Electronic Letters to:
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eLetters: Electronic letters published:
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Immortal medical model
- Anand Ganesan (28 November 2007)
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Redefining the medical model: "Does it work?" is not enough
- T Everett Julyan (28 November 2007)
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Is ‘the medical model’ medical enough?
- Kate S Robertson (28 November 2007)
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Time for the 'medical model' to evolve?
- Henry P O'Connell (28 November 2007)
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The medical model is dead - long live the medical model
- Michael J Shaw, Guy Dodgson (28 November 2007)
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The importance of medical model in psychiatric clinical practice
- Om Prakash, Krishna Meena (28 November 2007)
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Medical Model for Developing Countries
- Prof.K.A.L.A. Kuruppuarachchi MD,FRCPsych(UK), Dr. Aruni Hapangama MD, Lecturer in Psychiatry, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka (21 February 2008)
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Anand Ganesan, Senior House officer - Psychiatry South West London and St Georges mental health NHS Trust
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anandg1475{at}gmail.com Anand Ganesan
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In this editorial the authors have discussed the transitions of the medical model. I would like to highlight, there is a significant difference based on the context in which the term "medical model" is used. Say for example, a medical model of psycho-education is very different from a medical model in doctor - patient relationship. A medical model in service provision or care planning is very different from it being used in the context of power. I assume the authors use the term medical model as in the case of biomedical model of approach in care planning. The authors have highlighted the contributions of the medical model. Some of the terms used like “denigration”, “paternalistic”, “inhumane” and “reductionistic” sound a bit too far fetched. The editorial starts off by quoting, people criticise and Psychiatrists apologise for the use of medical model. Born out of Biology, one should be proud of the medical model and not apologetic. I agree with the authors and go further to beleive it is our responsibility to clear the myths around the medical model. Bearing in mind that nothing is flawless, one will have to exercise caution before launching any criticism on the medical model. I do not intend to compare the medical model with any other. For that matter, do we have measures to realistically compare different models? The holistic approach will not be truly holistic if it ignores the contributions of the Medical model, be it today’s contemporary one or yesterday’s so called reductionistic one. We are all aware the medical model has departed from where it was half a century ago. Shared decision making model is the heart of today’s practice. The paternalistic - patient era had ended giving way for a consumerist - client era. This is a positive refinement and in a way reflects the adaptability of the medical model and its quest for idealistic contemporary practice. Despite the divide between biological and psychosocial psychiatry, it seems sensible to acknowledge each others’ contribution and integrate models to work towards a common goal – good service delivery (Susan et al 2007). The medical model has in the past and will continue in the future to proudly contribute to the holistic health care. Reference Susan K McGeehan, Robert Applebaum. (2007) The Evolving Role of Care Management in Integrated Models of Care. Care management journals Newyork vol.8, lss.2; pg.64, 7pgs. |
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T Everett Julyan, SpR in Psychiatry Liaison Psychiatry, Donaldson Block, Stirling Royal Infirmary, Stirling FK8 2AU, UK
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everett.julyan{at}nhs.net T Everett Julyan
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Editor The recent editorial on the medical model by Shah & Mountain (2007) was thought-provoking. As a guiding principle, their suggested refined definition is appealing in its pragmatic simplicity – “does it work?” But as a model of healthcare this is over-simplistic, as some critical issues are not taken into account. Firstly, there is no guidance as to what problems should be treated. Focussing on the utility of treatments without clearly defining what constitutes a health problem leads to a loss of boundaries. For example, benzodiazepines may “work” in reducing anxiety in offenders receiving a custodial sentence. But does this make it a medical disorder that merits intervention? Conversely, health problems for which there are no current evidence-based treatments should not be ignored, as they may well be remediable in the future. Secondly, what constitutes “working”? Cure or remission? Reduced symptoms or better functioning? Objective or subjective improvement? Thirdly, does the model apply to individuals or society? What “works” for society may not be particularly beneficial for individuals, and vice versa. Failing to delineate the above may lead to indiscriminate, inappropriate