|Year : 2020 | Volume
| Issue : 1 | Page : 29-35
Impact of micronutrients on the psychological well-being of highly active antiretroviral therapy-naïve human immunodeficiency virus-infected patients
Victor Obiajulu Olisah1, Tajudeen Abiola2, Christopher I Okpataku3, Reginald O Obiako4, Ishaq A Audu1
1 Department of Psychiatry, Ahmadu Bello University Teaching Hospital, Shika, Nigeria
2 Department of Clinical Services, Medical Services Unit, Federal Neuropsychiatric Hospital, Barnawa, Kaduna State, Nigeria
3 Department of Psychiatry, College of Health Sciences, Bingham University, Jos, Plateau State, Nigeria
4 Department of Medicine, Ahmadu Bello University, Zaria, Nigeria
|Date of Submission||25-Jan-2019|
|Date of Decision||06-May-2019|
|Date of Acceptance||17-Jun-2019|
|Date of Web Publication||18-Mar-2020|
Dr. Victor Obiajulu Olisah
Department of Psychiatry, Ahmadu Bello University Teaching Hospital, Shika, Zaria, Kaduna State
Background: In human immunodeficiency virus (HIV)-infected persons, low serum concentrations of vitamins and minerals, termed micronutrients, may be associated with an increased risk of psychiatric morbidity and HIV disease progression. Objectives: This study investigated the effects of micronutrient supplementation on psychological well-being of highly active antiretroviral therapy (HAART)-naïve HIV-infected patients. Materials and Methods: A total of 90 HAART-naïve HIV-infected patients completed the Distress Thermometer and its Problem Checklist, the Hospital Anxiety and Depression Scale, the Oslo Social Support Scale, and the 14-Item Resilience Scale (RS-14) at baseline. They all received a micronutrient supplement for 6 months, and 68 of the participants who remained in treatment at 6 months were reassessed with the same instruments. Results: There was no significant difference between sociodemographic characteristics of participants at baseline and 6 months. After 6 months of micronutrient supplementation, participants were found to have significantly lower mean scores on the anxiety (P = 0.003), depression (P = 0.001), and overall distress (P = 0.001) subscales and significantly higher mean scores on the RS (P = 0.025). Conclusion: Micronutrient supplementation can reduce the experience of distress, anxiety, and depression and increase the resilience in HAART-naïve HIV-infected persons.
Keywords: Anxiety, depression, HAART naïve, HIV, micronutrients
|How to cite this article:|
Olisah VO, Abiola T, Okpataku CI, Obiako RO, Audu IA. Impact of micronutrients on the psychological well-being of highly active antiretroviral therapy-naïve human immunodeficiency virus-infected patients. Sahel Med J 2020;23:29-35
|How to cite this URL:|
Olisah VO, Abiola T, Okpataku CI, Obiako RO, Audu IA. Impact of micronutrients on the psychological well-being of highly active antiretroviral therapy-naïve human immunodeficiency virus-infected patients. Sahel Med J [serial online] 2020 [cited 2020 Mar 28];23:29-35. Available from: http://www.smjonline.org/text.asp?2020/23/1/29/280944
| Introduction|| |
Nigeria has the second largest human immunodeficiency virus (HIV) epidemic in the world and one of the highest new infection rates in sub-Saharan Africa. Although HIV prevalence among adults is remarkably small (2.9%) compared to other sub-Saharan African countries such as South Africa (18.9%), the size of Nigeria's population means that about 3.2 million people were living with HIV in 2016. Despite this large number, there is a scarcity of studies on their mental health burden.
