Social versus biological psychiatry: It’s time for integration!

Background

Psychiatry and its clinical practice are an amalgam of biological, psychological and social causative factors along with sociological, anthropological and philosophical underpinnings. In the past, the scientific debate has been too reductionist, as psychiatry is usually reduced in two different and divergent components: biological versus social psychiatry (Stier, Schoene-Seifert, Rüther, & Muders, 2014). For many decades, the neurobiological and psychosocial approaches to psychiatry have coexisted without a real integration (Arango & Fraguas, 2016; Kendler, 2016). According to neuroscientists, the brain was considered a biological machine (Searle, 2004), while for social scientists mental disorders are independent from brain processes (Maj, 2014). This dichotomy has been reinforced over the years by the different drives in action in our field, and it has contributed to promote a bad image of psychiatry among the general public, medical colleagues and also among users and carers (Katschnig, 2010; Lopez-Ibor & Lopez-Ibor, 2013). The bad image of the discipline and of psychiatrists has had detrimental effects on patients’ care, with a vicious cycle represented by delays in help-seeking, poor adherence to treatments and negative outcomes from mental disorders (Bhugra et al., 2015).

The need to counterbalance this overwhelming pessimism towards psychiatry has been strongly advocated by scientific associations and by the categories of users and carers (Fiorillo, Malik, et al., 2013).

In this debate, the relevance of integration of knowledge in psychiatry will be highlighted, the historical attempts to subdivide psychiatry into different approaches will be provided and recent attempts to integrate different approaches for mental health care will be described.

The relevance of integration of knowledge in psychiatry

Mental health is a complex phenomenon that can be approached from many angles, and recently we have witnessed an explosion of interest for interdisciplinary research in the field of mental health (Diez Roux, 2007).

Several models have been proposed for integrating biological and social aspects. These models have considered social factors as antecedents to biological processes (i.e. the biological consequences of social disadvantage accumulate over time), as modifiers of genetic effects (i.e. the gene-environment effect, Uher & Zwicker, 2017) or as an integral part of biological systems (i.e. biological and social aspects are intrinsically related as demonstrated in animal studies in which the social context changes the neuronal response to serotonin, Diez Roux, 2007). However, how social factors should be integrated with biological ones is still debated and no clear answers can be provided at the current level of knowledge.

Establishing the superiority of a model over another is not an easy task, considering that mental disorders are complex disorders reflecting the complex interplay between a complex organ, which is the brain, and an even more complex function that is that of human relationships (Maj, 2016). Thus, a balanced approach to mental disorders and to psychiatry as a whole seems absolutely needed.

The problem of separation is not unique for psychiatry or for medical disciplines; for example, anthropology has been characterised for decades by internal divisions, with physical or biological anthropology on one side and social and cultural anthropology on the other side. Recently, Ingold and Palsson stated that this fragmentation was unfortunate, weakened the discipline and diminished its voice (Havelka, Lucanin, & Lucanin, 2009; Ingold & Palsson, 2013)

A historical perspective on separation of knowledge in psychiatry

For many years, the biological and the social approaches have hypothesised and proposed different and, in some cases, antithetic causes and treatments of mental disorders. In the 19th century, the dementia paralytica was found to be caused by an organic pathology of the brain and the eradication of neurosyphilis gave a clear demonstration of the value of the biological approach in psychiatry. Consequently, almost all other mental disorders were considered to be degenerative conditions – mainly due to organic causes – that could only be prevented or treated by biological therapies. In the 1950s, the biological approach became the major pillar of psychiatry, following the discovery of the efficacy of pharmacological agents, such as chlorpromazine, iproniazide and imipramine to treat mental disorders.

The progresses in psychopharmacology largely contributed to a first shift in psychiatric care, which moved from the asylums to the community. Social and family relationships were studied as possible causes of mental disorders representing the focus of many psychological and psychosocial therapies in association with pharmacological treatments: this was the development of the bio-psycho-social approach to mental disorders (Kernberg, 2016; Walter, 2013).