or harmful treatment. Ideally, any comprehensive model of healthcare must include clear definitions of what constitutes a problem requiring treatment, what constitutes successful intervention and who is to benefit. It is unwise to decide whether or not a particular therapy “works” in isolation from these vital concepts. The traditional medical model is predicated upon the assumption that biological dysfunction underlies the clinical presentation. It has a good track record in helping patients, informing treatment and guiding research. Rejecting it wholesale would not be helpful. However, uncritical application of the medical model to all problems in everyone is equally undesirable. Shah & Mountain rightly warn against this Descartesian extremism, emphasising the importance of psychosocial as well as biological factors (see also Vivian, 2007). Balance is required. Models are intended to help and not to hinder, to guide and not to lead. As medical doctors, trained in diagnosing and treating mental disorders, psychiatrists have a special role in helping patients. We have a duty to avoid dichotomous formulation and to treat holistically. REFERENCES Shah, P. & Mountain, D. (2007) The medical model is dead – long live the medical model. British Journal of Psychiatry, 191, 375-377. Vivian, C.T. Talk of psychosocial factors: Tell the whole story. British Medical Journal, 335, 900. AUTHOR T.E. Julyan Liaison Psychiatry, Donaldson Block, Stirling Royal Infirmary, Stirling FK8 2AU, UK. Email: everett.julyan@nhs.net |
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Kate S Robertson, staff grade psychiatrist Huntercombe Hospital- Stafford
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kate.robertson{at}doctors.org.uk Kate S Robertson
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Drs Shah and Mountain’s editorial revisiting and rejuvenating ‘the medical model’ in psychiatry was useful and comprehensive, although I would take issue with their point that it is logical that a biological explanation of mental disorder would reduce stigma. Although it would indeed be logical, this has not been borne out by recent research, as Angermeyer and Matschinger (2005) found in Germany; when more subjects endorsed biological causes for a case vignette describing schizophrenia, their desire for social distance increased rather than decreased. Shah and Mountain, in a slightly different context, suggest redefining ‘the medical model’ as a process for psychiatrists continuing to act on the best available evidence, to improve health, assumption free; laudable, but more difficult to sustain in practice than it may at first appear. But theirs is perhaps a more workable, although less beautifully succinct, definition than that offered by Poole and Higgo, citing a clinical psychologist; the medical model is ‘anything that doctors do’. Clinical experience suggests that the latter version is very useful to non - medics, and that if doctors accept managing medical anxiety, other team members can work within their areas of competence with confidence; perhaps it is only psychiatrists who find the indiscriminate use of the phrase irritating. It is arguable that, in terms of managing anxiety about physical problems, and managing the physical problems themselves, psychiatrists do not take the medical model far enough, becoming stuck at its application to mind and brain, and sometimes appearing to forget that we are also doctors. We know that the major causes of death in our patients are physical illnesses (Harris and Barraclough 1998), often under-diagnosed and poorly treated. We prescribe medication with well recognised adverse effects on physical health, monitor inconsistently, investigate erratically, fail to recognise, prevent or treat risk factors for future disease, and provide trainees in psychiatry with little in the way of training or support in general medicine (Cormac 2005, Robinson 2005). If psychiatrists could expand their own medical model to include the body, perhaps we could provide better and more holistic care to our patients, even if this were only advocating for better physical healthcare systems on their behalf. Kate Robertson Staff Grade Psychiatrist Huntercombe Hospital- Stafford Ivetsey Bank, Wheaton Aston Stafford ST19 9QT Tel. 01785 840000 Fax. 01785 842192 No Competing interests References: Premal Shah, Deborah Mountain; The medical model is dead, long live the medical model The British Journal of Psychiatry (2007), 191, 375-377 Matthias C. Angermeyer, and Herbert Matschinger; Causal beliefs and attitudes to people with schizophrenia Trend analysis based on data from two population surveys in Germany The British Journal of Psychiatry (2005) 186: 331-334 Harris and Barraclough; Excess mortality of mental disorder, British Journal of Psychiatry 1998; 173, 11-52 Poole and Higgo: Psychiatric Interviewing and Assessment, Cambridge University Press, 2006 Irene Cormac; Physical health and health risk factors in a population of long-stay psychiatric patients Psychiatric Bulletin (2005) 29: 18-20 Laura Robinson; Are psychiatrists real doctors? A survey of the medical experience and training of psychiatric trainees in the west of Scotland Psychiatric Bulletin (2005) 29: 62-64 |
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Henry P O'Connell, Senior Registrar in Psychiatry Clare Mental Health Services, Stella Maris Day Hospital, Lisdoonvarna, Co. Clare, Ireland.
