impact of working hours on sleep and mental healthimpact of working hours on sleep and mental health

2023 Feb 28. doi: 10.1007/s00406-023-01567-0. [A systematic review of working hours and mental health burden]. 11 Productivity requirements and financial incentives to work have grown substantially. WebOur major findings are as follows: long working hours cause the mental health of white-collar workers to deteriorate even after controlling for individual fixed effects. failure to control. 2017;4(10):P749-P758. Would you like email updates of new search results? 2022;64:101646. doi:10.1016/j.smrv.2022.101646. The research team suggested that when a person sends a non-urgent message during their off hours, they have been thinking about a work task and want to tie up the loose end. The proportion of anxiety decreased in older age groups and decreased markedly in the oldest age group (36 years or more). Abbreviations: N, total number; n, number; P, P-value. Prevalence of anxiety in medical students during the COVID-19 pandemic: a rapid systematic review with meta-analysis, The association between long working hours and health: a systematic review of epidemiological evidence, Long working hours and risk of 50 health conditions and mortality outcomes: a multicohort study in four European countries, Impact of working hours on sleep and mental health, The negative impact of long working hours on mental health in young Korean workers, A Google-based approach for monitoring suicide risk, The effect of exposure to long working hours on ischaemic heart disease: a systematic review and meta-analysis from the WHO/ILO joint estimates of the work-related burden of disease and injury, International labor standards on working time. Effects of cognitive behavioral therapy for insomnia (CBT-I) on quality of life: A systematic review and meta-analysis. Data were analyzed using the SPSS version 24.0. Keywords: For healthy lifestyle, 24.0% of the participants exercised regularly and 31.0% were on a healthy diet. Despite this, no one can debate the importance of working hours regulations in maintaining the mental health and well-being of physicians.42 Prevention of mental disorders among physicians is crucial in producing decent medical care.21 To do that, adopting a systematic approach aimed at protecting physicians mental health and managing long working hours imposed by workplaces is mandatory.42, Age is one of the main factors related to mental disorders;43 this is consistent with our results. 2021 Mar 8;16(3):e0248117. Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Front Psychiatry. official website and that any information you provide is encrypted Step 3: Spend more time with offline friends. An official website of the United States government. It has associations with depression, anxiety, and low self-esteem. Another issue relates to the cross-sectional study design, which restricted the assessment of the temporality and causality of the observed associations. The annual campaign begins at the start of Daylight Savings Time, when Americans lose an hour of sleep. You may act erratically and feel like you have a short fusemaybe you yell at someone for making a mistake at work, or leave the room completely if someone says something that annoys you. ADHD is associated with sleep problems, and research also suggests that sleep disturbances may be a predictor or even a contributor to symptoms of the condition. Post-traumatic stress disorder (PTSD) can cause nightmares or night terrors. Bethesda, MD 20894, Web Policies 2015;36(6):294-299. doi:10.4082/kjfm.2015.36.6.294, By Kendra Cherry, MSEd doi:10.7759/cureus.2912, Baglioni C, Battagliese G, Feige B, et al. doi: 10.1136/bmjopen-2021-060673. Self-help cognitive-behavioral therapy for insomnia: a meta-analysis of randomized controlled trials. To them, sending the message is a way to get it off their to-do list and to stop thinking about it. The median age of the participants was 29 years, ranging from 24 to 64 years. For depression, the prevalence was 20.9% (n=54, 95% CI:16.126.4), while borderline and normal were (27.1%, n=70, 95% CI:21.833.0) and (51.9%, n=134, 95% CI:45.758.2), respectively (Table 2). As long working hours cause sleep disturbances and affect the efficiency of an individuals social role.12 Long working hours may also contribute to an increased risk of suicide. FOIA Insomnia disorder, according to theDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition(DSM-5), is characterized by difficulty falling asleep, staying asleep, or waking too early, resulting in daytime impairments. For example, ongoing sleep deficiency can raise your Not getting enough sleep may cause mood changes, including increased irritability. Severe sleep deprivation causes hallucinations and a gradual progression toward psychosis with increasing time awake. Sangyo Eiseigaku Zasshi. tolerance. We're more likely to feel irritable and less likely to feel in control of our emotions when we don't get enough sleep. The offers that appear in this table are from partnerships from which Verywell Mind receives compensation. The article shows the large interindividual variance in the working hours of teachers and a significant influence of sex, age, and subject profile. However, dont go to bed unless you are sleepy. Prevalence of Anxiety and Depression Among Study Participants. The prevalence of stress, anxiety and depression within front-line healthcare workers caring for COVID-19 patients: a systematic review and meta-regression. Statement of the problem. Smith L, et al.. Table 1 details the prevalence of depression and anxiety stratified by demographic characteristics. 