1. Introduction
Psoriasis is a chronic and recurrent disorder that affects approximately 125 million individuals globally, with an increasing prevalence.[1] The primary clinical manifestations include inflammatory papules or plaques on the skin, often accompanied by silvery-white scales. People are increasingly concerning the psychological well-being of psoriasis sufferers, driven by the rising prominence of the bio-psycho-social medical model.
A U.S. cross-sectional study of 556 participants revealed that patients with psoriasis are more prone to anxiety and depression than healthy controls. A bidirectional 2-sample Mendelian randomization study has confirmed the presence of a bidirectional causal relationship between psoriasis and depression. Multiple meta-analyses have demonstrated a significant positive association between psoriasis and anxiety symptoms.[2–5] Consequently, it is now widely accepted that psoriasis is a psychophysiological disorder, and the National Institute for Health and Care Excellence guidelines advocate for the assessment of depressive symptoms in all patients diagnosed with psoriasis.
Due to the differences in geographical environment, social customs, cultural background and other factors, teams from different regions have investigated the factors influencing anxiety and depression in patients with psoriasis, leading to diverse conclusions. Some researchers believe that the psychological impact of psoriasis is highly individualized, exhibiting significant variability among patients. Consequently, compared to objective indicators, patients’ subjective perception of their condition may more accurately predict the likelihood of anxiety and depression.[6]
Personal mastery is defined as an individual’s ability to adapt to and regulate changes in the surroundings, serving as a crucial personal resource for stress management.[7] Empirical evidence demonstrates a positive correlation between personal mastery levels and better mental and physical health of patients.[8] Personal resources can be further classified as external and internal resources.[9] According to studies, patients who have a strong sense of personal mastery are more likely to gain external resources, such as social support.[10]
Social support serves as a crucial external resource, refers to material assistance and emotional aid that individuals obtain in all social relationships.[11] Extensive studies have established its efficacy in attenuating the detrimental impacts of stressful events and ameliorating psychological distress in patients.[12] According to studies, insufficient social support can increase the risk of anxiety and depression among psoriasis patients.[13,14]
Acceptance of illness refers to the patient’s ability to accept the impact of the disease and adapt to the disease by adjusting psychological cognition and lifestyle.[15] It has been confirmed that better acceptance of illness in psoriasis patients is associated with a lower risk of depression and anxiety, as well as an enhanced prognosis and quality of life.[16] In clinical settings, poorer acceptance of illness correlates with a weaker sense of personal mastery among patients.[17]
According to the “common sense model of self-regulation” established by Leventhal for disease management, a patient’s internal cognition of the disease and the emotional feedback externally jointly influence depression and anxiety.[18] Therefore, we propose the following hypotheses. First, personal mastery, social support, and acceptance of illness are all influencing factors of anxiety and depression in patients with psoriasis. Second, personal mastery, social support, and acceptance of illness are interrelated and mutually reinforcing.
Third, personal mastery exerts indirect effects on anxiety and depression in patients with psoriasis through the mediating role of social support and acceptance of the illness.
A study has shown that the prevalence of psoriasis in China is 0.47%, with reports indicating a rising trend.[19] In China, research on factors influencing anxiety and depression in psoriasis patients has predominantly focused on objective factors such as economic status, age, duration of disease, gender and so on, with limited attention given to subjective aspects. The purpose of this study is to investigate the aforementioned hypotheses. If they are supported, this study can provide therapeutic recommendations for future diagnosis and intervention for psoriasis patients with comorbid depression and anxiety.
2. Methods
2.1. Study design and setting
This study employed a cross-sectional design. The convenience sampling method was used to recruit patients with psoriasis admitted to the Second Hospital of Hebei Medical University in Shijiazhuang, the capital city of Hebei Province, from January 31, 2024, to August 31, 2024 as the study subjects. The hospital is a grade III class A general hospital that integrates medical care, teaching, and scientific research.
Its Department of Dermatology is the Hebei Provincial Clinical Medical Research Center for Dermatology and Venereology and undertakes multiple national and provincial research projects. The department handles up to 150,000 outpatient visits annually, with >1500 surgical procedures performed each year.
The questionnaires were distributed by 4 trained researchers, all of whom had a medical background and experience in patient interviews. Their training covered the study objectives and procedures, questionnaire administration protocols, the standardized wording of each item, as well as issues related to informed consent and medical ethics. A pilot test involving 5 eligible patients was conducted before the formal survey to assess the clarity and comprehensibility of the items, and no major revisions were deemed necessary.
