|Year : 2020 | Volume
| Issue : 2 | Page : 219-222
Validity of the biopsychosocial model in contemporary psychiatry
Joel Philip1, Vinu Cherian2
1 Peejays @The Neurocenter, Kochi, Kerala, India
2 Department of Community Medicine, Sree Narayana Institute of Medical Sciences, Kochi, Kerala, India
|Date of Submission||22-Jun-2020|
|Date of Decision||20-Aug-2020|
|Date of Acceptance||20-Sep-2020|
|Date of Web Publication||25-Nov-2020|
Dr. Joel Philip
[email protected] Neurocenter, Ayesha Road, Vyttila, Kochi 682 019, Kerala
Source of Support: None, Conflict of Interest: None
The biopsychosocial model (BPSM) has been the foundation of psychiatric practice since it was first conceived four decades ago. However, recent advances in technology have led mental health professionals, as a fraternity, to turn to a purely biomedical model of disease, and remedy. We trace the lineage of the BPSM, examine its validity in today's scenario, and argue for the urgent need to reintegrate this model in current and future practice.
Keywords: Biopsychosocial model, current, validity
|How to cite this article:|
Philip J, Cherian V. Validity of the biopsychosocial model in contemporary psychiatry. Ann Indian Psychiatry 2020;4:219-22
| Introduction|| |
The proposition of the biopsychosocial model (BPSM) by Engel in 1977 as an alternative to the prevailing biomedical model at the time marked a sea change in the way physicians and nurses were expected to approach patients and their myriad of afflictions. Engel laid out his ideas in a landmark essay titled “The need for a new medical model: A challenge for biomedicine” in the April 1977 issue of “science;” and he was not without his critics. This commentary hopes to layout an objective appraisal of Engel's nest-egg, and its value in psychiatry nearly four decades later.
| Bio-Psycho-Social Model: A Historical Perspective|| |
Theodore Roosevelt famously said, “History is the best teacher. The more you know about the past, the better prepared you are for the future.” With this in mind, a historical narrative is perhaps a good starting point for a dissection of the BPSM.
Sound medical knowledge of today can be traced to the astute observations of clinicians examining patients by the bedside centuries ago. A firsthand account by Mikhail Bulgakov titled “A country doctors notebook” expounded the tales of a fresh medical graduate in Russia, as he navigated fortuitous medical scenarios in a small village in the former Union of Soviet Socialist Republics (USSR). This fascinating narrative emphasized the role played by social and psychological contexts prevalent in that tiny village in the presentation of various maladies in the local population. In penning his tales, the young Mikhail was also inadvertently highlighting the role of the BPSM, a concept that would not be brought into the limelight for decades. This model was valid then, by the flickering bed lamp of the sick patient, and continues to be of value today, in the pristine halls of superspecialty hospitals.
In the 13th century, Pope Innocent III permitted men of science to dissect the corpses of those who had died of serious afflictions, to determine pathology. The allusion was that while the body was simply a vessel that was useless after death, the mind was to remain firmly within the purview of religion. This sowed the first seeds of the mindbody dualism that came to characterize the biomedical model. In the centuries that followed, young doctors and nurses in training were taught to regard the body as a machine, the disease was a result of the breakdown of that machine, and the sole responsibility of the physician was to fix what was broken. In the bargain, the physician came to be seen as cold and unassuming. The realization that scientific medicine was slowly losing its humanity was one of the driving forces that led Engel to extrapolate his BPSM. Today, with an overemphasis on laboratory procedures, inappropriate utilization of diagnostic techniques, overuse of drugs, and unnecessary surgeries, we face the same perils. Perhaps the time is right for a return to the BPSM to restore a human face to the practice of medicine.
| Arguments for the Bio-Psycho-Social Model|| |
Mental health professionals often find that when they align themselves better with the prevailing socio-cultural milieu, they tend to create stronger alliances with patients who in turn begin to show more favorable progress. A better understanding of the circumstances surrounding mental illness leads one to conclude that the art of healing is more than just the correction of a neurochemical imbalance. In the words of Adolf Meyer, this is more a question of “why this person is afflicted with this illness at this time.” Purely reductionist views failed to provide a feasible explanation, and a biopsychosocial approach was perhaps the answer.
In today's world, psychiatry stands at a crossroads between evidence-based medicine and psychosocial approaches. The biomedical model was vigorously promoted as a line of defense against the anti-psychiatry movement of the 1970 s, which painted mental illness as a myth. Szasz and his followers were in favor of the removal of psychiatry as a medical discipline and its reallocation to behavioral sciences under the purview of laymen. In a quest to adjudicate psychiatry and firmly entrench its status as a medical discipline, psychiatrists focused somewhat narrowly, and excessively on the scientific method. This was a grave fallacy. The scientific principle demands that the whole be broken down into its constituent parts for the purpose of study, but this often becomes counterproductive in the study of human behavior. Perhaps there is no reason to choose one over the other. The BPSM provides an apt middle ground between puritanical neurobiology and the psychological and social factors that vastly impact mental illness.