2014;53(5):550558. official website and that any information you provide is encrypted Daily hassles can turn into major sources of frustration. doi:10.4103/2249-4863.201153. Fujino Y, Horie S, Hoshuyama T, Tsutsui T, Tanaka Y. Sangyo Eiseigaku Zasshi. Bhaskar S, Hemavathy D, Prasad S. Prevalence of chronic insomnia in adult patients and its correlation with medical comorbidities. Nakagawa K, Ishitake T, Iwamoto J, Suenaga T, Mori C, Matoba T, Takaki M, Hara H. Sangyo Igaku. More than half of the participants were males (n= 143, 55.4%). Exercise regularly (but not within the few hours before going to bed). Aims: The mental health of an individual can become severely compromised as a result of constant work pressures and related stressors. The bidirectional relationship between sleep and mental health offers some promiseresearchers hope that finding ways to improve sleep may have a beneficial impact on a number of conditions. These and numerous other physical and mental health issues are shaped by sleep quality, and may affect a persons attention and concentration. Working Hours per Week Among Study Participants Stratified by Anxiety and Depression. A. P., Chen-Edinboro, L. P., Wu, M. N., & Yaffe, K. (2014). Google Scholar; 141. Jt Comm J Qual Patient Saf. Results: These systems, however, have never been studied in concert. Other factors that need to be addressed are affective temperaments due to their relationship with mental health. Worrying leads to Fragmented sleep has also been found to negatively affect memory even if a person gets adequate hours of sleep. doi: 10.1097/MD.0000000000006093. ILO, international labour organization; GPs, general practitioners; CI, confidence interval; HADS, hospital anxiety and depression scale; OLR, ordinal logistic regression; OR, odds ratio. We conclude that working for long hours or irregular hours deteriorates the mental health of workers but its impact is likely to differ significantly across job types. The vast majority of participants had no history of chronic diseases (n=203, 78.7%) and no family history of psychological disorders (n=201, 77.9%). This is because when sleep-deprived, the brain cannot function normally, which means it can't suppress the reactivity of the amygdala (the emotional center of the brain). We might notice that we struggle to interact with other people when we're sleep-deprived. Cureus. Salari N, Khazaie H, Hosseinian-Far A, et al. Total sleep deprivation (TSD) may induce fatigue, neurocognitive slowing and mood changes, which are partly compensated by stress regulating brain systems, resulting in altered dopamine and cortisol levels in order to stay awake if needed. However, the results are not expected to be significantly affected by this factor. Our sample includes 1334 white-collar workers and 786 blue-collar workers observed from 2015 to 2016. Therefore, longitudinal studies should be conducted in the future to confirm the conclusions of our study. Participants were divided into two groups, RWHG and LWHG, based on working hours, with a cut-off of 48 h per week. Researchers examined data from seven previously published studies of work schedules and mental health involving a total of 28,438 participants. We took each hospital as a primary stratum and, according to the population of each, the size of the stratum was determined compared to the total population. As you can imagine, getting enough sleep with a typical work schedule may be easier to do for a lark than for a night owl. Step 2: Change your focus. Long working hours imply that people are spending more time at work, and, thus, when hours of work increase, hours available for sleep may be reduced. The mental health of an individual can become severely compromised as a result of constant work pressures and related stressors. [Factors associated with depressive symptoms in blue-collar and white-collar male workers]. In the multivariate OLR against anxiety (Table 5), working more than 64 hours per week was significantly associated (p=0.013) with increasing the odds of observing a higher level of anxiety by three times (OR=2.91, 95% CI:1.256.77) compared with working up to 40 hours per week. The Chi-square test and ordinal logistic regression (OLR) were used to test the association of all the variables with the dependent (anxiety and depression) and the main independent (total working hours per week) variables. Absolutely. Atten Defic Hyperact Disord. 