What's On Your Mind?

What’s On Your Mind?

As Editor in Chief, I strive for the material published in The Primary Care Companion for CNS Disorders to be responsive to our readers’ needs by making your interests inform our prioritization for the acceptance of high-quality work. Examination of the most frequently read material from 2018 highlights these interests—see the 5 most-accessed articles and letters in the Table.

The first article exposes the need for caregivers of individuals with dementia to have easy access to community resources that will help them better manage their loved one’s behavioral symptoms, in contrast to physicians’ usual reliance on medication treatments. The authors of the second article provide insight from a community physician perspective on the antecedents of suicide, including the finding that most patients who commit suicide have chronic physical illness and have recently been seen and evaluated for suicide risk. They suggest the need for a shift of risk assessment from prediction to identification of opportunities for prevention. The third most-read article clarifies the very different perspectives of family physicians and pediatricians compared to psychiatric specialists with regard to assessment and management of irritability in children, with implications for collaboration. Next, the fourth most-popular article discusses the intriguing possibility of cautiously rechallenging patients who develop skin rashes with lamotrigine, a situation that is not uncommon for both primary care and community-based psychiatrists to encounter when managing patients with treatment-resistant bipolar disorder. The final article in the top 5 reviews a multimodal intervention by a community behavioral service organization to reduce chronic sedative-hypnotic use. The intervention resulted in few short-term but substantial long-term reductions.

Quantitative studies, the mainstay of medical literature, are particularly helpful in diagnostic and treatment decisions. But the context (both of the patient and clinician) and individuality of patients are often stripped out of quantitative reports due to their focus on basic biology. A frustration in daily practice is how to tailor the resulting "evidence base" to patients in our offices. Qualitative investigations, in contrast, provide insight into human relationships and patient individuality that allows us to translate such science into effective care. The first and third most-accessed articles are such qualitative studies. They investigate concerns of clinicians working in community settings and, notably, cover childhood to old age, while the other 3 articles describe experiences with individual patients, patient populations, and clinical organizations that are very helpful for clinicians translating evidence to practice.

Our most-accessed letters provide additional perspectives on reader interests. Charles Bonnet syndrome (visual hallucinations related to impaired vision such as from macular degeneration) in older individuals and Pisa syndrome (a spinal tilt that may be chronic) potentially resulting from drug-drug interactions in patients on multiple medications, while unusual, may present to and be successfully managed by both primary care and psychiatric clinicians. Concern about retinal detachment related to intraocular pressure spikes during electroconvulsive therapy also bridges primary and psychiatric care, as does the insight from another letter that veterans may experience serious thoughts of suicide but not seek care or perceive the need for care. Finally, our second most-accessed letter reports on a woman admitted to the hospital in an acutely psychotic state a week following the 2017 presidential inauguration. During the presidential campaign, she had developed anxiety about being deported, and despite being a US citizen who had immigrated 15 years prior, was convinced she would be deported. This case brings home the potential impact of chronic societal stresses including, as the authors discuss, excessive dopamine release in the striatum leading to negative affective and psychotic symptoms.

These articles and case reports all provide vital insights that enrich our practices, especially at the intersection of primary and specialty-based care of psychiatric and central nervous system diseases. While none are randomized controlled trials—which we also publish—they do provide a nuanced understanding that enhances our ability to apply the evidence base from traditional medical and psychiatric studies.

Analysis of reader interests helps me in the final selection of manuscripts. If you are a clinician or investigator whose experience may be similarly valuable to our readers, we invite you to submit your research to PCC. Our peer reviewers, listed below and to whom we are deeply indebted, provide the varied perspectives and feedback to authors that ensure high quality in all manuscripts we accept.

Larry Culpepper, MD

Editor in Chief

Table. Top 5 Most-Accessed Articles and Letters in Rank Order From 2018

Reviewers for the
Primary Care Companion for CNS Disorders