Validity of biopsychosocial model of intervention in contemporary medical practice: Walking a few extra miles

Conceptualization of the Model The biopsychosocial model proposes that both health and illness are the result of the complex dynamic relationship between the biological, psychological, and social dimensions in making a medical diagnosis. Illness cannot be attributed solely to biological factors such as chemical imbalances, bacteria, viruses, or genetic predisposition, nor can it be solely linked to psychological, social, or environmental factors.[1] As a result, a wide range of diseases, including tuberculosis, schizophrenia, malignancies, and multiple sclerosis, are all caused by multiple genes and have varied causes. When the genesis of a disease is multifactorial, it warrants a multidimensional intervention to Cure the Soma and Heal the Soul. According to this model, physicians should adopt a comprehensive and compassionate approach towards treating individual illnesses and focus on treating the patient as a whole, rather than just addressing specific organs or test results. Evolution of the Model The origins of medicine are ambiguous, but all great ancient civilizations developed their own ways of treating diseases and healing the ill. The experience of diminished wellness was quickly recognized as a state that required further understanding, empathy, and remedies. Medicine developed as the art of healing, and as such attracted a huge human and economic capital to achieve its goals.[2] Before the inception of this model, Jewson had put forth three healthcare models: Bedside medicine, where illnesses were understood based on symptoms and external indications rather than biological origins; Hospital Medicine, which viewed illness as localized organ pathology; and Bio-Medical model, which posited that illnesses stemmed from intricate biochemical processes. Over time, it became clear that a patient’s well-being involves a subjective perception, which is influenced by psychological, social, and cultural determinants that cannot be ignored in the assessment of the patient’s illness. To overcome this limitation, George Engel introduced the concept of the “biopsychosocial” approach, where various psychosocial factors are considered with the biological ones in the diagnosis and management of illnesses and the assessment of outcomes.[1] Biomedical versus Biopsychosocial Model Today, in patients with a recent diagnosis of hypertension or diabetes, where biomedical interventions have been long established, lifestyle modification (a psychosocial intervention) has become the first line of management.[3] However, where we are still yet to understand the exact etiopathogenesis in various psychiatric disorders, biochemical and laboratory tests to establish the diagnosis are far from reality, and overemphasis on targeting only the biomedical model would not help achieve the desired result in the treatment of psychiatric illnesses such as schizophrenia, mood, and other neurotic disorders. It seems like “Ignoring the forest for a tree.” Role in Medical Disorders The psychological impact of various chronic medical conditions or terminal illnesses and the social consequences cannot be undermined. For instance, consider Mycobacteria tuberculosis, the bacterium responsible for TB. Scientists had identified it 40 years ago, standardized biochemical and histopathological diagnostic tests had been established, and a treatment protocol was already in place. However, there were huge social, emotional, economic, and other health-related issues pertaining to the diagnosis, treatment, recovery, and rehabilitation of the same patients. In this context, only prescribing the drugs would not have sufficed for the treatment of a disease like TB rather it mandated the development of DOTS as a part of the RNTCP (where free drugs were administered under the direct supervision of health workers). It is one of the best examples of the success of the biopsychosocial model. Relevance in Psychiatric Disorders The role of stress in precipitating or aggravating various psychiatric illnesses is stated without a doubt. The biomedical model today does not have an answer to the various psychosomatic disorders. From obsessive–compulsive disorder to dementia and from personality disorders to child and adolescent issues, psychosocial intervention has been the mainstay of therapy. With advances in scientific research, this has been time and again proved that psychosocial intervention augments the process of recovery in psychiatric disorders. Without a good psychological assessment and proper social engineering, the biomedical treatment stands incomplete.[4] Critical Appraisal There is a group who questions the relevance of the model. There has been a change in the approach to brain tumors. Magico-religious management is obsolete today. Neuroimaging techniques with high sensitivity and specificity have led the way for high-end stereotactic surgeries. Similar is the case with other medical illnesses ranging from infective disorders to endocrine and metabolic disorders. However, there is a set of medical and psychosomatic disorders where the exact biological correlate is not yet established. Hence, when there are some lacunae in the biological research to pinpoint the exact etiopathogenesis, we are trying to cover up the inadequacy with psychosocial interventions. The psychosocial interventions would not reverse the damage already caused. Hence, the critics see it as a modality the health professionals use to buy time, increase morbidity, and make the patients silently suffer the disability. They call the society of today’s physicians as intellectual hypocrites where they practice prescribing only pills, seeing 30 patients in 1 h (each patient given 2 min) and increasing the quantity rather than quality. They talk of such concepts in big forums to prove their narcissistic stance just because it sounds good. The society and the physicians have always given a step-motherly status to the paramedical staff and social workers; the critics make it a matter of laughing stock when the topic of including the nursing and social workers in the treatment is raised. It is like three wheels of an auto-rickshaw, with unequal weightage, which shall probably tumble in a while. Role of Psychosocial Intervention in Preventive Medicine Medical care involves four levels of health-care interventions. Psychosocial interventions have a role at all levels, from primordial prevention to tertiary prevention. Psycho-social interventions play a crucial role in primordial and primary interventions, including preventing and minimizing exposure to risk factors across various medical conditions. Secondary prevention, i.e., early diagnosis and intervention, is only possible with adequate information and awareness about the illness and the availability of treatment options. The backbone of tertiary level of prevention is psychosocial intervention which deals with the management of disability. Thus, diagnosis ranging from fracture to schizophrenia, leprosy to malignancy, and psychosocial interventions has played a major role in the management of morbidity, mortality, and disability. Challenges in Implementation The complexity of the model is the major limitation, with all modalities of intervention being vague in targeting the outcome, which remains undefined. The lack of a proper structured therapeutic regimen adds to the confusion. The transformation of a physician’s role from merely prescribing medication to becoming a therapist who offers both pharmacological and psychological support, while also addressing social and rehabilitation concerns, represents a significant change. This change demands significant effort on the part of the physician and necessitates a shift in perspective from the patient as well. Some critics question the feasibility of this model based on lack of time, lack of human recourses, and lack of funds allocated for mental health care. Overcoming the Bottlenecks Although most of the health professionals believe the biopsychosocial model to be ideal, the physicians today are overburdened and feel time and workforce to be the major constraints. This is the challenge for the contemporary medical fraternity not to focus on the limitations of the model, but to find ways to make it feasible. A senior psychiatrist had beautifully conceptualized that psychosocial interventions are like the mother figure and biological intervention is like the father figure. For adequate nurturing of a child, both should complement each other. Steps Taken so Far The Government of India has very well thought in this line. The development of the National Rural Health Mission in the last two decades and the creation of subcenters, PHCs, and CHCs with workforce development consisting of Anganwadi workers, ASHA, and multi-purpose health-care workers are a step in this direction. The concept of developing the Centre of Excellence as a part of the District Mental Health Program and National Mental Health Program, to produce more workforces by training clinical psychologists, psychiatry social workers, and psychiatry nurses, will bridge this gap further. Hence, medical care can be made comprehensive and accessible even at the doorstep for those who cannot reach the nodal centers.[5] Satisfaction The doctor who practices this model of intervention can not only give the cure to his/her patients but also communicate the message that there is some professional body who will also stand by the patient and his family and care for them. It can be confidently affirmed that a bio-psychosocial approach can ensure both definitive cure and enduring care. We can feel the joy when the patient recovers from the illness and the family heals from the psychological trauma, and there is optimum reintegration. Future Directions We can envision a future in which scientific research advances to a stage where a patient with chronic major depressive disorder visiting a Mental Health facility is diagnosed by the psychiatrist with precision, identifying the specific molecule and receptors responsible for their symptoms. A genetically tailored target molecule will then be selected to reverse the biological state, while the clinical psychologist addresses cognitive distortions and implements specific interventions, and the social worker manages the various social and vocational issues. This will enable a re-integration into society free of stigma and disability. The same level of comprehensive care will be provided for patients with polytrauma, drug-resistant TB, or stage II malignancy. The Important Question What do we choose – to take a back step thinking of the limitations and difficulties of this model of intervention or walk a few extra miles for holistic intervention and compete recovery? The choice lies with us, the health-care professionals. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.