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hpoconnell{at}yahoo.ie Henry P O'Connell
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Dear Editor, The wide-ranging editorial of Shah and Mountain on the ‘medical model’ in psychiatry is likely to stimulate discussion on a number of fronts (Shah and Mountain, 2007). The authors defend the use of the ‘medical model’ in psychiatry and they suggest a pragmatic redefinition of this model, focussing on the question ‘does it work?’ At least one part of the editorial requiring further discussion centres on the definition of ‘biological’ psychiatry, in the context of the ‘medical’ model. In challenging assumptions that ‘biological’ psychiatry is reductionist in nature, the authors rightly point out the broad-ranging implications of this term, incorporating pharmacotherapy and the study of brain structure and function, and its role in reducing fear, superstition and stigma, using the particularly relevant example of epilepsy. However, it should be added that a truly inclusive definition of ‘biological’ psychiatry should also be extended to include an evolutionary perspective: if evolutionary theory is a central concept within biology, then it follows that ‘biological’ psychiatry should involve an exploration of the role of evolution in shaping mental processes and behaviour, both normal and abnormal. Always on the fringes of both psychiatry and psychology, the application of evolutionary theory to the study of mental health had a brief spell in the limelight in recent years through the pages of this journal, with RT Abed’s (Abed, 2000) editorial on ‘Darwinian’ psychiatry and the ensuing flurry of letters to the correspondence pages. Essentially, evolutionary psychiatry goes beyond asking how a trait or system works, and asks why it exists in the first place. To use the example of simple phobias, an evolutionary approach would argue that, in the more dangerous and hostile environment of our ancestors, those who were avoidant of certain animals, insects or settings (e.g. open spaces) had a survival and reproductive advantage and so passed on their ‘phobic genes’ to subsequent generations. There is an ever-expanding literature on the application of evolutionary theory to both ‘normal’ mental states, cognition and behaviour, and to the most important psychiatric disorders, such as depression, anxiety disorders and even the psychoses. Interested readers are directed to the writing of the leading thinkers in this field, such as TJ Crow (Crow, 2006) and Randolph Nesse (Nesse, 2004). References Abed RT. (2000) Psychiatry and Darwinism. Time to reconsider? British Journal of Pychiatry, 177, 1-3. Crow TJ. (2006) March 27, 1827 and what happened later--the impact of psychiatry on evolutionary theory. Prog Neuropsychopharmacol Biol Psychiatry. 30(5):785-96. Nesse RM. (2004) Natural selection and the elusiveness of happiness. Philos Trans R Soc Lond B Biol Sci. 359(1449):1333-47. Shah P and Mountain D. The medical model is dead-long live the medical model. Br J Psychiatry (2007), 191, 375-377. |
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Michael J Shaw, Consultant Psychiatrist Northumberland Early Intervention Team, Northumberland Tyne and Wear NHS Trust, UK, Guy Dodgson
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Michael.Shaw{at}ntw.nhs.uk Michael J Shaw, et al.
