The points made by Dr G. Scott Waterman in his article, "Does the Biopsychosocial Model Help or Hinder Our Efforts to Understand and Teach Psychiatry?" (Psychiatric Times, December 2006) are right on target. Unfortunately, the biopsychosocial model of psychiatry is not merely conceptual; it is woven into the delivery of care at every level. Institutions of government, insurance, and hospital and outpatient services separate "behavioral" medicine from all other medicine and further separate substance abuse disorders from those deemed "psychiatric."
Emergency department doctors commonly regard any kind of cognitive or behavioral dysfunction as "nonmedical" and turn over decision making to barely trained mental health workers who are often simply not interested in the medical significance of differences, let's say, between hallucinations caused by alcohol withdrawal and those caused by a discontinuation of antipsychotic medication of a patient with schizophrenia or by a brain lesion.
State and county governments oversee and provide for treatment of psychiatric and substance abuse disorders separately from medical care and from each other. This applies not only to the hopelessly fractionated delivery of day-to-day service but to the bizarre legal tangle relating to the treatment of patients not able to make rational decisions about their own care. In the name of freedom, we restrict involuntary treatment only to those cases in which the patient represents an imminent threat to himself or herself or others, and even then we make exceptions for cases in which the threat is caused by substance abuse.
In other words, if you are suicidal with schizophrenia, you can be held involuntarily. If you are suicidal with alcoholism, you are out of luck. If you are merely killing yourself with neglect because "the voices tell you" to lie on subway vents and stare at the moon, you don't even come into the concern of the law.
Insurers welcome the medical-behavioral dichotomy because it allows them to shave treatment costs. They are able to bundle behavioral services separately from others in a way that gives the appearance of cost cutting. Implicit in the structuring of these services is the idea that behavioral illness is not really illness, or worse, that behavioral illness is essentially a life choice of the patient.
Psychiatry is as responsible for this dichotomy as are other institutions. As psychoanalytic domination of the field was waning, biological understanding of mental illness was expanding exponentially. The last few decades could have been a time in which the distinction between psychiatric and medical (or "real") illness faded into history.
Instead, along came DSM, a classification system only a committee could love. It not only reified the distinction between medical and psychiatric illness but separated psychiatric illness into 2 "axes" that defy any consistent rational definition.
Fortunately, 2 forces are poised to converge on this mess and cause an implosion that will resolve the dichotomy. The first is economics. It is likely that Congress will soon mandate equity for mental health coverage. This will have an impact that will ripple through the health insurance industry and create changes in the delivery of care at every level.
The second is the simple progression of science. The meeting of the DSM committee is reminiscent of those of the high priests in the Middle Ages who debated the relevance of bodily humors and divine forces in various medical conditions. The 5 axes, numerous qualifiers, and hundreds of diagnoses now listed will give way to diagnoses with etiologies, markers, and definitions as specific or general as type 1 or 2 diabetes or idiopathic hypertension.
How is schizophrenia different from type 1 diabetes? Each is a chronic condition that is inherited and has a lifetime progression that can be improved with medication. How is alcoholism different from type 2 diabetes? Each is caused by a combination of inherited, behavioral, and environmental factors that can be modified with medication and environmental management. How is anxiety different from hypertension? Each is clearly an identifiable entity that may be either idiopathic or symptomatic of another condition. Why should any of these conditions not be part of the same axis?
If I understand Dr Waterman's use of the "holobiological" model, it means that good medical assessment and treatment is based on the recognition that the biological condition occurs within a context that includes heredity, social and psychological history, and physical environmental forces. Good psychiatric assessment and treatment is no more or less than its "medical" counterpart. The holobiological model, then, is an improvement and unification forming from 2 perspectives toward a common goal.
William S. Greenfield, MD
Dr Greenfield is medical director of the Lenape Crisis Center at Lower Bucks Hospital and serves on the alumni board of Temple University School of Medicine in Philadelphia.