2.2. Participants and procedures
Inclusion criteria: diagnosis of psoriasis confirmed by 2 or more dermatologists based on medical history, clinical manifestations, and ancillary examinations; permanent residents of Hebei Province, with no experience living abroad for a long period in the past year; and ability and willingness to complete questionnaires and scales.
Exclusion criteria: patients who had anxiety or depression before their psoriasis diagnosis; patients with severe comorbid physical or mental illnesses; and patients with other skin diseases. Multiple studies have shown that various dermatological conditions, such as vitiligo, acne, atopic dermatitis, rosacea, and alopecia areata, can affect patients’ psychological well-being and are strongly associated with depression and anxiety.[20–22] Therefore, patients with coexisting skin diseases were excluded to minimize confounding and thereby enhance the internal validity of the study.
The researchers used a standardized script to explain the purpose and significance of the survey to eligible patients and distributed questionnaires after obtaining informed consent. The patients filled out the questionnaires independently, with researchers providing consistent explanations when questions arose during the completion process. Completed questionnaires underwent immediate verification through researcher review at the collection site.
Data were subsequently organized using a double data-entry method to ensure accuracy.
2.3. Measures
All surveyed people had to fill out the following: First, a general information questionnaire. Second, the Hospital Anxiety and Depression Scale (HADS). Third, the Social Support Rating Scale (SSRS).
Fourth, the Acceptance of Illness Scale (AIS). Fifth, the Personal Mastery Scale (PMS).
2.3.1. Hospital Anxiety and Depression Scale
The scale is primarily used in general hospitals to screen for patients’ levels of anxiety and depression. It comprises 14 items, equally divided into 2 subscales: the HADS-anxiety and HADS-depression. Each item is scored on a 4-point Likert scale (0–3), and the the total score for each subscale ranges from 0 to 21.
A score of ≥8 on either subscale indicates the presence of anxiety or depression, with higher scores reflecting greater severity. The HADS has been widely used in China and has been proven to have good validity and reliability, with a Cronbach’s α of 0.863.
2.3.2. Social Support Rate Scale
The comprises 10 items with varied scoring methods. Items 1 to 4 and 8 to 10 are scored on a standard 4-point Likert scale (1–4). Item 5 consists of 5 sub-items, each rated 1 to 4, and its total score is the sum of these sub-items.
Items 6 and 7 are scored by counting the number of support sources reported (0 points for none). The total score is the sum of all 10 items. The theoretical total score ranges from 12 to 66.
The scale demonstrates excellent internal consistency, with a Cronbach’s α coefficient of 0.92.
2.3.3. Acceptance of Illness Scale
The scale comprises 8 items, each rated on a 5-point Likert-type scale, yielding a total score ranging from 8 to 40 points. A score <20 implies complete rejection of the disease, whereas a score ≥30 indicates indicate high acceptance of the present situation. The scale demonstrates acceptable internal consistency, with a Cronbach’s α coefficient of 0.754.
2.3.4. Personal Mastery Scale
The scale comprises 7 items rated on a 5-point Likert-type scale, with the items 1–5 being reverse-scored. Total scores range from 7 to 35, where scores below 21 indicate low levels of personal mastery while scores exceeding 28 reflect high levels. The scale demonstrates good reliability and validity, with a Cronbach’s α coefficient of 0.81.
2.4. Statistical analysis
The data were analyzed using IBM SPSS (Version 26.0; IBM Corp.) and R (Version 4.4.1; R Foundation for Statistical Computing). Descriptive analysis was performed on demographic and clinical characteristics. Continuous variables with non-normal distribution were described by median and interquartile range, and categorical variables were described by frequency and percentage.
Two independent sample chi-square tests and the Mann–Whitney U rank sum test were used to compare the variables between the 2 groups. We utilized univariate and multivariate logistic regression analyses to investigate the associations between variables and depression and anxiety in psoriasis patients. The results were expressed as odds ratios (ORs), 95% confidence intervals (95% CIs), and P values.
Spearman correlation analysis was used to evaluate the correlation between variables. A chain mediation model was implemented using Bootstrap method with the PROCESS macro in the R environment via the lavaan package to investigate the complex relationships between multiple factors. Using 5000 bootstrap replications for sample calibration, the significance of the mediating effect was tested by calculating the 95% CI.
