Biopsychosocial Model in Psychiatry- Revisited.pptx

Over time our understanding of Psychiatric illnesses has undergone sea changes but yet the age old Bio-psycho-social model of etiology remains relevant. This presentation is an effort to explore the model in context of the newer developments.

1. Devashish Konar Consultant Psychiatrist Mental Health Care Centre, Kolkata Biopsychosocial Model in Psychiatry- Revisited Presidential Address IPS West Bengal 11-09-2022

2. Biopsychosocial Model in Psychiatry The model was developed by George L. Engel , a psychiatrist at the University of Rochester. He putatively discussed in an article published in 1977 in Science. He posited “the need for a new medical model” (Engel,1977). 2

3. Biopsychosocial Model Changed the Way We Conceptualize Disease & Wellness There are emerging efforts across all of medicine to integrate biological, psychological, and social factors in the exploration of the causes and outcomes of both physical an psychiatric illnesses…. These efforts are not eclectic but transdisciplinary, efforts which are leading to a much better understanding of how biological, psychological, and social factors interact through time. The proposed dynamic biopsychosocial model construes human health as a product of the reciprocal influences of biological, psychological, interpersonal. 3

4. The Biopsychosocial Model: Not Dead, But In Need Of Revival. With advancement in genetics, histopathology, biochemistry, neuroradiology and consequently precision medicine we are able to pin point the source of many of the maladies that we deal with. Coming to psychological part Positive Psychology and Person Centred Psychiatry are some of the models that suit in most clinical work and is able to satisfy the needs of the client. They are easiest to learn and apply. Covid has taught us the importance of socialisation . Due to covid phenomenon we all know how much we crave for socialisation . We have learnt about the limitations of digital media and also the problems emanating from its overuse. Environmental awareness has increased its forcefulness in our life. Respective enthusiasts will plead for their own cause but as clinician you always need the time tested and historically coveted the biopsychosocial model, which encompasses all of the above. 4

5. Precision Psychiatry While our strategies may vary, the vision of precision psychiatry is to optimize treatment for each and every patient. Toward this mission, dependable treatment selection algorithms, regardless of the indication, should not only match an individual to their best treatment option but also avoid an ineffective or potentially harmful one. Although this goal is seen by some as an impractical or, at best, naive blue-sky goal, contemporary clinical neuroscience research speaks to the ultimate achievability of this holy grail quest. If you look closely the recent contributions provide clear evidence that the goal is indeed within sight. 5

6. “We always overestimate the Change that will occur In the next two years and Underestimate the change That will occur in the next ten.” - Bill gates Jr. 6

7. Incorporation of Neurobiological Data into Clinics Just having machine or the data is not enough. You need to be able to translate them clinically towards better understanding about patient. No superiority of neurobiological data over clinical information. Rather, superiority of multimodal work up including clinic and neurobiological data. So ultimately it is not “man vs machine” but “man and machine”. 7

8. Pharmacogenetic Testing Results Patient History of Symptoms Personalized/Precision Medicine = Family History Neuroimaging Testing Results Therapeutic Blood Levels Informant History Patient History of Treatment Responses The Modern Model of Psychiatric Practice for Treatment Resistant Patients Stahl SM. CNS Spectr . 2017;22(1):1-4.

9. Genetics and Drug Metabolism PM Poor metabolizers or inhibitors of P450 may have increased drug serum levels and adverse events. IM Intermediate metabolizers or inhibitors of P450 may have increased drug serum levels and adverse events. EM Extensive metabolizers metabolize substrates normally. UM Ultra-rapid metabolizers or inducers of P450 may have reduced drug serum levels and poor efficacy.

10. How Genetic Testing May Help in Clinic Genetic testing adds to the balance of evidence when making treatment decisions Genotyping may be especially useful for patients who do not respond to or tolerate a drug as expected Caution is essential when bringing genetic testing into the selection of treatment in clinical practice

11. Genomic Study No More Something Esoteric, But At Your Doorstep! 11

12. Towards Deeper Understanding of Disease Model… A revolution is under way in psychiatry, one that integrates the scientific foundations of the discipline with recent advances in the neurosciences, data sciences, and technology in order to narrow the gap between discovery and clinical translation. This integration is motivated by the search for a model that connects a neurobiological understanding of mental disorder with clinical observation, in order to improve the precision of classification and treatment decisions. Precision psychiatry informed by neuroscience offers the opportunity to improve the precision of classification, treatment decisions, and prevention efforts. 12

13. Functional Neuroimaging gives us idea about the possible circuitry responsible for psychiatric illnesses 13

14. Doctors’ Place In Medicine Will Always be Safe & Secure !! Radiology, histopathology, bio-chemistry, genome, connectome will be studied to a great extent by machines but there will also be patients’ stories which will need to be heard by compassionate doctors. So being swayed by the enthusiasm of biological advancement don’t incur the risk of being reductionist and losing the charm of being close to the patients and their lives. 14

15. "A good physician treats the disease; a great physician treats the patient who has the disease." William Osler 15

16. The Understanding of Epigenetics Has Changed the Way We Conceptualize Biopsychosocial model 16 We used to accept genetics as a destiny. Our understanding in epigenetics give us insight into the possible changes in the genetic endowment of a person. It give us new insight into the interdependence of biopsychosocial model and how we evolve continuously.