To quote an example, multiple studies comparing the prognosis of schizophrenia in developed and developing nations have found that patient outcome tends to be better in the latter., This has been attributed to the role of the family as a support system. The importance of higher social constructs such as family and community in contributing to therapeutic intervention is recognized by the BPSM which is grounded in systems theory. Inculcating a biopsychosocial approach to the practice of medicine would hence be invaluable to improving the lives of patients.
The BPSM still has its role in today's day and age. To drive this point across one simply needs to look toward the state-of-the-art imaging techniques available today. These machines can localize the most minuscule pathologies and document subsequent improvement with pharmacotherapy. However, without a biopsychosocial approach that takes the circumstances surrounding the patient into account, a mere biochemical alternation fails to bring about a sustained improvement in the quality of life for the patient. Taking a detailed history pertaining to the patient's psychological state and social circumstances can identify roadblocks to clinical improvement in psychiatry. The biomedical approach hence may not be enough in itself in improving the patient's “happiness index.”
In contemporary psychiatry, the current scenario calls for a return to the idea of the “family physician.” This may be the need of the hour to generate trust in the medical fraternity and to ensure the well-being of the patient as a holistic entity, as a “person” and as a “whole.”
Today, with the focus on guidelines for diagnosis and management, the role of informed intuition is slowly losing value. Under the constant threat of litigation despite best interests, physicians and nurses are becoming more and more mechanical in their practice. It is, therefore, important that we draw a middle path to ensure that we do not lose the “art” of medicine.
| Arguments Against the Bio-Psycho-Social Model|| |
Ghaemi, one of the most prominent voices of critique against the BPSM, argues that the desire of the proponents of this model for eclectic freedom has sent modern medicine into a downward spiral into anarchy. He calls for a return of medicine to a “puritan science” and promulgates a scientific method that rewards the simplest answer to a question. This was perhaps reflected in the awarding of the Nobel Prize for the discovery of the role played by Helicobacter pylori in the pathogenesis of gastric ulcers; a simple cause-and-effect explanation for an age-old clinical problem. A broad disagreement with Ghaemi's standpoint is for the reason that human behavior is much more complex, and cannot be studied like laboratory animals; behavior changes during the process of the study itself. Hence, there is a need to embrace a more holistic view.
There are vested interests in the push toward a purely biomedical model. Insurance and pharmaceutical companies are ardent supporters of a grossly simplistic neurobiological perspective that peddles a one-time fix for psychiatric illness using drugs and molecules. Looking toward interventions to manage psychosocial issues fails to be as lucrative for them from a financial perspective. As mental health professionals, we are also guilty of over-reliance on the biomedical model as it spares effort in going beyond to fully understand the patient as a “human being,” an initiative that calls for more of our limited resources. In doing so we are selling ourselves short as medical practitioners and not realizing our full potential to instill change for good, in turn doing a gross injustice to the patient.
| Bio-Psycho-Social Model – A Typical Case Formulation|| |
Mr. X presents to the psychiatric outpatient department with features suggestive of a depressive episode. In seeking to understand how the patient's biological aspects contributed to the onset of the current illness, the psychiatrist takes a detailed history pertaining to his genetic predisposition, family history, physical illness, concurrent medications, presence of comorbid medical conditions, or physical disabilities that might impact his ability to tolerate distress, etc., Next, the psychological part of the BPSM is explored by asking for details about concurrent stressors or life events, coping skills, use of alcohol, or other substances of abuse to deal with stress, maladaptive defense mechanisms, etc., The role of social determinants in causing the depressive episode is also elicited by examining the patient's relationships with his family and friends, prevailing social support systems, cultural background, socioeconomic status, etc., Each of the contributing factors under the biological, psychological, and social realms of the BPSM are also categorized as predisposing, precipitating, and perpetuating factors for the current depressive episode. This helps to identify those areas that are amenable to change, not only to treat the current episode but also to prevent similar episodes in the future. Such a case formulation based on the BPSM can help the treating psychiatrist to choose a medication or psychotherapeutic technique that is best suited to the patient's biological make-up, psychological constitution, and social framework. In this manner, the three core components of the BPSM are amalgamated to better understand the patient's illness and to plan a therapeutic strategy that is tailored to the individual patient. This, in turn, can improve patient compliance, foster a strong therapeutic alliance, and facilitate a speedy recovery.
| Bio-Psycho-Social Model – What Lies Ahead?|| |
So what need steps to be taken moving forward to fix the current scenario?First and foremost, change must be implemented right at the beginning; in the hallowed halls of medical and nursing schools, and in teaching that occurs at the bedside. This is because how physicians approach patients is often imbibed not explicitly but in a tacit manner, through observing senior practitioners and in the behavior that young house officers are encouraged to follow. Adopting a BPSM of practice in the early years will ensure that it is firmly woven into the rubric of everyday practice. A physician or nurse trained in the biopsychosocial approach in medical or nursing school tends to be well versed in critical interview techniques. He learns to identify patient vulnerabilities and detect roadblocks in compliance. He constantly calibrates himself to the needs of the patient, thereby building a solid therapeutic relationship and facilitating a smooth road to recovery.