When the 95% CI did not include 0, the direct, indirect mediating, and chain mediating effects were considered statistically significant. P < .05 indicated statistical significance. In this study, samples with missing data will be excluded from the research cohort.
To ensure the robustness of the results, the analysis was confined to participants for whom complete data were available.
3. Results
3.1. Demographic and clinical characteristics
A total of 317 patients with psoriasis were see at the dermatology department during the study period. Following screening, 283 patients met the inclusion criteria and completed the questionnaire. After excluding invalid questionnaires, 235 valid responses were retained, yielding an effective response rate of 83%.
The final analytical sample therefore comprised 235 patients. (Fig. 1) (see Table S1, Supplemental Digital Content 1, which presents the raw data.)
The psoriasis patients were divided into 2 groups: the affected group presenting with comorbid depression and anxiety comprised 102 individuals. There were 62 men (60.78%) and 40 women (39.22%). The control group consisted of 133 patients who did not suffer from depression or anxiety.
There were 78 men (58.65%) and 55 women (41.35%). No significant differences were observed between the 2 groups in terms of gender, age, and disease course (P = .844, P = .106, and P = .109). Complete sociodemographic profiles are systematically presented in Table 1.
3.2. Scores of Psoriasis Area and Severity Index (PASI), PMS, SSRS and AIS
The median PASI score in the anxiety and depression group was 14.50, indicating moderate psoriasis severity and was significantly higher than that of the control group. Conversely, the median scores for PMS (13.00), SSRS (15.00), and AIS (13.00) were all lower than those of the control group, which suggests impaired personal mastery, limited social support, and reduced illness acceptance, respectively. The differences in these 4 scores between the 2 groups were statistically significant (P < .001) (Table 1).
3.3. Influencing factors of depression and anxiety in patients with psoriasis
Univariate logistic regression analysis was conducted to assess potential associations between depression–anxiety comorbidity and 7 clinical variables: gender, age, disease course, PASI, PMS, SSRS, and AIS. The analysis revealed that PASI, PMS, SSRS, and AIS were statistically significant (P < .001), indicating their potential role as independent determinants of depression–anxiety comorbidity in patients with psoriasis. Variables with P < .001 in univariate logistic regression analysis were incorporated into multivariate logistic regression analysis.
The results revealed that PMS (P = .037), SSRS (P = .020), and AIS (P = .005) were primary influencing factors for depression and anxiety in the surveyed psoriasis patients (Table 2).
3.4. Correlation analysis between depression and anxiety in patients with psoriasis and various influencing factors
Spearman correlation analysis showed that the scores of depression and anxiety in patients with psoriasis were significantly negatively correlated with PMS (r = −0.836, P < .01), SSRS (r = −0.797, P < .01), and AIS (r = −0.846, P < .01). Additionally, these 3 personal subjective factors exhibited strong positive correlations with each other (all P < .01). Detailed results are presented in Table 3.
3.5. Mediation analyses
This study employed the Bootstrap method and utilized the PROCESS program to analyze the mediating effects. The model specified depression–anxiety comorbidity in patients with psoriasis as the dependent variable, personal mastery as the independent variable, and social support along with acceptance of illness as the mediating variables. As shown in Table 4, the direct effect of personal mastery on depression and anxiety was significant (β = −0.028, 95% CI −0.037 to −0.019).
Consistent with prior research, social support and acceptance of illness also demonstrated the significant direct effect on depression–anxiety comorbidity in patients with psoriasis. The condition of depression–anxiety comorbidity in patients with psoriasis will be referred to as “Status” hereafter. Furthermore, multiple mediating pathways were identified as statistically significant (all P < .001).
Table 5 indicated that all 3 indirect paths were statistically significant: PMS → SSRS → Status (β = −0.009, 95% CI −0.017 to −0.002), PMS → AIS → Status (β = −0.017, 95% CI −0.025 to −0.010), and PMS → SSRS → AIS → Status (β = −0.012, 95% CI −0.018 to −0.007). The total indirect effect was −0.038, accounting for 57.6% of the total effect. We utilized the chain mediation model in Figure 2 to more clearly and intuitively illustrate the aforementioned conclusions.
Social support and acceptance of illness, as mediating variables, not only independently mediate the relationship between sense of personal mastery and status, but also jointly play a chain-mediating role between them. The 95% Cis for all paths did not include 0, indicating that all effects were robust, and the mediation model was supported by the data.
