PS516 Unit 6 Mood Stabilizer Case Paper Example

Lithium and the Harvest Heat: A PS516 Unit 6 Paper on a Mood Stabilizer for a Combine Driver With Bipolar I Disorder

[Student Name]

Purdue University Global

PS516: Psychopharmacology

Unit 6 Mood Stabilizer Case Paper

[Instructor Name]

[Date]

The client, her family, the clinic and every detail of the case are composite and illustrative; the sources cited are real.

The Client

Rhonda is 45 and drives a combine for a family wheat operation in the hills east of Walla Walla. Rhonda's diagnosis came at 31, after a manic stretch in which she stopped sleeping, spent her savings on farm equipment she did not need and was hospitalized. A second episode, a severe depression with thoughts of suicide, followed two years later. She has been taking lithium for three years, prescribed by our clinic's psychiatric nurse practitioner, and has had no episodes since. Her last lithium level, in March, was within the target range.

Every July she works twelve- to fourteen-hour days during harvest, often in temperatures above 100 degrees, in a cab whose air conditioning does not always keep up. Last summer she had two days of nausea, shaky hands and diarrhea in the middle of harvest and assumed it was the heat. She mentioned it to me in passing this spring.

Why Lithium

Geddes and Miklowitz (2013) survey bipolar treatment and give lithium the strongest record of any drug for keeping episodes from returning over years, mania in particular, while naming other mood stabilizers and several antipsychotics as fallbacks. They stress that long-term treatment combines medication with psychoeducation, attention to early warning signs and family involvement.

Cipriani et al. (2013) pooled controlled trials in depression and bipolar disorder and found fewer suicides among people given lithium than among those given placebo, a protective effect the comparison drugs in those trials did not clearly show. For Rhonda, whose second episode included suicidal thinking, that finding is a strong reason to stay on lithium.

Why Lithium Needs Care

Stahl (2021) puts lithium among the drugs with a slim safety margin, since the blood level that holds episodes off is close to the level that poisons. Lithium leaves the body through the kidneys, which treat it almost as if it were salt. Sweat out enough water and salt on a hot day and the kidneys start conserving salt, and lithium gets conserved along with it, so the blood level climbs. Some common medications have the same effect, including the ibuprofen Rhonda keeps in the combine cab for her back and certain blood pressure medicines.

Early signs of lithium toxicity include nausea, vomiting, diarrhea, worsening tremor, unsteadiness and confusion. Rhonda's two days last July fit that pattern. They may have been heat illness alone, but they may also have been rising lithium levels from dehydration, and the two are hard to tell apart without a blood test.

Rhonda's harvest season is exactly the setting in which lithium's narrow margin becomes a daily risk.

What I Did

Doses are the nurse practitioner's job; mine is to spot changes and pass them along. I sent a note to our nurse practitioner in May describing last July's symptoms, Rhonda's work schedule, her use of ibuprofen for back pain during harvest, which she mentioned when I asked, and the heat in the cab. I asked whether a lithium level should be checked before harvest and whether Rhonda should have a plan for July.

The nurse practitioner saw Rhonda in June. Together they agreed on a plan: a lithium level checked before harvest and again in the second week of July, a switch from ibuprofen to acetaminophen for back pain, a cooler of water and electrolyte drinks in the cab with a goal she set for how much to drink before lunch and a clear list of symptoms that mean she should stop work and call the clinic the same day.

Counseling Supports

Geddes and Miklowitz emphasize that people with bipolar disorder do better when they recognize their own early warning signs. Harvest also carries mood risks for Rhonda: very long days and short nights can disrupt sleep, which can set off mania. In our sessions, Rhonda named her earliest signs of mania, sleeping fewer than five hours and feeling she could "run the whole farm," and her earliest signs of depression, avoiding her daughter's calls. Her husband agreed to watch for both during harvest and to call me if he noticed them.

Planning for the Rest of the Year

Harvest is not Rhonda's only risk period. Winter brings a different pattern: shorter days, less work and more time alone, which in past years has preceded her low moods. Geddes and Miklowitz (2013) describe psychoeducation and family-focused work as parts of treatment that reduce relapse when added to medication, so Rhonda and I mapped her year. July and August carry the toxicity and sleep risks described above. September brings relief and, in her history, sometimes a burst of energy that she now treats as a signal to slow down rather than to start new projects. January and February bring the risk of depression, for which we planned weekly sessions, a daily walk with her dog and a standing Sunday call with her daughter.

Lithium itself needs steady monitoring in every season. Besides blood levels, the nurse practitioner checks kidney and thyroid function at least once a year, since long-term lithium can affect both. My part is to remind Rhonda when tests are due and to tell the nurse practitioner if she starts any new medicine, including over-the-counter pain relievers or herbal products.

Ethical Points

Rhonda is entitled to know what her lithium can do to her and to have a real say in how it is managed. Explaining lithium toxicity clearly, without frightening her into stopping a drug that protects her, is part of that. Reporting her symptoms to the prescriber with her agreement, rather than only reassuring her, was part of my duty to her safety.

Limits

The trials that Cipriani and colleagues reviewed were not designed mainly to study suicide, and suicide is rare, so the finding rests on a small number of events. Rhonda's symptoms last summer cannot be attributed to lithium after the fact, and the plan is based on risk, not certainty.

Conclusion

Lithium protects Rhonda against relapse and, according to Cipriani and colleagues, against suicide, which matters given her history. Its narrow therapeutic index, explained by Stahl, means that harvest heat, sweating and ibuprofen can push levels toward toxicity. By noticing last summer's symptoms and bringing them to the prescriber, the care manager helped Rhonda go into harvest with blood tests, a different pain reliever, a hydration plan and a list of warning signs for both toxicity and mood.

References

Cipriani, A., Hawton, K., Stockton, S., & Geddes, J. R. (2013). Lithium in the prevention of suicide in mood disorders: Updated systematic review and meta-analysis. BMJ, 346, Article f3646. https://doi.org/10.1136/bmj.f3646

Geddes, J. R., & Miklowitz, D. J. (2013). Treatment of bipolar disorder. The Lancet, 381(9878), 1672-1682. https://doi.org/10.1016/S0140-6736(13)60857-0

Stahl, S. M. (2021). Stahl's essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). Cambridge University Press.