17. New Learnings The mind gut connection: How food decides our mental wellbeing Chronic stressor and mental illness Digital wearables and Apps- Industry is investing heavily on this Increasing use of rTMS 17

18. Physical Health Conditions In Psychiatry Obesity Diabetes Hypertension Hypothyroidism Dyslipidemia Hyperprolactinemia QT interval prolongation Arrhythmia Sudden cardiac death risk Myocarditis Neutropenia Thrombocytopenia GI bleeding, bleeding in Brain Deranged LFT Deranged Kidney Function Hyponatremia Drug induced seizure NMS Serotonin Syndrome Dry eye. Glaucoma Steven Johnson Syndrome Exacerbation of Psoriasis due to Lithium 18

19. Positive Psychology Positive psychology is the scientific study of the strengths and virtues that enable individuals and communities to thrive. The field is founded on the belief that people want to lead meaningful fulfilling lives, to cultivate what is best within themselves, and to enhance their experiences of love, work, and play. Development of pathology Negative thinking pattern Maladaptive belief systems Theory of change : develop positive thinking and adaptive belief systems. 19

20. Person Centered Therapy 20 Therapy as a journey shared by two fallible people The person’s innate striving for self-actualization The personal characteristics of the therapist and the quality of the therapeutic relationship The counselor’s creation of a permissive, “growth promoting” climate People are capable of self –directed growth if involved in a therapeutic relationship

21. Three Attitudes Therapist Must Convey in Person-Centered Therapy: 21 Genuineness: open, real, honest Unconditional positive regard and acceptance: value and accept client as they are Empathic understanding

22. Life Style How much of our time do we pass with patients talking about life style? Our clients really love to know about healthy habits from us. However brief our encounter with patient may be, a part of it should be kept reserved for life style discussion. Exercise and play Food choice Addicting substances Sleep hygiene Healthy sexual practices Spiritual practices 22

23. With Post Covid Psychological Difficulties In Children We Re-learnt : “It takes a village to rear a child.” 23

24. 24 The Metaverse will reshape our lives. Let’s make sure it’s for the better. Right from entertainment to infrastructure, education and healthcare it has potential to improve many.

25. 25 The idea of the metaverse means an ever-growing share of our lives, labor, leisure, time, wealth, happiness, and relationships will be spent inside virtual worlds, rather than just aided through digital devices. It will produce new technologies, and behaviours . But that doesn’t mean we leave what we prefer, behind.

26. Post Covid ,it is enthusing to see that: “The good old universe is taking over and prevailing.” To think beyond just digital, you need to exceed Meta You need to go back to basics 26

27. Climate and Mental Health Climate change is a growing threat to mental health. Extreme weather events like wildfires and hurricanes can lead to depression, anxiety, and post-traumatic stress disorder in people of all ages, sometimes by causing displacement and food insecurity. Research indicates that higher temperatures are associated with an increased risk of suicide and mental health-related hospital admissions. Many people are also experiencing climate anxiety, or existential dread about the future of the planet. According to a study published in the Lancet in 2021, 84% of people aged 16 to 25 from 10 countries—including India —are at least moderately worried about climate change, while 59% are very or extremely worried. 27

28. The most valuable thing we can learn in life is how to care for ourselves, each other and the planet. It’s time to regenerate to connect with the world and cultivate our innate human values so that we can be well in our lives, feel valued in our communities and live in balance with our planet. Nurture relationship with wider world and nature to feel belonging to the universe and stay connected. 28 Environment at the Centre of Wellbeing

29. 29 Dr Thomas Insel , Ex Director NIMH, USA Currently in Google Life Sciences Team Interview given to The Economist, Sep 1st 2022 A sense of belonging and engagement in the community is the foundation for improving overall health and wellbeing for individuals with serious mental illness. Scalable Quality Mental Health clinical interventions, delivered by therapists, and maintained through social support

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31. To Apply The Biopsychosocial Approach i n Clinical Practice, The Clinician Should: • Recognize that relationships are central to providing health care • Elicit the patient’s history in the context of life circumstances • Decide which aspects of biological, psychological, and social domains are most important to understanding and promoting the patient’s health • Provide multidimensional treatment 31

32. Practice Is Changing And Will Change Further ,Rather Fast ! Number of Medical Colleges increasing every year. Psychiatrist being available now even in smaller places. Huge number of patients being catered by one doctor will be something of past very soon. We will have more time to pass with one patient. Quality of our work will improve with time. Our orientation will soon become person centred . We will have time to think of bio psychosocial model and having a comprehensive story of a given patient. So younger folks , please keep tuning up for the new normal. 32

33. ALL IS WELL When Mental Health is Also Well BIO PSYCHO SOCIAL 33