Micronutrient deficiencies are common in patients with HIV disease and are associated with higher risks of HIV disease progression and mortality. Micronutrients are essential for maintaining proper immunologic function. Compared with HIV-negative person, HIV-infected persons have lower serum concentrations of several micronutrients., Studies have shown that insufficient dietary intake, malabsorption, diarrhea, impaired storage, and altered metabolism of micronutrients contribute to the development of micronutrient deficiencies in people living with HIV., Low serum levels of Vitamins A, E, B6, B12, and C, carotenoids, selenium, and zinc are common in many HIV-infected populations and may occur early in the course of the disease. Micronutrient deficiencies may contribute to the pathogenesis of HIV infection through increased oxidative stress and compromised immunity. Some studies have shown that micronutrient interventions have cellular and clinical benefits in HIV-positive persons not receiving highly active antiretroviral therapy (HAART).,,
People living with HIV are about 2–3 times more likely to experience mental health disorders during the course of their illness, especially chronic mental disorders such as depression and anxiety than the general population which, in turn, reduce their quality of life and adherence to treatment and contribute significantly to their premature deaths. More recent evidence on brain metabolism suggests that deficiencies of certain micronutrients can influence the development and progression of mental illnesses.,, A study in Iran evaluated the correlation between daily dietary antioxidant micronutrient intake and mental health outcomes (depression, anxiety, and stress) in Iranians living with HIV infection and found a significant negative correlation between daily dietary intake of zinc, selenium, and Vitamin C with mental health outcomes, implying that the intake of these micronutrients lead to a reduction in the prevalence of depression, anxiety, and stress. Another study in South India had similar findings. Studies have indicated a link between Vitamin B6 (pyridoxine) and folic acid deficiency and mental illness., There are some indications that Vitamin B6 helps to combat depression among premenopausal women. Low serum concentrations of folic acid have been found in particular among untreated depressed patients, as well as depressed persons treated with antidepressants who did not achieve a significant improvement. A lack of folic acid and Vitamin B12 has been linked to an increase in plasma concentrations of homocysteine and a reduction in cognitive performance. Vitamin B12 deficiency has also been described in the context of various other mental illnesses, such as depression, bipolar disorder, panic disorder, schizophrenia, and phobias. Zinc is important for immune regulation, energy metabolism, and insulin storage, influencing protein synthesis, DNA transcription, and the metabolism of nerve modulators and neurotransmitters. Several studies indicate a link between zinc balance and mental illnesses involving extreme mood and drive-related symptoms (affective disorders). Some evidence suggest that Vitamin D could be a marker of resilience to the fatality of potentially deadly diseases. Sufficient Vitamin D serum concentrations may be needed to regulate the response of the immune system when it is challenged by severe diseases to prevent a fatal course of the disease.
While a targeted intake of individual micronutrients appears to have prophylactic or therapeutic effects on certain mental disorders,,,, none has been found to have overall effectiveness when used alone in the treatment of mental disorders.
Most studies on micronutrient deficiency in HIV/AIDS have focused on its effect on physical outcomes of the disease rather than psychological. Mental disorders are common in patients with HIV/AIDS, and the prevalence increases with HIV disease progression. Studies on the possible mental health implication of micronutrient deficiency in HIV and the role or benefits of supplementation are lacking, especially in sub-Saharan Africa. In this study, we examined the impact of micronutrient supplementation on the psychological well-being of HAART-naïve HIV-infected patients in Nigeria.
| Materials and Methods|| |
This study was part of a larger study on the effects of micronutrients on immunological outcomes of HAART-naïve patients with HIV infection in Kaduna State conducted by some physicians in a tertiary health institution in Nigeria.
Sample size and technique
A minimum sample size of 88 was determined from the Fisher's sample size formula for longitudinal studies:N = Z2 P (1 − P)/d2 × 1 (1 − f), where N = desired sample size when population is over 100,000; Z = confidence interval at 95% (1.96); P = prevalence rate of HIV infection in Kaduna State, Nigeria (5. 1%);d = sampling error at 5% (0.05); and f = Attrition rate of 10%. However, in order to increase the power of the study, 90 HIV-positive HAART-naïve adult patients aged 18–59 years were recruited at baseline through consecutive sampling of every eligible patient meeting the inclusion criteria at the clinics during the study period.
This was a longitudinal study.
