Twenty Years!

Twenty Years!

With this issue, The Primary Care Companion for CNS Disorders enters its 20th year of publication. Since its first issue in 1999, PCC has been steadfast in its mission to provide information relevant to clinical practice at the interface of primary care with psychiatry and neurology. This clinical realm has seen drastic changes over these 20 years, both in practice and in the conveyance of cutting-edge professional information.

In 1999, evidence and guidelines did not support screening for major depressive disorder. Many in primary care practice reported, in good faith, that they had never or rarely ever encountered a patient with bipolar disorder. Primary care physicians routinely were ineligible for payment for visits with a psychiatric diagnostic code. All selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors were branded, and the tricyclic antidepressants remained in common use. The goal of treatment was to obtain a response. Practice mainly centered on solitary doctor-patient relationships, and contact between primary care physicians and psychiatrists was unusual—the sharing of even the most limited of clinical information was often considered a breach of patient confidentiality reinforced by completely separate record systems. Yet, Dr J. Sloan Manning eloquently captured in his inaugural editorial how some primary care clinicians were recognizing that treatment of psychiatric disease in the primary care setting leads to marked patient improvement, although not without risks. Professionally, many of us in primary care practice were limited by a lack of knowledge of psychiatry and expertise in psychiatric diagnosis and in use of medications and nonpharmacologic therapies. The field was limited by a dearth of publications responsive to this need. Our publisher, Dr John Shelton, was visionary in recognizing this gap and launched The Primary Care Companion to The Journal of Clinical Psychiatry. Only 5 years later, in 2004, the need for this quality initiative was recognized by PCC’s acceptance by the US National Library of Medicine (NLM) for inclusion in PubMed Central. The expansion to include full indexing and abstracting by NLM in PubMed/MEDLINE in late 2016 further affirmed Dr Shelton’s vision.

Over the past 20 years, primary care psychiatry has come into its own. Its scope has greatly expanded—primary care clinicians now routinely attend not only to major depressive disorder and anxiety but also to bipolar disorder, attention-deficit/hyperactivity disorder, posttraumatic stress disorder and other trauma-related disorders, eating disorders, addiction care, and even the long-term care of those with schizophrenia. This expansion has been made possible by the restructuring of clinical care from the solitary physician-patient visit to one that is team-based involving primary care advanced practice nurses, physician assistants, psychiatric social workers, psychologists, and clinical pharmacists and case managers. Patient visits have been augmented by continued contact using electronic modalities. The chasm between primary care physicians and psychiatrists is being replaced by collaborative engagement that responds to individual patient complexities and provides a rich vehicle for the bidirectional education of the primary care team and psychiatrist. The goal of treatment has evolved to include obtaining remission of symptoms and improving functioning.

The content and potential for benefit of primary care psychiatry also has expanded. The conceptual mind-body framework that historically separated psychiatry from the rest of medicine is being replaced by the realization that the brain does not recognize or abide by this split. We have advanced from recognizing that primary care clinicians can effectively treat psychiatric disease to understanding that an integrated approach of treating psychiatric and medical disease can improve the outcomes of both. To date, guidance regarding such integration has primarily focused on reducing the potential for deleterious treatment effects by psychiatric or medically oriented interventions on other conditions. However, advances in our understanding of the central nervous system provide opportunity for greater treatment synergy using a whole-person orientation. Exploration of the biological mechanisms by which alterations in the brain at the synaptic, network, and system levels lead to psychiatric symptoms as well as cardiac, endocrine, immunologic, and other vulnerabilities will most likely lead to treatments that simultaneously target an extended range of pathologies. The move by the National Institute of Mental Health to emphasize research domains rather than only symptom-based diagnostic criteria reflects this potential, as does the increasing interaction and overlap of psychiatry and neurology. At the clinical level, those of us in primary care will continue to expand our knowledge and skill so that our patients benefit. Currently, we often consider integrated treatment of psychiatric and medical disease of particular value for “treatment-resistant” patients. In the future, we may optimize initial treatment by seeking a much broader understanding of patient vulnerabilities at the early stages of their pathologies. In the future, we may seek to not only obtain full recovery but also strive to prevent the onset of first or new episodes of illness and improve the course of comorbid medical conditions as well.

In 2011, we modified the title of PCC to The Primary Care Companion for CNS Disorders in recognition of the importance of neurology and the brain sciences and their potential to benefit patients through clinical primary care practice. Changes in the organization, financing, and consequent practice of medicine from emphasizing the processes of care delivery to focusing on outcomes and improved health status of patients provide the impetus for a true integration of psychiatric and primary care practice. Physicians Postgraduate Press, Inc., and PCC will continue to provide the premier vehicle to educate medical and behavioral health professionals involved in primary care and to report new knowledge and clinical insights of relevance to them.

Our platform to provide clinicians with up-to-date information has expanded over the past 20 years, as exploration of the Physicians Postgraduate Press, Inc., website demonstrates. In addition to its 2 publications and their weekly updates, the website includes the CME Institute, Neurology Knowledge (a compendium of neurology resources), Strong Veterans (resources for those caring for veterans), curated content collections, blogs, and our publisher’s podcasts. Our PCC readership benefits from features including Rounds in the General Hospital, Psychotherapy Casebook, and Rounds From Banner Alzheimer’s Institute, which bring perspective from the inpatient setting, daily practice, and a neurologic consulting service thanks to the long-term support and wisdom of Dr Theodore A. Stern, Dr Dean Schuyler, and the staff at the Banner Alzheimer’s Institute. We also are indebted to the many contributions by authors and our reviewers, who bring their insights and judgment to you from all corners of the globe. PCC is supported by an incredible professional staff—Sallie Gatlin, our managing editor, attends to the journal with finesse and tremendous professionalism.

At the start of this milestone year, I reflect on the great potential PCC provides for improving the lives of our patients and thank all who contribute in the myriad ways.

Larry Culpepper, MD, MPH

Editor in Chief

Reviewers for The Primary Care Companion
for CNS Disorders

January 1, 2017-December 31, 2017

Published online: March 1, 2018.

Prim Care Companion CNS Disord 2018;20(1):18ed02285

To cite: Culpepper L. Twenty years! Prim Care Companion CNS Disord. 2018;20(1):18ed02285.

To share: https://doi.org/10.4088/PCC.18ed02285

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