Secondary Mania in HIV Dr Chioni Siwo

M.Med (Psych) 2nd year studentUniversity of Zambia

2012

GOOD MORNING

OUTLINEWhat is it Secondary Mania (in HIV)?PrevalenceCausesClinical PictureTreatment Gaps in literatureProposed study

What is it?Manic-like disorder occurring as a direct

effect of the HIV infection

No delirium

No prior history of Bipolar disorder or Major Depressive disorder.

Otherwise has DSM-IV manic-like symptoms

Prevalence

Not known globally

Not known in sub-Saharan Africa

Study by Owen Larsson et al in Australia showed a prevalence of 8% over 17 months

Most common cause of admission to psychiatric hospital in Uganda especially females

Causes• Medication e.g. Isoniazid, anti-depressants, steroids

• Direct Insult to the brain e.g. traumas, strokes, tumours

• Systemic Disorders such as Hyperthyroidism, Hyperparathyroidism

• Substance Abuse

Clinical Picture Study by Ethel Mpungu et al in Uganda in

2006, found that HIV positive patients with Mania were:

found to have more manic symptoms (YMRS)

more irritable

more aggressive and disruptive

Clinical Picture contd… more talkative and had decreased need for

sleep

had more delusions, auditory and visual hallucinations

mostly female

Treatment

Studies have reported the use of Haloperidol and Diazepam in acute phase

It was found that HIV patients with secondary mania responded in 2 weeks or less than

• Patients with Secondary mania in HIV respond faster to antipsychotic drugs than patients with Bipolar mania

Gaps in the scientific literature• Do they benefit from continued anti-manic

medication?

• Do they have a complete recovery? In particular do they function behaviourally, socially, and occupationally?

Proposed studyCase Series of 30 patients with secondary

mania HIV followed up for 6 months

Focusing on clinical, biological and psychosocial measures

Results will be analyzed for patterns in the illness and this will help with future management of patients

ObjectiveTo gain greater knowledge of the secondary

mania, its clinical and psychosocial correlates and its response to treatment.

• To improve the management of patients by using evidence based management interventions including treatment of associated physical health conditions.

Also to get a better understanding of the burden of disease resulting from this mental disorder in HIV

MethodologySITE A case series of 30 patients will selected

from Chainama Hospital (Zambia’s only psychiatric tertiary hospital) and University Teaching Hospital (HIV) clinic both in Lusaka

SETTING It will be a longitudinal study observing

progress of the cases from commencement over a period of 6 months

Methodology contd…..Selected clinical observations will be made

at 1, 3 and 6 months

Family will be included

Selection: patients will included upon meeting DSM-IV criteria A-D for manic episode

MeasuresSemi-structured Psychiatric interview of

patient

Young’s mania rating scale

AUDIT a measure of alcohol intake

MMSE

Measures contd…

Measure of behaviour in home circumstances – semi-structured interview

Semi-structured interview of informants e.g. relatives

• For female patients menstrual cycle will be included

Measures contd…Physical examination

For female patients menstrual cycle will be included

CD4

Sputum for AAFB, CXR

C-Reactive protein

FBC/ESR

Measures contd…LFT, Creatinine

RPR

Renal function

Nutritional status and BMI

MRI of brain – near first episode when any secondary mania neuropathology may be detectable

EthicsApproval will be sought from the University

of Zambia Research and Ethics Committee

Informed consent will be sought from the participants

There may be issues of confidentiality in the follow up and the involvement of the relatives when a manic patient may not be able to give informed consent

Limitations of the Study

There will be a bias in the case selected in that uncooperative patients and relatives will be excluded

No intervention will be evaluated, study will

not lead directly to improvement of patient management.

No epidemiological conclusions can be drawn

Acknowledgements

Dr Ravi Paul, HOD, Department of Psychiatry, School of Medicine, UNZA

Dr Gil Blackwood Honorary Lecturer, School of Medicine, Department of Psychiatry, UNZA

ReferencesE Nakimuli-Mpungu, S Musisi Clinical presentation of Bipolar

mania in HIV positive patients in Uganda Psychosomatics 50:4 July-august 2009

Nakimuli-Mpungu, S Musisi Early onset versus late onset HIV related secondary mania in Uganda Psychosomatics 49:530-534 2008

E Nakimuli-Mpungu, S Musisi Primary mania versus HIV related secondary mania in Uganda American Journal of Psychiatry 163:8, August 2006

Owen-Larsson HIV infection and Psychaitric illness African Journal of Psychiatry Volume 12, no.2 2009

Charles Krauthammer, MD; Gerald L. Klerman Secondary mania Arch Gen Psychiatry 35(11):1333-1339, 1978

THANK YOU!