Participants were 90 HAART-naïve and newly diagnosed HIV-infected patients who were not eligible for ART medication on the basis of their CD4 count of 500 and above. They were recruited as they present to the HIV clinics of two major hospitals in Kaduna State, Nigeria, namely the Nasara HIV Treatment and Care Centre at Ahmadu Bello University Teaching Hospital, Zaria, and the Caritas Catholic Relief Foundation HIV Centre at Saint Gerards Catholic Hospital, Kaduna. Both centers provide free ART to eligible patients and supportive care to ART-ineligible patients.
Participants were aged 18–59 years, physically fit, and mentally alert, without evidence of physical deformity. Other eligibility criteria were HAART naïve, the WHO clinical Stage I and II, and CD4+ count >500.0 cells/μl.
Participants were excluded from the research if they had a history of alcohol and substance abuse, past psychiatric history, chronic hepatitis B or C or HIV-2 infection, vegetarian diet, chronic hypertension, and immunosuppressive illnesses (such as diabetes mellitus, chronic renal disease, malignancy, and sickle cell anemia). Others are refusal to give consent to participate, pregnancy, the presence of AIDS-defining illness, and default from one clinic visit.
Enrollment and evaluations of human immunodeficiency virus-infected antiretroviral therapy-naïve patient
At the various enrollment centers, all the patients meeting the inclusion criteria were educated and counseled on various aspects of HIV care and support by nurse HIV counselors, before the research objectives and protocol were explained to them, with emphasis on the voluntary nature of the study and assurance of the confidentiality of all information divulged/volunteered. Participants were made to sign informed written consent. The sociodemographic data and history of illness were obtained from each participant. They completed the Distress Thermometer (DT) and its Problem Checklist, the Hospital Anxiety and Depression Scale (HADS), the Oslo Social Support Scale (OSS), and the 14-Item Resilience Scale (RS-14) at baseline. All participants received daily doses of one capsule of a micronutrient supplement for 6 months. Participants who completed 6 months of the treatment were reassessed with the same instruments. The research lasted for 3 years, from September 2013 to September 2016.
Instruments of study
Distress Thermometer and its Problem Checklist
The level of psychosocial and physical distress experienced by the participants was assessed by the DT. The DT is a 1-item visual analog scale that rates the level of distress experienced over the past week on an 11-point scale ranging from 0 (no distress) to 10 (extreme distress). The DT also has a problem list (PL) that helps in identifying the part of life that may be contributing to the distress. The PL problem areas can be grouped into five broad categories of practical, family, emotional, spiritual/religious, and physical. The DT was developed by the National Comprehensive Cancer Network for the detection of distress in cancer patients. However, since cancer is a chronic illness, the DT has been employed in the detection of distress in infectious chronic illnesses such as HIV too., A validation study of the instrument among patients with recurrent respiratory papillomatosis in the Netherlands and Finland showed that a DT cutoff score of ≥4 gave the best sensitivity and specificity of 89% and 74%, respectively, and a positive and negative predictive values of 29% and 98%, respectively. There is currently no published validation study of the DT and its Problem Checklist in Nigeria.
Hospital Anxiety Depression Scale
The HADS is a portable easy to administer measure that screens for the presence of anxiety or depressive state of both clinical and nonclinical population. It consists of seven depression items and seven anxiety items and has been validated for use in Nigeria. A score of 8 and above on either of the two components is regarded as a case.
Oslo Social Support Scale
The OSS-3 provides a brief measure of social functioning and it is considered to be one of the best predictors of mental health. It covers different fields of social support by measuring the number of people the respondent feels close to, the interest and concern shown by others, and the ease of obtaining practical help from others. The structure and reliability (Crohnbach's alpha of 0.60) of OSS-3 have not been well documented despite widespread use in several European countries. It has been used and validated in Nigeria.
The 14-Item Resilience Scale
The RS-14 is a measure of psychological resilience, that is, the capacity to withstand life stressors and thrive and make meaning from challenges. This short version is an offshoot of the original 25-item psychological RS of Wagnild and Young. The nine items excluded were those that showed an inter-item correlation above 0.40. The RS-25 and RS-14 were strongly correlated (r = 0.97, P < 0.001). Resilience, as construed by Wagnild, comprises five essential characteristics of meaning life (purpose), perseverance, self-reliance, equanimity, and existential aloneness (i.e., coming home to yourself). The RS-14 has been used and validated in Nigeria.
