapists and did not consider their broader role in adult acute inpatient mental health settings, which encompasses activities including assessments, discharge planning, and multidisciplinary interventions (Simpson et al., 2005). Inclusion of studies related to these areas would have provided information about opportunities for occupational focussed interventions at specific points in the consumer care pathway and the role of occupational therapy in multidisciplinary interventions.
CONCLUSION
This scoping review affirmed the pivotal role of occupational therapy interventions in acute mental health settings. Through the use of consumer‐centred and occupation‐based/focussed interventions, occupational therapists can minimise the negative impacts of acute inpatient mental health hospitalisation. These include creating supportive environments that reconnect consumers with everyday life, enabling activity engagement, preventing functional decline, promoting recovery, and reducing the need for restrictive practice through offering alternative distress management approaches, namely, sensory modulation. The effectiveness and experiences of occupational therapy interventions warrant further investigations.
AUTHOR CONTRIBUTIONS
The authors declare substantial contributions to the concept (C. D. and R. S.), design (N. D., C. D., and R. S.), data acquisition (A. A., K. B., and S. T.), analysis and interpretation of data for the work (A. A., K. B., and S. T.), writing the manuscript (A. A., K. B., S. T., and N. D.); and making revisions (N. D., A. A., K. B., S. T., C. D., and R. S.). The intellectual content has been approved by all authors, and they agree to be accountable for all aspects of the work (N. D., A. A., K. B., S. T., C. D., and R. S.).
CONFLICT OF INTEREST STATEMENT
The authors have no conflict of interest to declare.