John J. Miller, MD, on the Biopsychosocial Model in Psychiatry

John J. Miller, MD, shared more on his editorial for Psychiatric Times August 2026 issue to call for renewed clinical emphasis on the biopsychosocial model, expanded to incorporate cultural and spiritual dimensions of patient assessment.

Miller's article, titled "Resuscitating the Biopsychosocial Model in Psychiatry," traces his concern to 2013, when the fifth edition of the DSM-5 eliminated the 5-axis diagnostic system that had been in use for 33 years, replacing it with a single diagnosis.¹ Miller argued that this shift, while streamlining documentation, risks narrowing clinical attention to the labeled diagnosis at the expense of the broader context in which a patient's illness occurs.

"It really is imperative that we understand the totality of our patients, not only the diagnosis that's listed on their chart or they're presenting with, but the various psychological factors that can contribute to it," Miller said.

Beyond psychological factors, Miller pointed to the social milieu and social variables that shape a patient's presentation, along with cultural elements that influence how patients communicate and respond to treatment. He noted that although the fourth edition of the DSM added a cultural component in 1994, that content remains situated in the manual's "emerging measures and models" chapter rather than treated as a primary diagnostic consideration.²

Miller's editorial extends beyond the standard biopsychosocial-cultural framework, proposing that clinicians also weigh a patient's spiritual orientation as a fifth domain of assessment. "Because someone's spiritual perspective, be it a religion or agnosticism or atheism or science or whatever their deep-rooted belief system is that helps them make sense of the world is also going to be an important part of their understanding in how we approach treatment," Miller said. He described this spiritual domain as his own addition to the model, distinct from the biopsychosocial-cultural framework already discussed in the literature.

Taken together, Miller advocated for what he termed a biopsychosocial-cultural-spiritual model of assessment, arguing that diagnosis alone cannot capture the totality of a patient's clinical picture, and that psychological, social, cultural, and spiritual factors all warrant deliberate consideration in treatment planning.

Dr Miller is the medical director of Brain Health in Exeter, New Hampshire; editor in chief of Psychiatric Times; a voluntary consulting psychiatrist at Seacoast Mental Health Center in Exeter/Portsmouth, New Hampshire; and a consulting psychiatrist at Insight Meditation Society in Barre, Massachusetts.

References

1. Kress VE, Barrio Minton CA, Adamson NA, et al. The removal of the multiaxial system in the DSM-5: implications and practice suggestions for counselors. Prof Couns. 2014;4(3):191-201.

2. Bäärnhielm S, Rohlof H, DeMarinis V. Editorial: clinical implementation of the DSM-5 cultural formulation interview. Front Psychiatry. 2024;15:1520122.