Each micronutrient capsule is made up of a mixture of 11 vitamins (A, B1, B2, B3, B6, B12, biotin, folate, pantothenate, C, and E), 6 trace elements (selenium, copper, zinc, ferrous, molybdenum, and manganese), 2 electrolytes (potassium and magnesium), 2 essential amino acids (L-glycine and L-lysine), and 1 peptide (choline bitartrate).
The research was reviewed and approved by the Institutional Health Research Ethical Committee (IHREC) of the Ahmadu Bello University Teaching Hospital, Zaria. This approval with protocol number ABUTH/HREC/102/2013 dated January 7, 2014, was communicated to the IHREC of the Saint Gerards Catholic Hospital, Kaduna. All procedures were in accordance with the guidelines of 2013 Helsinki's guidelines and declaration.
The IBM-SPSS version 21 statistical package (IBM SPSS Inc., Armonk, New York) was used for data entry and analysis. Data were analyzed by descriptive statistics, including frequencies, percentages, means, and standard deviation. The Chi-square test was used to characterize the significance of the difference between categorical variables, whereas t-test statistics was used to characterize the significance of the difference between mean scores. All statistical evaluations were considered statistically significant at P < 0.05, two-tailed.
| Results|| |
Ninety participants were recruited at baseline, but 68 (75.6%) of them completed the study at 6 months. Majority of the participants at baseline were <41 years in age (62.2%), belonged to the female gender (76.7%), were of the Christian faith (81.1%), had at least 12 years of formal education (88.9%), currently unmarried (53.3%) as at the time of assessment, and gainfully employed (75.6%). There was no significant difference between sociodemographic characteristics of participants at baseline and 6 months, as shown in [Table 1].
|Table 1: Sociodemographic characteristics of HIV-infected highly active antiretroviral therapy-naïve patients at baseline and 6 months of treatment with micronutrient supplementation|
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The prevalence of anxiety and depression among participants at baseline was 23.2% and 23.2%, respectively. After 6 months of micronutrient supplementation, the prevalence of anxiety and depression was 13.2% and 4.4%, respectively, as shown in [Table 2].
|Table 2: Prevalence of anxiety and depression at baseline and after 6 months of micronutrient supplementation among HIV-infected highly active antiretroviral therapy-naïve patients|
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Mean scores of psychological variables at baseline and after 6 months of micronutrient supplementation among participants showed a statistically significant difference in the overall experience of distress (P = 0.001) and resilience (P = 0.025) and also had significantly lower HADS mean scores of anxiety (P = 0.003) and depression (P = 0.001), as shown in [Table 3].
|Table 3: Mean scores of psychological variables at baseline and after 6 months of micronutrient supplementation among HIV-infected highly active antiretroviral therapy-naïve patients|
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| Discussion|| |
This study examined the effects of micronutrient supplementation on the psychological well-being of HAART-naïve HIV patients. A total of 90 participants were recruited for the study at baseline, but 68 (75.6%) of them completed the study at 6 months. Twenty-two participants were unable to complete the study at 6 months for various reasons including loss to follow-up, default from a clinic visit, drop in CD4 count below 500 cells/μl, and pregnancy.
The sociodemographic characteristics of participants at baseline did not differ significantly from the values at 6 months. Most participants were aged between 21 and 40 years with a preponderance of the female gender similar to findings from other related studies among adult HIV-positive population in Africa.,, Women, especially those in childbearing age, are more likely to have their HIV disease detected either through routine screening in the antenatal clinics or when their babies develop HIV-associated illnesses shortly after birth.