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By attempting to re-brand the medical model as evidence based practice, Shah and Mountain (The medical model is dead – long live the medical model) miss an opportunity and thereby do a disservice to both the medical model and the prospects for bio-psychosocial integration. As the authors point out, the medical model has oft been criticised, without a viable alternative emerging (Thomas et al 1996). It can be argued that the modern medical model owes its origins to an entirely laudable attempt by the Macmillan Commission to move mental health problems and their treatment out of a model of partition, blame and stigma towards one of diagnosis and treatment: ‘There is no clear line of demarcation between mental and physical illness’ (Royal Commission 1926). The socio-political context in 1926 was one in which state intervention and social welfare were becoming increasingly accepted and the recent experience of the Great War had altered perceptions of the aetiology and vulnerability to mental illness with the recognition of “shell shock”. Seventy years on, in 1997, even after the advent of the Care Programme Approach, it did not appear that conditions were conducive to abandonment of the medical model as this required better science in terms of prevention and epidemiology combined with greater investment in community care (Shaw 1997). Now, 80 years after the Macmillan Commission, with ten years of a government that has invested an unprecedented amount in mental health care, is there at last a viable alternative offering integration rather than abandonment of the medical model? A bio-psychosocial model supplies the opportunity to combine the best aspects of a medical model, a psychological framework and a public health or epidemiological perspective. Each of these disciplines are enhanced by evidence based practice and impeded by a reliance on non evidence based theories. Unfortunately in psychiatry one of the central pillars of a medical illness model, diagnosis has a questionable evidence base. This is particularly true in the area of psychosis where the concept of schizophrenia is, it can be argued, a constellation of symptoms that pays insufficient attention to other predictors of morbidity and chronicity. Not surprisingly, therefore, it is in the treatment of psychosis that in our opinion there is much to be gained from the move towards a bio- psychosocial model, with evidence to support this. This move may provide more meaningful groupings. Formulation approaches can identify important similarities and differences between groups of people who share symptoms. For example, women who experience the voice of their childhood sexual abuser are no longer labelled psychotic and are generally treated as if the causal factor is childhood sexual abuse. The interaction between bio- psychosocial factors in categorisation and treatment may lead to the medical model struggling with a “garbage in - garbage out” problem. Within this framework it is important to understand the pros and cons of the individual components. The medical model pros: removes blame; gives a simple answer; reduces uncertainty. Cons: reduces agency; over simplifies; is subjective; creates stigmatised groups; can result in invasive interventions. Psychological model pros: increases agency; creates more treatment options creates hope or expectation for change. Cons: can imply blame; increases uncertainty; subjective; employs vague concepts. Social epidemiological approach pros: Includes family and community wide solutions; looks at change in whole populations; is atheoretical. Cons: Relies on association rather than causation; difficult to apply to individuals versus groupings; is atheoretical. Utilising evidence based practice beyond a medical model necessitates a broader framework than reliance on the double blind random controlled trial as a gold standard. This as a method favours diagnostic groupings and interventions that use those groupings, primarily pharmacological but also notably cognitive behavioural therapy. Interventions that have a different approach both to classification and identification are often poorly served by the RCT model of evidence and can therefore be devalued whereas broadening this to a symptom approach and dimensional approach might broaden the range of useful evidence that can influence practice. In our clinical practice we see the fruits of a fundamental bio- psychosocial approach. Using this approach to formulate the onset of psychosis leads to more refined treatment decisions. For example, where there is a strong family history, prioritising medication compliance and using psychological approaches to enable symptom management. Whereas, if there is a rapid onset and suspected trauma, prioritising sedation, using a psychological approach to facilitate disclosure and trauma work. A bio-psychosocial approach, where the three approaches work in tandem on conceptualisation and treatment, will lead to better outcomes, better evidence and better research. This may revive the medical model, which is at heart a research paradigm that is strongly connected with treatment. It is the domination of the medical model, not its assumptions that have led to such difficulties in psychiatry. The medical model is dead – long live the medical model P Shah and D Mountain British Journal of Psychiatry (2007), 191, 375 -377 Psychiatry and the Politics of the Underclass Philip Thomas, Marius Romme and Jacobus Hamelijnck British Journal of Psychiatry (1996), 169, 401-404 Psychiatry and the politics of the underclass (letter) M Shaw British Journal of Psychiatry, Feb 1997; 170: 191a. Royal Commission (1926) Report of the Royal Commission on Lunacy and Mental Disorders (Cmd. 2700). London: Stationery Office |
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Om Prakash, Assistant Professor of Psychiatry National Institute of Mental Health And Neurosciences(NIMHANS), Bangalore, Krishna Meena
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op{at}nimhans.kar.nic.in Om Prakash, et al.
