Dr Chioni Siwo
M.Med (Psych) 2nd year student
University of Zambia
 What is it Secondary Mania (in HIV)?
 Prevalence
 Causes
 Clinical Picture
 Treatment
 Gaps in literature
 Proposed 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
 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
• Medication
e.g. Isoniazid, anti-depressants, steroids
• Direct Insult to the brain e.g. traumas, strokes,
• Systemic Disorders such as Hyperthyroidism,
• 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
mostly female
 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
Gaps in the scientific literature
• Do they benefit from continued anti-manic
• Do they have a complete recovery? In particular do
they function behaviourally, socially, and
Proposed study
 Case Series of 30 patients with secondary mania HIV
followed up for 6 months
 Focusing on clinical, biological and psychosocial
 Results will be analyzed for patterns in the illness and
this will help with future management of patients
 To gain greater knowledge of the secondary mania, its
clinical and psychosocial correlates and its response to
• 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
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
It will be a longitudinal study observing progress of
the cases from commencement over a period of 6
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
 Semi-structured Psychiatric interview of patient
 Young’s mania rating scale
 AUDIT a measure of alcohol intake
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
Measures contd…
 LFT, Creatinine
 Renal function
 Nutritional status and BMI
 MRI of brain – near first episode when any secondary
mania neuropathology may be detectable
 Approval 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
 Dr Ravi Paul, HOD, Department of Psychiatry, School
of Medicine, UNZA
 Dr Gil Blackwood Honorary Lecturer, School of
Medicine, Department of Psychiatry, UNZA
 E 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
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