The prevalence of anxiety and depression among participants at baseline was 23.2% and 23.2%, respectively. After 6 months of micronutrient supplementation, the prevalence of anxiety and depression was 13.2% and 4.4%, respectively. The differences in both psychological parameters between baseline values and after 6 months of micronutrient supplementation were statistically significant. This finding is similar to those from other studies., Previous studies have shown that micronutrients, especially folic acid, Vitamins B6 and B12, zinc, and some amino acids play a role in anxiety and depression. Low levels of folic acid and Vitamin B12 have been found in studies of depressive patients, and a targeted intake of these micronutrients may have prophylactic or therapeutic effects on some mental disorders including anxiety and depression as suggested in this study.,,
Furthermore, cross tabulation of mean scores of psychological variables at baseline and after 6 months of micronutrient supplementation among participants showed a statistically significant difference in the overall experience of distress (P = 0.001) with participants experiencing less distress after 6 months of micronutrient therapy. Furthermore, the Problem Checklist of the DT showed a significant difference in the mean scores of participants' in all the subscales, with participants experiencing less distress in these parameters after 6 months of micronutrient supplementation. Similarly, participants were significantly more resilient (P = 0.025) after 6 months of treatment with micronutrients.
Only, a few studies have previously examined the role of micronutrient supplementation in people's emotional resilience and the experience of distress in the various aspects of life following a diagnosis of HIV infection. A study evaluated the correlation between daily micronutrient intake and mental health outcomes in Iranians living with HIV infection and found that those who had micronutrient supplementation experienced significantly less anxiety, depression, and distress. Similarly, another study investigated whether individuals with attention-deficit hyperactivity disorder (ADHD) taking micronutrients showed more emotional resilience associated with a category 7.1 earthquake than individuals with ADHD not taking the micronutrients. The study found that those taking micronutrients reported feeling significantly less anxious and stressed than those not taking micronutrients, showing a medium-to-large effect size. Some researchers have tried to explain why micronutrients may be beneficial to mental health. Micronutrients serve as essential cofactors for manufacturing neurotransmitters required for optimal brain functioning. Others have speculated that the physiological mechanisms involved in stress response and short-term survival have a high nutritional requirement and take precedence over other long-term biological needs to ensure the survival of the organism. It is possible that during high stress, other normal biochemical reactions of the body become compromised. Adding micronutrients at a time of stress may then meet the biological needs of the whole organism.
Even with the availability of HAART in many African societies and the current recommendation to commence treatment as early as possible in course of the disease, complementary micronutrient supplementation should be viewed as an important and integral part of HIV and AIDS treatment to improve their general physical and mental health status, thereby improving quality of life.
The study is limited by the relatively small sample size and hospital based, so findings cannot be generalized to the entire population of people living with HIV. The instruments were not administered to a control group who did not receive micronutrient supplementation, and diagnostic instruments for anxiety and depressive disorders were not used. Furthermore, the study did not account for other possible factors which can affect participants' mental well-being such as personality factors, nutritional factors, and knowledge about HIV/AIDS which may serve as confounders.
| Conclusion|| |
This study provides preliminary evidence that micronutrients positively influence the psychological well-being and reduces the experience of distress that abounds in recently diagnosed patients with HIV. The data are compelling enough to warrant further studies investigating the role that micronutrients might play in reducing mental illness and stress responses in people living with HIV/AIDS in the community.
We are grateful to the doctors and nurses at the Ahmadu Bello University Teaching Hospital Zaria HIV/AIDs Treatment and Care Centre and the Saint Gerards Catholic Hospital HIV Treatment Unit (Caritas Catholic Relief Foundation HIV Centre) for their help during data collection. We are also grateful to the management of Synergy Healthcare Limited, Lagos, Nigeria, for donating the Synovit Capsules used for the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kupka R, Msamanga GI, Spiegelman D, Morris S, Mugusi F, Hunter DJ, et al.
Selenium status is associated with accelerated HIV disease progression among HIV-1-infected pregnant women in Tanzania. J Nutr 2004;134: 2556-60.
Cunningham-Rundles S, McNeeley DF, Moon A. Mechanisms of nutrient modulation of the immune response. J Allergy Clin Immunol 2005;115: 1119-28.