4. Discussion
The purpose of this study is to investigate the influence of individual subjective factors on depression and anxiety in patients with psoriasis. According to the findings, personal mastery, social support, and acceptance of illness can influence depression and anxiety in patients with psoriasis in direct or indirect ways. Specifically, social support and acceptance of illness serve as mediators between personal mastery and the levels of depression and anxiety.
We employ a chain mediation model to explore the relationship between the factors above. The model fits the data well and verifies all proposed hypotheses.
Patients with chronic skin diseases frequently suffer from mental or psychological issues. It has been reported that the prevalence of mental disorders in psoriasis patients is 4-fold higher than in patients with other dermatological conditions.[23] Consistent with previous studies, 43.4% of the psoriasis patients in our survey exhibited symptoms of depression or anxiety. These psychological comorbidities can create barriers to work, marriage, and even trigger suicidal thoughts, thereby causing serious health problems and significant economic burdens on families and society.[24,25] Furthermore, mental complications have been found to diminish the therapeutic effect of psoriasis.
Due to frequently low treatment adherence and poor responsiveness in these patients, the prognosis of the disease is often poor.[26,27] In addition, studies have indicated that depression also raises the risk of cardiovascular mortality in psoriasis patients.[28] The bidirectional relationship between psoriasis and mental health issues such as depression and anxiety creates a detrimental feedback loop.[29]
Several studies have shown that higher PASI scores correlate with more severe psoriasis and an increased likelihood of depression and anxiety in patients.[25] However, our research reveals that PASI scores are not the influencing factor for depression and anxiety in patients with psoriasis. Research has found that once patients experience negative emotions, the psychological trauma can persist even after the skin lesions have healed.[30] The psychological problems of psoriasis patients are highly individualized. Compared with the objective dimension, they may be largely attributed to patients’ views on the disease and other psychological factors.
Personal mastery serves as a crucial protective mechanism for individual emotional regulation and stress management. A pathophysiological study has pointed out that a high level of personal mastery can modulate physiological functions, alleviate stress, through neuroendocrine and immune systems.[31] Although personal mastery has been proven to be an influencing factor of depression and anxiety across multiple diseases, its psychopathological implications in psoriasis remain inadequately investigated. Our study reveals that personal mastery is negatively correlated with depression and anxiety in patients with psoriasis.
In contemporary society, maintaining a positive personal image is critical for social interaction and career advancement. The characteristic skin manifestations of psoriasis, such as erythematous plaques and scaling lesions, often cause embarrassment and feelings of inferiority by altering visible body image. A study surveyed 8338 psoriasis patients from 31 countries, 84% of whom had experienced discrimination and stigmatization due to obvious skin symptoms.[32] They are often mistakenly perceived as inattentive to personal hygiene or suffer from infectious diseases, which reduced their self-esteem and increased their social pressure.
More severely affected individuals may develop a victim mentality, believing they will be universally excluded. This fosters a fear of socialization, leading to avoidance and self-isolation.[33,34] However, such behavior will wide the gap between patients and others, affecting interaction in work and social lives. According to a study on the impact of psoriasis on major life decisions, 66% of patients said that the disease has influenced their career choices.[35] As a chronic, relapsing–remitting dermatosis psoriasis imposes substantial financial burden due to treatment costs.
According to a study conducted in the United States, psoriasis patients may lose their jobs or encounter difficulties in securing employment due to disease flares, which seriously compromises their financial stability.[36] In the field of intimate relationships, studies have observed that psoriasis can strain the marital relationship, potentially leading to divorce.[37] When symptoms such as itching and skin lesions affect the genital area, patient’s sexual health can be impaired, further increasing their psychological burden.[38]
When interpersonal relationships, career, and family life are disrupted, psoriasis patients are highly likely to experience a profound sense of helplessness, resulting in diminished personal mastery. Chinese Confucian culture emphasizes self-reflection. However, since the exact cause of psoriasis is often difficult to identify, patients may be more inclined to engage in self-blame.
This internal attribution can reinforce negative cognitions about one’s inability to control life events, leading to learned helplessness and exacerbating the loss of control.[39] Furthermore, the concept of karma in traditional Chinese culture may compound this psychological burden. If patients perceive that they have not committed any wrongdoing yet still suffer from this disease, which has a long-term impact on their personal lives, they may view it as a capricious manifestation of fate. Consequently, they may adopt a pessimistic outlook, believing that they are powerless against destiny and lose their subjective initiative in life.