15, 18 Work hours are distributed increasingly across all hours of the day Working hours, common mental disorder and suicidal ideation among junior doctors in Australia: a cross-sectional survey. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Common sleep disturbances include problems falling or staying asleep, sleeping less, and experiencing worse quality sleep. 5 Further research has shown that organizations are suffering as well. WebIntroduction. Long working hours are killing hundreds of thousands of people a year, according to the World Health Organization (WHO). Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the Hospital Anxiety and Depression Scale. Getting better sleep isn't a cure or a quick fix for mental health disorders, but it can be an important part of a comprehensive treatment plan. Healthy worker effect; Japan; Mental health; Nightwork; Short rest period; Weekend work; Working hours. Think more clearly and do better in school and at work. Work Emails and Attitudes. In 2015, it was estimated that losses related to sleep deprivation cost the United States between $280 billion and $411 billion, or between 1.56% to 2.28% of the countrys gross domestic product (GDP). Mood Changes. While insomnia symptoms and insufficient sleep were already a widespread problem pre-pandemic, people are reporting more sleep problems than ever before. Abbreviations: OR, odds ratio; CI, confidence interval. Sleep and sleep disorders. Research suggests that the relationship between sleep and mental health is complex. Resident physicians in Makkah public sector hospitals comprised about 600 residents, which represented the targeted study population. If lifestyle changes do not relieve sleep problems, a doctor may recommend psychotherapy and medications. Genetics can determine how long you sleep. Overtime work, job autonomy, and employees' subjective well-being: Evidence from China. Effects of Lack of Sleep on Mental Health. Long work hours harm employees' bodies and minds. gaming to escape or relieve anxiety, guilt, or other negative mood states. Such problems can include insomnia, irregular sleep-wake cycles, and nightmares. Long work hours harm employees' bodies and minds. Santabrbara J, Bueno-Notivol J, Lipnicki DM, et al. March 16, 2022 Share by email Americans were having trouble sleeping before COVID-19. Background In China, long working hours and insomnia are relatively common among internet company employees. Accessibility The authors report no conflicts of interest in this study. If you have been struggling with a sleep problem or are experiencing excessive daytime sleepiness, talk to a doctor about your treatment options. official website and that any information you provide is encrypted Injustice was also added to the final models due to its significant association with long working hours and both depression and anxiety. Longer work hours, constant access to social commentary and entertainment, and increased stressors all contribute to people getting less sleep. Published by Oxford University Press on behalf of the Society of Occupational Medicine. The https:// ensures that you are connecting to the downplaying use. 2017;7(9):e016873. Epidemiological studies have shown the negative effects of long working hours on the risks of cardiovascular diseases [ 3, 4, 5, 6 ]; chronic fatigue, stress [ 7 ]; Does improving sleep lead to better mental health? In a review of the existing research on shift work and diabetes risk, researchers concluded that men in particular were more likely to develop the disease if they had irregular working hours. 14 to 17 hours. Some of these adverse effects include decreased productivity, lower levels of employee commitment and increased Bueno-Notivol J, Gracia-Garca P, Olaya B, Lasheras I, Lpez-Antn R, Santabrbara J. The site is secure. This site needs JavaScript to work properly. 2019 Apr 19;110(2):115-129. doi: 10.23749/mdl.v110i2.7640. Participation in the study was voluntary and the participants were not allowed to proceed to the questionnaire until they acknowledged the informed consent statement, in compliance with the Declaration of Helsinki. However, other systematic reviews concluded that the COVID-19 pandemic affect the mental health of all health care workers and general population.47, According to the adjusted OLR for depression, all working hours categories of 48 hours or more were associated with more than double the odds of having depression compared to 40 hours per week (Table 6). Thank you, {{form.email}}, for signing up. Incidence of sleep disturbances in patients with familial Mediterranean fever and the relation of sleep quality with disease activity. loss of interest in other activities. Ogawa R, Seo E, Maeno T, Ito M, Sanuki M, Maeno T. The relationship between long working hours and depression among first-year residents in Japan, Long working hours and depressive symptoms: systematic review and meta-analysis of published studies and unpublished individual participant data, Prevalence of anxiety and depressive symptoms and related risk factors among physicians in China: a cross-sectional study. 