Dworkin BM, Rosenthal WS, Wormser GP, Weiss L, Nunez M, Joline C, et al.
Abnormalities of blood selenium and glutathione peroxidase activity in patients with acquired immunodeficiency syndrome and aids-related complex. Biol Trace Elem Res 1988;15: 167-77.
Semba RD, Shah N, Strathdee SA, Vlahov D. High prevalence of iron deficiency and anemia among female injection drug users with and without HIV infection. J Acquir Immune Defic Syndr 2002;29: 142-4.
Batman PA, Miller AR, Forster SM, Harris JR, Pinching AJ, Griffin GE. Jejunal enteropathy associated with human immunodeficiency virus infection: Quantitative histology. J Clin Pathol 1989;42: 275-81.
Abrams B, Duncan D, Hertz-Picciotto I. A prospective study of dietary intake and acquired immune deficiency syndrome in HIV-seropositive homosexual men. J Acquir Immune Defic Syndr 1993;6: 949-58.
Baum M, Cassetti L, Bonvehi P, Shor-Posner G, Lu Y, Sauberlich H. Inadequate dietary intake and altered nutrition status in early HIV-1 infection. Nutrition 1994;10: 16-20.
Allard JP, Aghdassi E, Chau J, Tam C, Kovacs CM, Salit IE, et al.
Effects of vitamin E and C supplementation on oxidative stress and viral load in HIV-infected subjects. AIDS 1998;12: 1653-9.
Jiamton S, Pepin J, Suttent R, Filteau S, Mahakkanukrauh B, Hanshaoworakul W, et al.
A randomized trial of the impact of multiple micronutrient supplementation on mortality among HIV-infected individuals living in Bangkok. AIDS 2003;17: 2461-9.
Humphrey JH, Iliff PJ, Marinda ET, Mutasa K, Moulton LH, Chidawanyika H, et al.
Effects of a single large dose of vitamin A, given during the postpartum period to HIV-positive women and their infants, on child HIV infection, HIV-free survival, and mortality. J Infect Dis 2006;193: 860-71.
Fawzi WW, Msamanga GI, Spiegelman D, Wei R, Kapiga S, Villamor E, et al.
A randomized trial of multivitamin supplements and HIV disease progression and mortality. N
Engl J Med 2004;351: 23-32.
World Health Organization. HIV/AIDS and Mental Health Report by the Secretariat. World Health Organization; 20 November 2008.
Hinze-Selch D, Weber MM, Zimmermann U, Pollmächer T. Thiamine treatment in psychiatry and neurology. Fortschr Neurol Psychiatr 2000;68: 113-20.
Akhondzadeh S, Gerbarg PL, Brown RP. Nutrients for prevention and treatment of mental health disorders. Psychiatr Clin North Am 2013;36: 25-36.
Crellin R, Bottiglieri T, Reynolds EH. Folates and psychiatric disorders. Clinical potential. Drugs 1993;45: 623-36.
Jamali F, Izadi A, Khalili H, Garmaroudi G. Correlation between daily dietary micronutrients intake and mental health outcomes in Iranians living with HIV infection. J Assoc Nurses AIDS Care 2016;27: 817-25.
Adhikari PM, Chowta MN, Ramapuram JT, Rao SB, Udupa K, Acharya SD, et al.
Effect of vitamin B12 and folic acid supplementation on neuropsychiatric symptoms and immune response in HIV-positive patients. J Neurosci Rural Pract 2016;7: 362-7.
] [Full text]
Williams AL, Cotter A, Sabina A, Girard C, Goodman J, Katz DL. The role for vitamin B-6 as treatment for depression: A systematic review. Fam Pract 2005;22: 532-7.
Morris MS, Fava M, Jacques PF, Selhub J, Rosenberg IH. Depression and folate status in the US population. Psychother Psychosom 2003;72: 80-7.
Clarke R, Smith AD, Jobst KA, Refsum H, Sutton L, Ueland PM. Folate, vitamin B12, and serum total homocysteine levels in confirmed Alzheimer disease. Arch Neurol 1998;55: 1449-55.