Beck’s cognitive theory of depression proposes that diminished control over problems during adverse events triggers negative automatic thoughts, which aligns with our research findings.[40]
Social support is acknowledged as a critical component of chronic disease self-management and a protective factor in stressful circumstances. Many studies have pointed out that psoriasis patients often experience lower social support due to active or passive social isolation.[41] Our findings corroborate previous research by demonstrating a significant inverse correlation between social support levels and depression and anxiety severity in this population. Simultaneously, our results reveal that the mediating role of social support between personal mastery and both depression and anxiety in patients with psoriasis.
Social support encompasses subjective support, objective support, and the utilization of available support resources. Evidence suggests that patients with poor personal mastery have impaired mobility, are likely to adopt negative disease coping strategies and struggle to conduct health promotion actions autonomously.[42] They exhibited impaired perception acuity toward available social support, reduced efficiency in utilizing received assistance, and diminished propensity for external help-seeking behavior.[10]
Acknowledging one’s illness does not equate to fully accepting the disease. In our survey, some patients objected to being assessed as having a low level of illness acceptance, arguing that they were not denying the presence of psoriasis. However, acceptance of illness is a multifaceted concept.
It also entails that patients can accept all of the constraints imposed by the disease, comprehend its unpredictability, and actively adjust their psychological and physiological state to adapt to the new situation.
The subjective acceptance of one’s health condition significantly influences emotional responses. Our study found that the acceptance of illness is negatively correlated with depression and anxiety in patients with psoriasis, which is consistent with the findings of other teams. Previous studies have demonstrated that even after seeking medical treatment, patients with psoriasis continue to struggle with psychological acceptance of the disease due to visible skin imperfections.[43] Some patients lack adequate knowledge of psoriasis, which frequently leads to unrealistic expectations.
They hope to cure the disease once and for all. However, subsequent disease recurrence following initial symptom alleviation tends to exacerbate psychological distress and may precipitate maladaptive cognitive patterns, particularly ruminative behaviors that intensify depressive and anxious symptoms.[44] The cognitive dissonance between these unrealistic expectations and the reality of a high recurrence rate a key factor contributing to the low acceptance of the illness. This conflict can also fuel patients’ skepticism towards medical professionals, potentially leading to nonadherence to prescribed therapeutic regimens.
Meta-analyses have indicated a strong correlation between patient adherence and personal cognition. The lower the level of disease-related concern and the higher the acceptance, the better the treatment adherence among patients with dermatological conditions.[45] It has been demonstrated that patients who accept their illness poorly exhibit poorer treatment compliance and find it more challenging to engage actively in their management.[17,46]
Through mediation analysis, we found that acceptance of illness mediated the effects of personal mastery and social support on both anxiety and depression in patients with psoriasis. Furthermore, social support and acceptance of illness sequentially mediated the effects of personal mastery on depression and anxiety in psoriasis patients. Previous research suggests that patients who attribute their health to external factors such as fate or opportunity, often struggle to accept their disease.[17] Patients with low personal mastery are more prone to self-criticism, resulting in pessimistic views on disease curability.
Some scholars consider that this mindset can impair objective assessment of one’s situation, potentially reducing acceptance of illness.[47] The mental and psychological well-being of patients with chronic diseases is highly influenced by social relationships, thus these patients require substantial social support.[14] Enhanced social support not only fosters positive emotional experiences but also strengthens patient’s sense of security and belonging. Moreover, it can improve the ability of patients to cope with the disease and motivate themselves to engage in health-promoting activities. Optimizing the utilization of social support shows significant potential in enhancing acceptance of illness.
It has been reported that tangible social support, which refers to material help, including financial aid and specific physical assistance, is the most effective way to improve acceptance of illness in psoriasis patients.[48] These findings highlight the need for policymakers to prioritize structural reforms in healthcare security systems to ensure that patients receive practical assistance.
This study found that personal mastery, social support, and acceptance of illness can serve as targets for interventions aimed at alleviating depression and anxiety. To our knowledge, this is the first empirical investigation in this region to simultaneously examine the relationships between these specific psychosocial variables and depression and anxiety in patients with psoriasis. We can conclude that early monitoring and intervention for mental health in patients with psoriasis is crucial.