The BPSM also needs to be applied to healthcare reform occurring at higher levels of Government. National policies need to implement steps to support the poor and marginalized, as improvements in the social backgrounds and living conditions of people have been found to lead to better mental health outcomes. The World Health Organization encourages multisectoral cooperation between governments, the private sector, nongovernmental organizations, and local communities in tackling widespread poverty. This can, in turn, bridge the treatment gap and improve access to mental health services for large sections of the population. Global mental health initiatives focused on addressing the biological, sociocultural, and psychological factors affecting persons with mental health issues, in tandem, have indeed produced positive results.,
The future of the BPSM lies in personalized medicine–an approach that takes into account the individual genetic, biochemical, psychological, and social makeup to tailor highly specific treatment regimens to optimize response and maintain wellness. Unfortunately, the term “personalized medicine” has, over the years, come to take on a somewhat narrow perspective as simply the application of genetics to individualized therapies. The stress on genomics underlies the importance of social and psychological determinants of health on personalized medicine. There have been arguments that the prevailing focus on an individual's genes and biology insufficiently incorporates the important role of environmental factors in disease etiology and health, prompting calls for a more holistic view of “personalized medicine.” Such an all-encompassing approach would reap the best dividends for society in the years to come.
| Conclusion|| |
The BPSM is not without its limitations, no doubt, but there is immense scope for its utilization in contemporary psychiatry. This model was instrumental in introducing patient-centric health care in modern medicine. It meant physicians learned to formulate treatment regimens taking into consideration the patient's psychosocial attributes leading to better compliance and response to treatment. Physicians and nurses began to treat patients and not diseases, thereby reintroducing trust in the therapeutic relationship. The BPSM opened our eyes to the reality that the art of healing is more than simply a neutralization of biochemical disturbances, that relationships are central to the healing process. Most importantly, we finally began to recognize our role as healers in the holistic sense; that our penultimate aim is simply to restore happiness in the life of the patient, a noble and worthy cause indeed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Engel GL. The need for a new medical model: A challenge for biomedicine. Science 1977;196:129-36.
Bulgakov MA. In: Country Doctor's Notebook. Collins & Harvill, London,1975.
O'neill YV. Innocent III and the evolution of anatomy. Med Hist 1976;20:429-33.
Jacob K. Patient experience and psychiatric discourse. Psychiatrist 2012;36:414-17.
Jacob KS. Patient experience and the psychiatric discourse: Attempting to bridge incommensurable worlds. Indian J Psychiatry 2015;57:423-6.
] [Full text]
Szasz TS. The Myth of Mental Illness. New York: Harper Collins Publishers; 1974.
Leff J, Sartorius N, Jablensky A, Korten A, Ernberg G. The international pilot study of schizophrenia: Five-year follow-up findings. Psychol Med 1992;22:131-45.
Verghese A, John JK, Rajkumar S, Richard J, Sethi BB, Trivedi JK. Factors associated with the course and outcome of schizophrenia in India. Results of a two-year multicentre follow-up study. Br J Psychiatry 1989;154:499-503.
Ghaemi NS. The Rise and Fall of the Biopsychosocial Model: Reconciling Art and Science in Psychiatry. Baltimore: JHU Press; 2010.
Marshall B. Helicobacter pylori
-A Nobel pursuit? Can J Gastroenterol 2008;22:895-6.
Fernald LC, Hamad R, Karlan D, Ozer EJ, Zinman J. Small individual loans and mental health: A randomized controlled trial among South African adults. BMC Public Health 2008;8:409.
Flisher AJ, Lund C, Funk M, Banda M, Bhana A, Doku V, et al
. Mental health policy development and implementation in four African countries. J Health Psychol 2007;12:505-16.
Mathur S, Sutton J. Personalized medicine could transform healthcare. Biomed Rep 2017;7:3-5.
Fava GA, Sonino N. From the lesson of George Engel to current knowledge: The biopsychosocial model 40 years later. Psychother Psychosom 2017;86:257-9.
Carlsten C, Brauer M, Brinkman F, Brook J, Daley D, McNagny K, et al
. Genes, the environment and personalized medicine: We need to harness both environmental and genetic data to maximize personal and population health. EMBO Rep 2014;15:736-9.