2022 Oct 31;19(21):14256. doi: 10.3390/ijerph192114256. 2022 Dec;83:1-7. doi: 10.1016/j.jsr.2022.07.015. Methodology. Turns out, there's science behind this advice. FOIA Curr Psychiatry Rep. 2016;18(10):92. doi:10.1007/s11920-016-0728-8, Tanahashi T, Kawai K, Tatsushima K,et al. Pearsons Impact of Long Working Hours on Mental Health: Evidence from China. A descriptive analysis was used to describe, summarize and report the data, while inferential statistics were used to identify risk factors for depression and anxiety and to measure the association between working hours and mental health status. The role of shift scheduling and holidays in predicting near miss and incident likelihood. Recent findings: Shift work is associated with considerable impacts on sleep, depressed mood and anxiety, substance use, impairments in cognition, lower quality of life, and even suicidal ideation. Sleeping during the day and working at night increases your risk of obesity and diabetes. For people without ADHD, who may be tempted to take Ritalin or Adderall as a study drug, this can end up making them feel jittery and anxious, causing them to focus In order to see a shift in sleep behaviors, ongoing work is needed to promote science-based policies that help improve sleep health, such as encouraging employers to help promote healthy sleep and introducing later school starting times. However, according to the univariate OLR, the breaks during duties were not related to anxiety (p=0.505) or depression (p=0.171). Do employees' work schedules put them at-risk? Age was significantly associated: those less than 27 years (p=0.013), 2731 years (p=0.002) and 3236 years (p=0.001) experienced a higher level of anxiety (OR=2.93, 95% CI:1.256.84), (OR=3.51, 95% CI:1.587.79) and (OR=5.09, 95% CI:2.0312.76) respectively, compared to those more than 36 years old. Purpose . However, those with more chronic insomnia should seek professional help, including cognitive behavioral therapy for insomnia (CBT-I), which is recognized as a first line treatment for insomnia. Another study found that internet-based cognitive-behavioral therapy (CBT) was helpful for relieving symptoms of insomnia. The damage from sleep deficiency can happen in an instant (such as a car crash), or it can harm you over time. However, there was no significance in the univariate OLR with total working hours per week (p=0.067). Fatigue is a significant problem in modern society, largely because of high workplace demands, long duty periods, disrupted circadian rhythms, social and societal demands, and insufficient sleep (Sadeghniiat-Haghighi and Yazdi, 2015; Luckhaupt, 2012).It is a complex phenomenon that occurs as a function of time awake, time The good news is that there is increasing awareness of the importance of sleep for daily functioning and health. Differential associations of affective temperaments and diagnosis of major affective disorders with suicidal behavior, Psychology Research and Behavior Management, http://creativecommons.org/licenses/by-nc/3.0/, https://www.ilo.org/global/standards/subjectscoveredbyinternationallabourstandards/workingtime/langen/index.htm, https://hrsd.gov.sa/sites/default/files/14012021.pdf, https://ec.europa.eu/social/main.jsp?catId=706&langId=en&intPageId=205, https://www.ilo.org/wcmsp5/groups/public/ed_norm/relconf/documents/meetingdocument/wcms_618485.pdf, https://www.nice.org.uk/guidance/cg123/resources/common-mental-health-problems-identification-and-pathways-to-care-pdf-35109448223173, Family history of psychological disorders. A review of epidemiological studies across the adult life span, Organizational injustice as an occupational health risk. Genetics, age, and other factors impact whether you are more likely an owl or a lark. Ethical approval was obtained from the Institutional Review Board, General Directorate of Health, Makkah (H-02-K-076-0320-273). Associations of sleep disturbance with ADHD: implications for treatment. This approach allowed the researchers to reach almost all members of the targeted population to gain the participation of the largest possible number. The two most well-known chronotypes are often referred to as night owls and early birds (or morning larks), though many people likely fall somewhere in between. The study included 2285 healthcare professionals aged 1865 years. Even people without chronic insomnia often struggle with sleep problems. Poor sleep may often be a symptom or consequence of an existing psychological condition, but sleep problems are also thought to cause or contribute to the onset of different mental disorders including depression and anxiety. Attention-deficit hyperactivity disorder (ADHD) is a common psychiatric condition, affecting as many as 5.3% of children between the ages of six and 17 years old. Poor sleep leads to worrying. 