Abstract
There is much to both agree and disagree with in De Rosa et al.’s argument for integrating biological and social psychiatry. Their central argument is that knowledge of social and biological dimensions of mental impairments should be integrated to better identify the causes as well as better manage and treat old and new mental impairments.
Furthermore, they argue that the lack of integration has been a or perhaps the dominant cause of the bad reputation of psychiatry and psychiatrists among the general public, other medical colleagues, users and carers. In turn, this bad reputation has resulted in delays in help-seeking, poor adherence to treatments and negative outcomes. De Rosa et al. also posit various dichotomies such as biological versus social psychiatry, neurobiology versus psychosocial approaches and neuroscientists versus social scientists. While there is much to question about this framing as well as other aspects of their argument, their call for more coherence in psychiatry through integrating individual biology and the social environment is a profoundly important and timely exhortation.
Recognizing and integrating the links and loops between the biological and social is a concern for psychiatry as well as for the health sciences as a whole. And the ‘integration concern’ cannot be limited just to the causal aspects. For example, social epidemiologists and increasingly economists and sociologists have been showing how social factors are part of the causal chain of disease as well as impact the overall levels of morbidity and premature mortality in a population, their distribution patterns, severity and experience, and non-health consequences of morbidity. Social epidemiologists generally accept that there are socio-psycho-biological pathways to morbidity and mortality. For example, the experience of discrimination in the social environment enters a person through psychological process and impacts biological functioning either immediately or over the long term. So, it should not be surprising that such socio-psycho-biological pathways also exist for psychological morbidity and related mortality. Importantly, within this approach, social epidemiologists acknowledge that some morbidity can have largely biological causes.
While the bifurcation of psychiatry into the biological versus social camps may be explained through historical or sociological analyses, there is still the fundamental and underlying problem of the lack of a robust explanatory paradigm for psychiatric morbidity and mortality. I would argue that it is not the lack of integration of the social and biological that is affecting the reputation of psychiatry but the coherence and productivity of the explanatory or causal paradigm in psychiatry. Epidemiology is currently undergoing a profound transformation as it searches for a more robust explanatory paradigm, and it seems prudent for psychiatrists to engage with those discussions. Central to the search for a better explanatory paradigm is the long-standing issue of how to best integrate the natural and social sciences. And finally, there is the important question of the moral purpose of psychiatry.
While De Rosa et al. understandably argue for a pragmatic approach to integration with some practical steps forward, without giving due attention to the more fundamental conceptual and ethical foundations being further developed, psychiatry will continue to fall short of its full potential to protect, mitigate, restore and improve human wellbeing.