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The medical model is dead – long live the medical model

  • Premal Shah (a1) and Deborah Mountain (a1)
Summary

Many people criticise, and psychiatrists apologise, for the use of the ‘medical model’. We examine what is currently meant by this term and suggest a refinement of definition to reflect the ideals and contemporary practice of medicine. We propose that psychiatrists should use the medical model to improve and validate bio-psychosocial psychiatric medicine.

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Corresponding author
Dr Premal Shah, Royal Edinburgh Hospital, Morningside Terrace, Edinburgh EH10 5HF, UK. Email: premal.shah@lpct.scot.nhs.uk
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Declaration of interest

None.

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References
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
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The medical model is dead – long live the medical model

  • Premal Shah (a1) and Deborah Mountain (a1)
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eLetters

Medical Model for Developing Countries

Prof.K.A.L.A. Kuruppuarachchi MD,FRCPsych(UK), Professor of Psychiatry
21 February 2008

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 sufferingfrom non- communicable and communicable diseases and that people sufferingfrom 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 ofthe world tend to attribute symptoms of mental illness to supernatural powers, planetary effects, etc resulting in the mentally ill being treatedby ritualistic healers or not being taken any treatment at all. The medical model can be used effectively to educate the public with regard tothe nature of the symptoms and the course of psychiatric disorders as wellas 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 SubstanceDependence. 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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Conflict of interest: None Declared

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The medical model is dead - long live the medical model

Michael J Shaw, Consultant Psychiatrist
28 November 2007

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 themedical 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 stigmatowards 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 bestaspects of a medical model, a psychological framework and a public health or epidemiological perspective. Each of these disciplines are enhanced byevidence 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 thatin 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 consof the individual components.

The medical model pros: removes blame; gives a simple answer; reducesuncertainty.

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 necessitatesa 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 assumptionsthat have led to such difficulties in psychiatry.

The medical model is dead – long live the medical modelP Shah and D Mountain British Journal of Psychiatry (2007), 191, 375 -377

Psychiatry and the Politics of the UnderclassPhilip 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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Conflict of interest: None Declared

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The importance of medical model in psychiatric clinical practice

Om Prakash, Assistant Professor of Psychiatry
28 November 2007

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 difficultto 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 alsostrengthen 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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Conflict of interest: None Declared

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Redefining the medical model: "Does it work?" is not enough

T Everett Julyan, SpR in Psychiatry
28 November 2007

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, uncriticalapplication 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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Conflict of interest: None Declared

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Is �the medical model� medical enough?

Kate S Robertson, staff grade psychiatrist
28 November 2007

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 andMountain, in a slightly different context, suggest redefining ‘the medicalmodel’ as a process for psychiatrists continuing to act on the best available evidence, to improve health, assumption free; laudable, but moredifficult 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; perhapsit 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 RobertsonStaff Grade PsychiatristHuntercombe Hospital- StaffordIvetsey Bank, Wheaton AstonStafford ST19 9QTTel. 01785 840000Fax. 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, 2006Irene 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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