8600 Rockville Pike In Japan, some residents develop mental health problems. Researchers suggest that addressing insomnia early on may be an effective preventative measure to help reduce the risk of depression, although further investigations into this possibility are needed. Lack of sleep is linked to a number of unfavorable health consequences including heart disease and type 2 diabetes. Coping with feelings of anxiety can be that much more difficult when you are tired from chronic sleep disturbances. Questionnaires were administered to 369 In addition, a variety of factors, including age, family responsibilities, social skills, speciality satisfaction, physical activity, amount of sleep, and exposure to major events, violence, injustice, and loneliness have been shown to significantly affect the risk of anxiety and depression. Insomnia and other sleep problems can be a symptom of depression, but more recently,research has implicated lack of sleep in actually causing depression. Its no secret that sleep plays an important role in good physical health. Summary. The Chi-square test and ordinal logistic regression (OLR) were used to test the association. The full terms of this license are available at, long working hours, mental health, anxiety, depression, physicians. Columbia Psychiatry News spoke with Zakarinabout the psychological impact of sleep deprivation, challenges brought on by the pandemic, the influence of food on our sleep patterns, and effective treatments for sleep difficulties. The Author 2017. The workplace injustice was defined for the participants as being exposed to harassment, discrimination or bullying based on sociodemographic characteristics, health condition and job title in their hospitals. Unable to load your collection due to an error, Unable to load your delegates due to an error. If youre having trouble falling asleep, dont lie in bed awake. Demographic Features Among Study Participants and Their Association with Anxiety and Depression. Establish a relaxing bedtime routine that helps to transition from your day. This research did not receive any grant from funding agencies in the public, commercial, or not-for-profit sectors. Reduced sleep has been linked with increased eating and higher risk for weight gain and obesity. Exposure to injustice negatively impacts emotional responses and reinforces unhealthy behaviors. Table 4 examines the possible confounding factors through the univariate analysis using OLR against the dependent variables anxiety and depression, with the total working hours per week as the main independent variable. Federal government websites often end in .gov or .mil. Verywell Mind's content is for informational and educational purposes only. Verywell Mind articles are reviewed by board-certified physicians and mental healthcare professionals. 8600 Rockville Pike Those with mental health disorders are even more likely to experience chronic sleep problems and, in turn, thesesleep problems are likely to exacerbate psychiatric symptoms and even increase risk for suicide. Poor sleep can make it much more difficult to cope with even relatively minor stress. Sleep Med Rev. Additionally, there is a need to implement interventions for the prevention and screening of physicians mental health disorders to improve performance and health care outcomes. Most of the participants did not have breaks during their duties (n=144, 55.8%): apart from those who worked up to 40 hours per week, 66.7% (n=34) of them had a break (p=0.002). The increase in insomnia and related sleep problems related to stress caused by the COVID-19 pandemic have been labeled Coronasomnia.. The electronic self-administered questionnaire, written in English, consisted of four parts: personal and demographic factors, general health, work history, and mental health status. The .gov means its official. Additionally, sleep problems appear to be a risk factor for developing anxiety disorders. Mental health status (depression and anxiety) is measured using hospital anxiety and depression scale. Although the amount of sleep we get is important, good quality sleep is also essential. and transmitted securely. 2006 Jul;48(4):87-97. doi: 10.1539/sangyoeisei.48.87. Exercise. Johns G, Samuel V, Freemantle L, Lewis J, Waddington L. The global prevalence of depression and anxiety among doctors during the covid-19 pandemic: systematic review and meta-analysis, Depression in resident physicians: a systematic review, The Hospital Anxiety and Depression Scale. WebLiving with a mental health problem can affect how well you sleep, and poor sleep can have a negative impact on your mental health. Read about the world of psychiatric research, education, and patient careand see what's happening here at Columbia Pyschiatry. Rotating and scheduling are the main Abbreviations: OR, odds ratio; CI, confidence interval; P, P-value. S, afety and health topics, long work hours, extended or irregular shifts, and worker fatigue, General Survey concerning working-time instruments - Ensuring decent working time for the future, information and reports on the application of conventions and recommendations. 