For the subsequent 20 or so years, following the enthusiasm raised by the discovery of pharmacological agents, many psychothropic drugs were developed and marketed with the ‘illusion’ of being the ‘magic pill’ for the treatment of this or that mental disorder (Walter, 2013). Recently, the ‘bio-bio-bio model’ of mental disorders, with a ‘pill and appointment’ paradigm for the treatment of mental disorders, has been proposed to replace the biopsychosocial approach (Sharfstein, 2005). This paradigm has been reinforced by the first findings coming from neuroimaging research Weinberger, Wagner, Wyatt, 1983. In fact, in the late 1970s, Johnstone, Crow, Frith, Husband and Kreel (1976) described an association between the cerebral ventricular size and cognitive impairment in patients with chronic schizophrenia. Since then, a variety of techniques, including electroencephalography, magnetic resonance imaging and positron emission tomography, have been used. However, until now, these studies have failed to identify the presence of a brain damage or soft signs that are unequivocally present in a given mental disorder (Bachmann, Degen, Geider, & Schröder, 2014; Borgwardt & Schmidt, 2016; McGuire & Dazzan, 2017).

This bio-bio-bio approach has been criticised as it appeared to be too reductionist, since the complex social interplay in which human beings are all immersed is not considered (Brown & Harris, 2008). In fact, in the last 10  years evidence has accumulated on the role of social factors in the development of mental disorders and their impact on brain functioning. In particular, studies have drown the attention on migration (Butler, Warfa, Khatib, & Bhui, 2015), poverty (Rapp et al., 2015; Selten, van Os, & Cantor-Graae, 2016), war exposure (Vostanis, 2016), traumas (Morgan & Gayer-Anderson, 2016), belonging to minority ethnic groups (Gevonden et al., 2016), social deprivation (Chan et al., 2015) and economic recession (Economou, Angelopoulos, Peppou, Souliotis, & Stefanis, 2016; Frasquilho et al., 2016).

Moreover, social factors have also an impact on the clinical presentation of some new psychiatric disorders (Ventriglio & Bhugra, 2015). For example, the spread and misuse of new technologies have ‘created’ new forms of mental disorders, such as hikikomori, Internet gaming disorder or cyberbullying, for which psychiatrists are not well prepared (Starcevic & Aboujaoude, 2015). Social psychiatry has provided a framework for understanding the individual within a wider context and has considerably enhanced understanding of many facets of mental disorders and how culture can shape the manifestation of mental disorders (Morgan & Bhugra, 2010). Moreover, the contribution of social psychiatry has been crucial in developing and implementing complex psychosocial interventions. For this reason, Priebe, Burns and Craig (2013) recently affirmed that ‘all psychiatry is social’, with a call for action for all mental health professionals and psychiatrists to take care of their responsibilities towards society.

However, paradigms that conceptualise mental disorders only as responses to ‘adverse environmental situations’ or to ‘problematic interpersonal relationships’ also seem to be too simplistic. Although social psychiatry provides a framework for understanding the impact of social contexts on mental disorders (Cicchetti & Doyle, 2016; Priebe et al., 2013), it must be acknowledged that social psychiatry cannot stand isolated from the rest of psychiatry. The perspective of social psychiatry should be integrated with findings coming from genetic, biological and neuroimaging studies, if we really want to understand the complexity of mental disorders.

Social neuroscience as an example of integration between social and biological approaches

Kendler, Zachar, & Craver, 2011; Kendler 2016 recently pointed out the importance to integrate social and biological models of mental disorders. A good example of this need is given by the study of social cognition in patients with schizophrenia and schizophrenia spectrum disorders (Adolphs, 1999) that consists in patients’ difficulties in social interactions, empathy and recognition of facial expressions. Deficits in social cognition significantly contribute to the poor functional outcomes of patients with schizophrenia (Burns, 2006; Fett et al., 2011; Galderisi et al., 2014; Gallagher & Varga, 2015). The neural pathways of deficits in social cognition have been recently identified in the first studies of a branch of psychiatry that we now call ‘social neuroscience’. According to Cacioppo et al. (2014), social neuroscience is a ‘conceptual perspective focused on the specific delineation of the neural, hormonal, cellular, molecular and genetic mechanisms underlying social structures and processes’, and it endorses an interdisciplinary approach to identify the link between deficits in social cognition and brain functioning. Social neuroscience includes components derived from social psychology, anthropology, neuroeconomics, cognitive neuroscience, classical neuropsychology, endocrinology, immunology and animal models and uses neurobiological techniques to assess bio-signals in patients with mental disorders (Fett, Shergill, & Krabbendam, 2015).

