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Clinical Pearls

Ever said something to a patient that was just right – helpful, meaningful, right on target?  And you found that you could use it again and again, in a number of situations?  Ever tried a medication or combination of medications that had surprisingly good results in a particular situation?

Welcome to Clinical Pearls -

a section of the Utah Psychiatric Association website where you and your colleagues get to share your collective wisdom.  Contribute one, take one.  They are here to enjoy and use.  Send your contributions to mikalm@me.com and be immortalized!  We will credit the pearl with your name, or you can remain anonymous.  Your choice!  
Courtesy of Dr. Susan Mirow, a diagnostic pearl for ADHD.  Those free prescription pads we’re sometimes sent – the ones that have the imprint “illegal if not safety blue background.”  Did you know that if you try to photocopy those prescriptions, the word “illegal” appears all over the copy?  Well, what Dr. Mirow discovered is that untreated ADHD patients can see that “ILLEGAL” on the original prescription AND when they’re treated successfully, they can no longer see it!  Try it.  See if it works.
Speaking of ADHD, so many kids do well on stimulants with no side effects, but what about the child who has persistent insomnia and/or appetite loss?  Two pearls here: 1) Make sure they take the medication every day, including weekends.  Side effects usually subside after two weeks if there are no drug holidays. 2) add mirtazepine 15mg at bedtime.  Not only helps them sleep, but improves appetite as well.
For those patients who think they should be able to solve everything without help – I talk to them about Tiger Woods: “Tiger Woods is the best golfer in the world.  He pays his teacher, Butch Harmon, $1,000,000 a year to follow him around the world to just watch his golf swing.  Tiger knows that good as he is, there are things about his own swing he can’t see. He hires Butch to help him see what he can’t so that he can constantly get better.”
For a patient with social anxiety disorder who finally got herself to date someone only to have it fail – She was on the verge of withdrawing into being a recluse again.  I compared her first “boyfriend” to a prize in a Cracker Jacks box, to encourage her to think of better prizes in the future.  Before I could get to the encouragement part, she interjected with a chuckle, “And it broke.”  It was her self reminder of “all that glitters is not gold.”  She was able to put the “failure” into perspective and look optimistically toward a more engaged, better future.
For patients with substance abuse problems who don’t understand why we want them to stop drugs they are abusing, yet at the same time, recommend a medication for them to take – I explain that using drugs like alcohol, cocaine and heroin are like making purchases with a credit card.  You get an immediate reward, but you also get a mounting debt.  Unlike finances, when the brain is depleted (of neurotransmitters or receptor sites) you can’t just declare bankruptcy.  You either die, or wish you were dead.  I explain that medications like the modern antidepressants and mood stabilizers are like putting money in the bank.  It takes a while to grow into something substantial, but ultimately, you get something really worthwhile.  
I had a Bipolar patient who managed to give up dependency on Alcohol and Xanax after years of struggle.  Flushed with success, he mused about the idea of giving up his Depakote and Neurontin as well.  I reminded him of our previous discussion of how these drugs worked, ending with the admonition, “It can make a lot of sense to tear up a credit card that you keep maxing out, but that doesn’t mean you should follow it up with throwing your money down the toilet.”
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