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Shah & Mountain (2007) highlighted the importance of medical model in psychiatry in their recent editorial. The content of the article is more relevant to the current scenario when we are moving from mind apparatus (psychological approach) to brain (biological approach). This model is also more important to developing countries where it is difficult to explain psychiatric disorders with psychological theories. The medical model also helps in alleviating myths and misconceptions associated with psychiatric disorders and their management. This will also strengthen the current anti-stigma program "Open the Doors" of the World Psychiatric Association (http://www.openthedoors.com/english/01_01.html). Finally, this model helps to close the gap between psychiatry and other medical sciences and definitely advances towards a new era in psychiatry. Psychiatrists should be aware of this model and take necessary steps to incorporate it in their patient management. |
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Prof.K.A.L.A. Kuruppuarachchi MD,FRCPsych(UK), Professor of Psychiatry Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka, Dr. Aruni Hapangama MD, Lecturer in Psychiatry, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
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lalithkuruppu{at}lycos.com Prof.K.A.L.A. Kuruppuarachchi MD,FRCPsych(UK), et al.
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The editorial on “The medical model is dead – long live the medical model” by Shah P et al (2007) was read with interest and the contents of the article are very relevant to the practice of Psychiatry in developing countries like Sri Lanka. There is a considerable overlap between the psychiatric practice and medical practice in developing countries. Comorbidity seems to be common (Goldberg 1995, WHO 2003) yet often seems to be under diagnosed and mismanaged. Research supports that many mental disorders(WHO 2003) e.g. depression, anxiety and substance abuse co exist, more in people suffering from non- communicable and communicable diseases and that people suffering from chronic physical conditions have a greater probability of developing mental disorders such as depression. The medical model is being used effectively in communicating about these patients, with colleagues from other disciplines of Medicine. It has been shown that one of the least attractive aspects of psychiatry among medical students is its perceived absence of a scientific foundation(Malhi G.S. et al 2002). This can act a factor resulting in lesser number of medical students opting Psychiatry as a future career which can have a negative impact on the already resource poor countries like ours. Therefore the Medical model may be utilized to attract more medical students to do psychiatry in our part of the world. Another factor that needs to be highlighted is that, public in our part of the world tend to attribute symptoms of mental illness to supernatural powers, planetary effects, etc resulting in the mentally ill being treated by ritualistic healers or not being taken any treatment at all. The medical model can be used effectively to educate the public with regard to the nature of the symptoms and the course of psychiatric disorders as well as to reduce the stigma of having a mental illness. Another reason for medical model being more effective in a developing country like Sri Lanka, is the gross inadequacy of psychologists, social workers, occupational therapists, inadequate support from the state for the mentally ill( poor funding) etc, which results in inability to effectively practice the psychosocial approaches. Psychiatrists tend to rely heavily on pharmacological agents for management of patients. Therefore continuation of already existing medical model will be more appropriate for us until we develop other facilities such as psychotherapeutic interventions and social services etc. References Shah P, Mountain D. The medical model is dead- long live the medical model. British Journal of Psychiatry. 2007; 191: 375-377 Goldberg R.J. Psychiatry and the practice of medicine: the need to integrate psychiatry into comprehensive medical care. South Medical Journal. 1995; 88(3):260-7. Investing in MENTAL HEALTH. Department of Mental Health and Substance Dependence. World Health Organization.2003 Malhi G.S, Parker G.B, Parker K, Kirkby K.C, Boyce P, Yellowlees P, Hornabrook C, Jones K. Shrinking away from psychiatry? A survey of Australian medical students’ interest in psychiatry. Australian and New Zealand Journal of Psychiatry.2002;.36(3):416-423 |
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