Since its initial developments, social neuroscience has progressed as a really integrated approach, significantly contributing to understand the relationship between modifications in genetic regulation and complex cognitive functions (O’Donovan, 2015; Reichenberg et al., 2009). In fact, recently social neuroscience has contributed to describe the interaction between early social stressors and gene regulation, which is responsible of long-lasting changes in behaviours, cognition, mood and neuroendocrine responses (Cacioppo, Grippo, London, Goossens, & Cacioppo, 2015; Schneider et al., 2016).

The approach proposed by social neuroscience has clear implications for psychiatrists and other mental health professionals (Bolwig, 2015; Rose, 2016). From a research viewpoint, social neuroscience can be considered the ‘ideal basic science for psychiatry’ (Maj, 2014; Rose, 2016), since it represents one of the most relevant attempts to overcome the ancient dualism in mental health and fits with the integrative nature of psychiatry as a clinical discipline. As Craddock (2014) recently pointed out, it is time to put an end to the destructive ‘social’ versus ‘biological’ dualism in psychiatry, and the approach proposed by social neuroscience can give a possible answer.

Social neuroscience – bringing together social, cognitive, affective and functional neuroimaging sciences – may have a significant role both from a research and a clinical viewpoint. In fact, this approach holds promises for shed light on the underlying mechanisms of many psychiatric symptoms, through the early detection of neural systems implicated in affect and cognition. However, although the approach carried forward by social neuroscientists is promising, it is still in its infancy and findings have to be confirmed in future studies.

Future perspectives

A further example of the integration of knowledge for explaining mental disorders is represented by the recent initiative carried out by the US National Institute of Mental Health. The Research Domain Criteria (RDoC) project aims to ‘develop, for research purposes, new ways of classifying mental disorders based on dimensions of observable behaviors and neurobiological measures’ (Cuthbert et al., 2014). The RDoC reflects a wide conceptual framework that considers mental disorders as the result of individual (e.g. the biological and psychological ones) and contextual (e.g. social) factors. To this aim, five functional domains have been identified on the basis of a consensus between experts, each consisting of behavioural dimensions that have been at least preliminarily related to a particular brain circuit or area (Maj, 2016). The RDoC attempts to develop a new classification system for mental disorders, based on observable behaviours and neurobiological measures, thus translating neuroimaging and neuroscience findings into psychiatric clinical practice.

The ROAMER (Roadmap for Mental Health Research in Europe) Consortium represents another successful example of integration of competencies of researchers and clinicians with different backgrounds, including clinical psychiatry, public health, neuroscience, social psychiatry and clinical psychology.

The ROAMER Consortium has produced a comprehensive roadmap for research in mental health in the coming years, taking into account all aspects of mental health, including the views of the categories of users and carers, and those of other stakeholders involved in mental health (Evans-Lacko et al., 2014; Fiorillo, Luciano, et al., 2013; Forsman et al., 2015; Haro et al., 2014). Priorities for research in psychiatry have been proposed by this Consortium and include prevention and early recognition of mental disorders, assessment of causal mechanisms of mental health symptoms, stigma and discrimination, implementation of new interventions using new scientific and technological advances, development of health-systems and social-systems research that addresses quality of care (Wykes et al., 2015).

Conclusion

The debate between biological and social psychiatry has been reinvigorated by a series of contradictory studies that have highlighted the importance of both biological and social factors. We believe that the time for separating has gone, and that the integration of knowledge represents the richness of psychiatry, not a weakness (Ghaemi, 2006). Our own history has told us that separation drives have been useless and self-defeating for patients, carers and professionals.

As pointed out by Kendler (2005), there is the need for psychiatry to move away from a pre-scientific ‘battle of paradigms’ towards a more mature approach that embraces complexity along with empirically rigorous and pluralistic explanatory models of mental disorders (Ventriglio & Bhugra, 2015). Only a real integration of the different perspectives of psychiatry will allow clinicians and researchers to get a comprehensive view of the patients and of their disorders, avoiding unnecessary and dangerous biological, psychological and social reductionisms.

There is the need to counterbalance the separation of knowledge in psychiatry and possible suggestions for a real integration could be the following: