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| ADVOCACY/DEBATE |
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| Year : 2020 | Volume
: 2
| Issue : 2 | Page : 156-158 |
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Should the 2020s be the Psychiatric Decade of the Social? A Debate
H Steven Moffic
Private Community Psychiatrist, Milwaukee, WI, USA
| Date of Submission | 09-Apr-2020 |
| Date of Acceptance | 16-May-2020 |
| Date of Web Publication | 14-Aug-2020 |
Correspondence Address:
Dr. H Steven Moffic
1200 E. Bywater Lane, Milwaukee, WI 53217
USA
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/WSP.WSP_12_20
Although the biopsychosocial has been the primary model in medicine and psychiatry for decades, there has been increasing concern over whether it is comprehensive enough and/or whether each of the categories get enough attention. For example, the bio, standing for the biological, has received the most attention in the new millenium in most countries. However, the relative neglect of the social component may be causing significant omissions of understanding and interventions in providing mental health care for patients and the public. Most recently, that has become clear in the global coronavirus pandemic in its social spread, contagion of fear, escalation of various psychiatric problems, and disparities in receiving care. Indeed, this journal is a crucial globally social way to communicate to our colleagues and reverse this trend.
Keywords: Bio-psycho-social, decade, model of mind, psychiatry, social
How to cite this article:
Moffic H S. Should the 2020s be the Psychiatric Decade of the Social? A Debate. World Soc Psychiatry 2020;2:156-8 |
| An Internal Debate | |  |
“I am large, I contain multitudes” - Walt Whitman, from poem Leaves of Grass
Let's assume, for the moment, that I, in my intrapsychic multitudes, contain the world of social psychiatrists. At least I was trained during the early 1970s in the heyday when the biopsychosocial model emerged out of the dominant psychoanalytic model, and then, recently, in 2016, received the Administrative Psychiatry Award from the American Psychiatric Association for my leadership in various social systems of care. This conceit can thereby hopefully justify the debate to follow.
In most countries, the biopsychosocial has been the model of medicine in general and psychiary in particular.[1] Even so, various practical and theoretical forces have periodically challenged its priority. Most recently, Psychiatric Times had a set of articles discussing the controversy.[2],[3],[4] Coincidentally, a recent article in the New England Journal of Medicine caused controversy about the identity crisis of psychiatry.[5]
As business methods and the pharmacological companies have come to dominate psychiatry in the USA and other countries, this model at times has come down to the more simple bio–bio–bio.[6]
“Just see your patients for 10 min, Dr. Moffic. After all, you eat what you kill.”
In other words, to be compensated adequately, I – and perhaps you – got 10 min for your medication visits and five of those are for your electronic health record. When that was formalized at my medical school that is when I decided to retire.
On the other hand, aren't all aspects of psychiatry, including the psychological and social, mediated though biological processes in the brain? If so, maybe the simple bio model makes sense.
To complicate this matter some more, on occasion, others have actually advocated for other components to be added to the model, spirituality for one. Spirituality and religion would posit that there may be other aspects of reality, such as a God, that are separate from our brains and may influence them. No specific proof, one-way or another, is close to providing any definitive answers about this.
Now, as I have recently done, adding ecology to the model has been advocated.[7] Ecology has to do with the interaction of humans with the environment, whereas the social has to do with the relationship of humans to one another. With humans seemingly the major cause for climate instability and no clear place in the biopsychosocial model for the environment, why not expand to biopsychosocialeco or even biopsychosocialecospiritual? Perhaps that is making the model too complicated and cumbersome. So back to the bio, then, in consideration for what may be most essential psychiatrically in the 2020s.
| The Decade of the Brain | | |
Perhaps, the best evidence for not adopting a biological model of psychiatry, and thereby, a 20/20 vision for the 2020s as the Decade of the Brain, is that it has already been tried, at least in the USA. President George H. W. Bush dedicated the 1990s to the Decade of the Brain, with increased funding for the National Institute of Mental Health and the National Institutes of Health “to enhance public awareness of the benefits to be derived from brain research.”
So, what's been the result of the Decade of the Brain for psychiatry? Not much. If only. What new clinical tools do we have for our patients? Surely, there are more psychiatric me-too drugs, but not much more.[8] Is there any more convincing causative biological evidence for major psychiatric disorders in contrast to psychological findings? No. Neuroscience and genetic research have made contributions to many neurological brain disorders but not psychiatric ones. Advances have been made in the treatment of migraine, multiple sclerosis, acute stroke, and epilepsy, for instance. Nothing comparatively has advanced in psychiatry. There is hope for immunology, bio in the gut flora, or artificial intelligence, but that is yet to be manifested.
Maybe, there will eventually be a more productive decade of the brain for psychiatry, but it is nowhere in sight. Either the brain is still too complicated and protected to get to its secrets or there is something more that needs to be emphasized first.
| The 2020s as the Decade of the Social | | |
The time is right for a decade of the social. One reason is the neglect of the social. One of the many areas where this occurs is in the International Classification of Diseases Z diagnostic codes. It seems that physicians rarely document the Z-codes of some of the social determinants of health. In the United States, only about 10% of the traditional medicare claims from 2016 to 2017 had Z codes, ranging from Z 55 to 65, which includes problems related to education, employment, housing, upbringing, social support, and psychological circumstances. Is this due to lack of knowledge of these Z-codes and their importance, rather than a choice to ignore them?
We do know so many social factors that contribute to mental illness: socioeconomic factors, trauma, conflict, and the key variable of the therapeutic relationship, among the most prominent. We know that socioeconomic status and sociocultural factors are associated with health-care disparities around the world. In the United States, social factors are responsible for the new surge of “deaths of despair”-from drugs, alcohol, and suicide-among working class Caucasians who have lost their economic opportunities. Even among psychiatrists and other physicians worldwide, the despair association with our epidemic of burnout is associated with our business-oriented social systems of healthcare.[9]
Social resources are necessary for using any of the treatments we do have. Unfortunately, for the poorer in most every country, there are disparities in the availability of those resources. There are also widespread disparities based on cultural and religious backgrounds. Unfortunately, it seems that we continue to add to that list, now including Islamophobia and Anti-Semitism, as in the books that I have recently edited.[10],[11]
There are new frontiers that need the social psychiatric input. One of them is death, dying, and even after death. Death and dying, and perhaps, after death is what we all have in common, at least for now. However, we do differ in how we think about and approach death, let alone what we believe in for any after life. It is crucial for all mental health-care clinicians to ask each patient about their beliefs about death and dying. Usually, that is not a required part of the routine psychiatric evaluation.
In the USA, there is a shortage of forensic pathologists. Perhaps that reflects the American suspicion of anyone who voluntarily deals with the dead. Nevertheless, the dead tell us how we were living, how we are dying, and who has a better shot at a healthy life.
Forensic pathologists have a unique role in spotting social psychiatric problems.[12] The medical examiner's office can be the first to recognize when a new synthetic opioid hits the streets, crucial for addressing the opioid epidemic and heroin overdoses. This led to training in the use of naloxone to blunt the overdose. The medical examiner's office is also contributing to recognizing the increasing rate of suicide among black American teenagers. This specialty seems like a natural collaborative group for social psychiatrists, does it not?
There is a looming paradox in death and dying. On the one hand, led by Google, there is a quest to end death and establish immortality. On the other hand, there is a development in some countries and states for physicians to help end life earlier when there is terminal illness and/or unrelenting, severe pain, physical, and even psychological in some European countries. One social danger is that the richer will get to prolong their health and life, whereas the poor will have theirs shortened.
Then, there are the social relationships and conflicts that threaten the lives and mental health of so many. This is the social relationships in politics. If these social relationships of leaders go awry, we are all in danger. Perhaps, we need social psychiatrists as political advisers in the 2020s.
| A Decade of the Psychological | | |
You may have noticed that there is one more aspect of the biopsychosocial model that has not been considered in this debate. That is the psychological. In our treatments, that is reflected in the psychotherapies. Similar forces that have enhanced the focus on the biological have diminished a focus on the psychological. In many countries, they are taught less than they used to be. Psychiatrists drift more toward psychopharmacology. Even so, psychotherapy has become more research based, especially cognitive behavioral therapy.
Hence, the psychological also needs more emphasis. Yet, it has had its decade – even decades – of emphasis. From the theoretical and practical Freudian advances, modern psychiatry was born in the 1900s. However, some of those theories have been disproven, some of the therapeutic outcomes long in obtaining benefits, unpredictable, and then, there are also watered down versions produced by those less trained and not well accountable.
| The Debate Winner is..... | | |
Truth be told, perhaps, this debate with and within myself about what should be emphasized in psychiatry in the 2020s, with our current 20/20 vision, is a spurious and subjective contest. Doesn't psychiatry in general tend to be the least developed and most stigmatized of all medical specialties, thereby needing special focus itself first of all? Of course it does. So, maybe let's call off this debate as being premature.
But, wait. There is a last-minute tragic example to include. That is the coronavirus pandemic, which began just as the 2020s were beginning. Social relationships were suddenly and dramatically altered. Physicians on the frontlines dress like astronauts exploring outer space and because of inadequate safety resources are at increased risk for illness and death. Stay at home edicts. The economy tanks in mid-March. The rate of mental disturbance escalating led by anxiety and grief. Socially minded psychiatrists recognize the importance of all these factors and more, including that resilience needs to be enhanced as we go along.
Clearly, then, the social seems to deserve the most focus of all. Due to various cultural values around the world, social psychiatry may benefit the most by a worldwide focus, just the kind that is the raison d'etre for this publication. Medications are basically the same worldwide. Psychology is individualized, as we each are different. However, we are social creatures and the social varies around the world in terms of economics, relationships, and values. Nowhere in psychiatry is our global world more apparent than in the social and don't forget those relevant socially oriented Z-codes!
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 5. | Gardner C, Kleinman A. Medicine and the mind – The consequences of psychiatry's identity crisis. N Engl J Med 2019;381:1697-9. |
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| 8. | Kingdon H. Why hasn't neuroscience delivered for psychiatry? Br J Psychiatry Bull 2020;44:107-9. |
| 9. | LoboPrabhu S, Summers R, Moffic HS, editors. Combating Physician Burnout: A Guide for Psychiatrists. Washington (DC): American Psychiatric Association Publishing; 2020. |
| 10. | Moffic HS, Peteet J, Hankir A, Awaad R. Islamophobia and Psychiatry: Recognition, Prevention, and Treatment. Switzerland: Springer Nature; 2019. |
| 11. | Moffic HS, Peteet J, Hankir A, Seeman M. Anti-Semitism and Psychiatry: Recognition, Prevention, and Interventions. Switzerland: Springer Nature; 2020. |
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