1993 May;35(3):188-97. doi: 10.1539/joh1959.35.188. Given these facts, we emphasize the need to find solutions for this issue. The .gov means its official. Stay at a healthy weight. For the depression multivariate OLR model (Table 6), the regression coefficients for working hours per week categories (4148, 4964, and more than 64 hours) were significant compared to working up to 40 hours per week. doi:10.1136/bmjopen-2017-016873, Waters F, Chiu V, Atkinson A, Blom JD. Sangr PS, Ribeiro TC, Esteban-Seplveda S, Pags EG, Barbeito BL, Llobet JA, Moya-Prats JLP, Prez LP, Mir SA. In asurvey by AASM, over half (56%) of Americans (and 70% among those 35-44 years old) say they have experienced sleep disturbances during the pandemic. Lee et al. [ 36] found that working more than 45 h per week decreased the risk of psychological stress. The relationship between working long hours and work stress requires more investigation. 1.6. Health Behaviours Working longer hours has yielded economic prosperity and, on average, a higher standard of living, but has also resulted in increased levels of risk related to mental fatigue. According to the Centers for Disease Control and Prevention (CDC), a third of adults in the United States report that they get less than the recommended amount of sleep each night. Half of the participants (n=132, 51.2%) were the main provider for their families. A total of 258 medical residents participated in the study. For example, a 2016 review of multiple studies on sleep deprivation among nurses found that 55% work over 40 hours a week and 30%-70% report getting fewer than six hours of sleep a night. Avoid caffeine and nicotine late in the day and limit alcoholic drinks before bed. Unfortunately, it only got worse when the pandemic isolated us from friends and family, closed our schools and offices, and sent shock waves through the economy. Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book.". Effects of health care provider work hours and sleep deprivation on safety and performance. 2016;5(4):780784. HADS is a validated tool, designed in 1983 by Zigmond and Snaith to diagnose and evaluate anxiety and depression symptoms using 14 items.26 HADS consists of two scales, one for anxiety (HADS a) and the other for depression (HADS d). Those who struggle with sleep problems may be more likely to develop an anxiety condition, particularly if their sleep problems are prolonged and left untreated. According to estimates, it is believed to affect approximately 33% of the world's population. Unable to load your collection due to an error, Unable to load your delegates due to an error. Far from enough sleep was also associated significantly (p=0.010) with an increase in the odds of observing a higher category of anxiety (OR=5.96, 95% CI:1.533.20) compared to definitely enough sleep. Saragih ID, Tonapa SI, Saragih IS, et al. Try to keep a consistent sleep schedule, waking up around the same time even on weekends. Those who work more than 11 hours per day have a 2.5 times greater risk of developing depression than those who work regular hours, according to a recent study on long working hours. Create a healthy sleep environment avoid bright lights and loud sounds, keep the room at a comfortable cool temperature, and try to limit electronics in your bedroom. The OR of anxiety for those working more than 64 hours per week was 2.9 compared with those working up to 40 hours per week, after adjusting for confounders using OLR. Research suggests that most people with eating disorders (EDs) experience disrupted sleep; however, more information is needed to understand the relationship between EDs and sleep. P T. 2018;43(12):758-763. Without proper sleep, our minds begin to slow, unable to operate at their full potential. Moreover, HADS scores were positively correlated with PSQI scores and negatively correlated with age. Federal government websites often end in .gov or .mil. Careers. Melatonin: What you need to know. Attention needs to be paid to these associations and the impact of physician mental health on the quality of care. The first three parts of the questionnaire were validated by experts in the field. For the depression multivariate OLR, it would increase the odds of observing a higher level of depression for working 4148, 4964 and more than 64 hours per week by 2.21 (95% CI:1.074.58, P=0.033), 2.07 (95% CI:1.014.27, P=0.049) and 2.37 (95% CI:1.035.50, P=0.044) respectively, compared with working up to 40 hours per week and adjusting for the amount of sleep and exposure to injustice. Helping a child or teen with unhealthy social media use. If you cant get to sleep, get out of bed, and do something relaxing until you feel tired. 2018 Oct;21(10):1849-1856. doi: 10.1111/1756-185X.13104.