However, both previous studies and this investigation show that Chinese dermatologists do not devote sufficient attention to the psychological assessment of these patients.[49,50] This can be attributed to 2 primary reasons. Firstly, in China, doctors have relatively limited time for in-depth communication with outpatients because of the high patient volume.[51] Secondly, many patients are also reluctant to talk about their psychological distress.[52] This situation creates significant challenges for nonpsychiatric physicians in identifying and diagnosing mental disorders within these constrained timeframes.[53]
The World Health Organization recommends establishing a multidisciplinary team to provide individualized comprehensive treatment for psoriasis patients.[33,54] A multidisciplinary team typically comprises professionals such as dermatologists, psychiatrists, psychotherapists, and nurses. While managing the physical manifestations of the disease, dermatologists are responsible for helping patients develop an accurate understanding of their condition, thereby enhancing their acceptance of illness. Psychiatrists conduct comprehensive assessments of patients’ mental health, diagnose comorbid psychiatric disorders such as anxiety and depression, and provide pharmacological treatment when indicated.
Psychotherapists assist patients in adjusting their psychological state, fostering an increased sense of personal mastery. Nurses are tasked with delivering daily care and conducting regular health education sessions, serving as an essential source of social support for patients.
Although our research is well-designed, it still has some limitations. First of all, as a cross-sectional study, it is challenging to establish clear causal inferences between variables. Moreover, given that psychological factors are dynamic, cross-sectional can only reflect the current state.
Therefore, more longitudinal studies are needed in the future. Second, the survey was conducted with patients from a single center, limiting the representation of the sample and potentially introducing regional bias. To improve the generalizability of the findings, we recommend expanding the scope of research in the future and carry out multicenter, large-sample studies.
Third, although our analysis is internally consistent with the existing literature and we have adjusted for known confounding factors such as age and gender, the possibility of residual confounding remains. Several subjective factors, including self-efficacy, can influence depression and anxiety in psoriatic patients. This study only discusses a few of these relevant factors, and more research is needed in the future to thoroughly investigate the complex interactions between them.
Fourth, no a priori power analysis was conducted before data collection, and the sample size was determined by the total number of consecutive eligible patients enrolled from the dermatology department. The sensitivity power analyses indicated that the minimum detectable effect sizes fell within the small-to-medium range per Cohen’s conventions. The study was therefore adequately powered to detect effects of small-to-medium magnitude or larger, but may have been underpowered to detect very small effects.
Future studies with larger samples and a priori power calculations based on expected effect sizes are needed.
5. Conclusion
This study reveals that personal mastery, social support, and acceptance of illness significantly influence depression and anxiety in patients with psoriasis. Mediation analyses demonstrate that personal mastery exerts indirect effects on these outcomes through the mediating roles of social support and acceptance of illness. Therefore, clinicians are encouraged to assess patients’ psychological status during treatment.
Interventions aimed at enhancing these 3 factors could help alleviate negative emotions and improve psychological stability in patients. By elucidating the psychological mechanisms linking these subjective factors to depression and anxiety, this study provides valuable insights and a foundation for further exploration of disease management and psychological intervention in patients with psoriasis.
Acknowledgments
The authors would like to express their gratitude to all participants.
Author contributions
Conceptualization: Yi Cheng Yang, Yan Zhi Bai.
Data curation: Yi Cheng Yang, Xiao Guang Zhang, Shen Bing Guo, Feng Wei, Xi Xing Ma, Yan Zhi Bai.
Formal analysis: Si Jia Li.
Funding acquisition: Xiao Guang Zhang, Yan Zhi Bai.
Investigation: Yi Cheng Yang, Xiao Guang Zhang, Shen Bing Guo, Feng Wei, Xi Xing Ma, Yan Zhi Bai.
Methodology: Yi Cheng Yang, Si Jia Li, Yan Zhi Bai.
Project administration: Xiao Guang Zhang, Yan Zhi Bai.
Resources: Xiao Guang Zhang, Shen Bing Guo.
Supervision: Yan Zhi Bai.
Validation: Yi Cheng Yang, Ling Ling Xue.
Visualization: Yi Cheng Yang, Si Jia Li.
Writing – original draft: Yi Cheng Yang.
Writing – review & editing: Xiao Guang Zhang, Shen Bing Guo, Ling Ling Xue, Yan Zhi Bai.