Reynolds E. Vitamin B12, folic acid, and the nervous system. Lancet Neurol 2006;5: 949-60.
Lai J, Moxey A, Nowak G, Vashum K, Bailey K, McEvoy M. The efficacy of zinc supplementation in depression: Systematic review of randomised controlled trials. J Affect Disord 2012;136: e31-9.
Schöttker B, Brenner H. Vitamin D as a resilience factor, helpful for survival of potentially fatal conditions: A hypothesis emerging from recent findings of the ESTHER cohort study and the CHANCES consortium. Nutrients 2015;7: 3264-78.
Bottiglieri T. Folate, Vitamin B12
, and S-adenosylmethionine. Psychiatr Clin North Am 2013;36: 1-3.
Annweiler C, Rolland Y, Schott AM, Blain H, Vellas B, Herrmann FR, et al.
Higher vitamin D dietary intake is associated with lower risk of Alzheimer's disease: A 7-year follow-up. J Gerontol A Biol Sci Med Sci 2012;67: 1205-11.
Araoye MO. Research Methodology with Statistics for Health and Social Sciences. Ilorin: Nathadex Publishers; 2004. p. 117-20.
Schofield PE, Butow PN, Thompson JF, Tattersall MH, Beeney LJ, Dunn SM. Psychological responses of patients receiving a diagnosis of cancer. Ann Oncol 2003;14: 48-56.
Tesfaye SH, Bune GT. Generalized psychological distress among HIV-infected patients enrolled in antiretroviral treatment in Dilla university hospital, Gedeo Zone, Ethiopia. Glob Health Action 2014;7: 23882.
Cohen M, Hoffman RG, Cromwell C, Schmeidler J, Ebrahim F, Carrera G, et al.
The prevalence of distress in persons with human immunodeficiency virus infection. Psychosomatics 2002;43: 10-5.
San Giorgi MR, Aaltonen LM, Rihkanen H, Tjon Pian Gi RE, van der Laan BF, Hoekstra-Weebers JE, et al.
Validation of the distress thermometer and problem list in patients with recurrent respiratory papillomatosis. Otolaryngol Head Neck Surg 2017;156: 180-8.
Abiodun OA. A validity study of the hospital anxiety and depression scale in general hospital units and a community sample in Nigeria. Br J Psychiatry 1994;165: 669-72.
Dalgard OS, Bjørk S, Tambs K. Social support, negative life events and mental health. Br J Psychiatry 1995;166: 29-34.
Abiola T, Udofia O, Zakari M. Psychometric properties of the 3-item Oslo social support scale among clinical students of Bayero university Kano, Nigeria. Malays J Psychiatr 2013;22:32-41.
Abiola T, Udofia O. Psychometric assessment of the Wagnild and Young's resilience scale in Kano, Nigeria. BMC Res Notes 2011;4: 509.
Olisah VO, Baiyewu O, Sheikh TL. Adherence to highly active antiretroviral therapy in depressed patients with HIV/AIDS attending a Nigerian university teaching hospital clinic. Afr J Psychiatry (Johannesbg) 2010;13: 275-9.
Ngum PA, Fon PN, Ngu RC, Verla VS, Luma HN. Depression among HIV/AIDS patients on highly active antiretroviral therapy in the southwest regional hospitals of Cameroon: A cross-sectional study. Neurol Ther 2017;6: 103-14.
Rucklidge J, Johnstone J, Harrison R, Boggis A. Micronutrients reduce stress and anxiety in adults with attention-deficit/hyperactivity disorder following a 7.1 earthquake. Psychiatry Res 2011;189: 281-7.
Kaplan BJ, Crawford SG, Field CJ, Simpson JS. Vitamins, minerals, and mood. Psychol Bull 2007;133: 747-60.
McCann JC, Ames BN. Vitamin K, an example of triage theory: Is micronutrient inadequacy linked to diseases of aging? Am J Clin Nutr 2009;90: 889-907.
[Table 1], [Table 2], [Table 3]