How Do I Wrap My Head Around What's Going on in My Head — The Biopsychosocial Model Part One

Hi Guys!

If you or your loved one are struggling with symptoms of a mental illness, it’s helpful to have a way to make sense of things so that then you can figure out how best to tackle these symptoms.  That’s one of the major roles of a mental health provider — to help you make sense of what you’re experiencing and what you are struggling with.  Because if we can better understand the problem — if we can clearly determine and define the problem — then we can really roll up our sleeves and get to work solving the problem.  

So, if you’re new to me, I’m Dr. K Martin also known as Dr. K.  I’m both a child and adolescent psychiatrist and general psychiatrist based in the Southeast.  My goal for these brief posts is to provide you with quick and easy access to information about mental health.  And hopefully, I will deliver it in a way that you can understand.  Do note, however, this information is not meant to serve as a substitute for your personal mental health care.  Please talk to your provider before implementing any suggestions that I mention in these talks.  Now for today, I want to offer you a framework for understanding and treating mental illness.

It's called the biopsychosocial model.  You may be like, what in the world did you just say?  Okay—so, let me explain.

Whenever I am evaluating a new patient, I usually start by asking what they are seeking treatment for.  That’s what we call the “chief complaint.”  Let’s say a patient comes in with a “chief complaint” of persistently sad mood for the last three months.  I will start asking more questions to better determine what factors could be contributing to this sad mood and I’ll start cataloging these factors.  These factors can be broken down into at least three categories — biological factors, psychological factors, and social factors.

The first category of factors are biological.  That is what the “bio” stands for in biopsychosocial — biological.  So, now I’m looking for clues in what the patient reports to understand what biological factors could be contributing to the sad mood.

Here are some of the major biological factors that I take into account:

1. Past medical history.  I need to know whether the patient has physical illness or any other symptoms that may indicate the presence of a physical illness that has yet to be diagnosed.  This is a huge factor.  So huge that, in fact, that during our training as psychiatrists, we are taught that we must do a thorough medical evaluation before we diagnose a patient with a mental illness.  The reason is that there are so many physical illnesses that may cause symptoms of mental illness.  For example, I’ve had a patient who was experiencing auditory hallucinations of random music playing that seemed to come from nowhere.  What we later discovered is that she had severe anemia due to heavy menstrual periods.  Her anemia was so severe that she required a blood transfusion in the emergency department.  Soon after receiving the blood transfusion, the auditory hallucinations stopped.  I’ve also had a young male patient who was admitted to children’s hospital with symptoms of bipolar disorder, and we later found that he had a severe vitamin B12 deficiency.  As an infant, he required surgical removal of the part of his intestines where vitamin B12 is absorbed.  After this surgery, he needed to receive vitamin B12 injections on a regular basis.  For some, he had stopped receiving these injections and ended up with a severe deficiency that triggered symptoms of bipolar disorder.  Now in addition to these unique circumstances, there are also common physical illnesses like obesity and heart disease that are linked with depression.  The biological link may occur because both obesity and heart disease are associated with increased inflammation within the body and this inflammation may be linked to increased risk of developing depression.  I’ve also had adult patients come in with complaints of symptoms of poor concentration and attention, which might look like symptoms consistent with Attention Deficit Hyperactivity Disorder—or ADHD, but one of the major concerns was that they had sleep apnea and had not been wearing their CPAP, which could cause problems with attention and concentration.  Another very important piece of information I want to obtain from patients is hormone status as hormones can clearly and impact mental health.  As we know, the hormonal changes of puberty can affect emotions and behavior as well as hormonal changes associated with menstruation, pregnancy, and menopause.  For example, it is very common for female patients to experience a worsening depression and irritability around menstruation and worsening concentration and mood with menopause.  For men, I often see struggles with mood or sleep associated with declining testosterone levels.     So, what I am saying is that it is necessary to consider the physical health of a person.  Physical illness may make a person more vulnerable to mental illness.  If this physical illness is appropriately addressed, then the symptoms of mental illness may improve if not resolve altogether. 

2. Another biological factor that I consider when evaluating a patient is the patient’s family history — this also is a very important factor.  I need to know if depression or struggles with mood run in the family, because, if this is the case, I know that the patient may be genetically predisposed or have a genetic set up that renders them more vulnerable to depression.  Now, it’s important to lock in your brain that genes do NOT necessarily determine destiny.  Genes do NOT necessarily determine destiny.  Just because a person has a family history of depression does not mean that they are “doomed” to become depressed.  There are multiple other factors that could determine if a person actually shows symptoms of depression.  Still, it does potentially make them more likely to develop depression than if they did not have a family history of depression.

3. The third biological factor that I consider is a patient’s nutritional status and ask what kind of diet they adhere to.  As I mentioned earlier, vitamin and mineral deficiencies can trigger symptoms of mental illness.  In our example of persistently sad mood, there are several vitamin and mineral deficiencies that can trigger a negative change in mood.  For example, deficiencies in B vitamins, Vitamin D, magnesium, and zinc are associated with increased risk of depression.  

4. Another biological factor that must be considered is the patient’s medication list.  Some prescription medications can be associated with increased risk of depression or sad mood or other symptoms of mental illness.  Some of the most common medications that may cause mood changes as a side effect include isotretinoin for acne, oral contraceptives or birth control pills, steroids like prednisone or methylprednisolone or Medrol dose packs, and treatments for reflux like Prevacid or Nexium.  I’ve had a patient who had the sudden onset of symptoms of bipolar disorder that started shortly after she received a steroid injection.  This patient had never experienced symptoms like this before, but it should be noted that her family had a history of bipolar disorder that seemed to have rendered her more vulnerable to developing symptoms of bipolar disorder after the steroid injection.  I’ve also had patients undergoing testosterone therapy have struggles with anger and irritability and increased propensity toward aggressive behavior.  Also, patients with known thyroid illness must make sure to stay in touch with their endocrinologist to make sure replacement hormone levels are within target range because symptoms of mental illness may occur if their hormone levels are off.

5. Substance use history — Okay, when I say “substance” I mean alcohol, tobacco, and drug use.  It’s one of those areas that patients tend to minimize or try to avoid talking about altogether.  However, it’s so important for your mental health provider to know what substances you are using because they can often trigger or worsen symptoms of mental illness, or they can be the illness itself.  So many people out there have undiagnosed symptoms of mental illness that they have been trying to treat on their own through the use of substances, but most of the time, these substances have such detrimental effects that they do far more harm than good.  So, when I’m doing an evaluation, it’s important for patients to just tell me what they’re using.  For example, cannabis use is becoming more and more widespread — sometimes, it’s people with higher levels of stress and anxiety who use marijuana to facilitate relaxation, but in the process, they create a whole other list of problems — lack of motivation, poor concentration, and subsequent depressed mood.  Also, it’s important for a mental health provider to consider substance use history because if the treatment plan is to include medications, the combination of prescription medications and substances can have some bad outcomes — even and including death. 

6. Another biological factor that must be taken into account is how well a person sleeps.  If a person is not getting adequate and refreshing sleep, then their mental health can be negatively impacted.  People with poor sleep often have an irritable or sad mood; increased levels of anxiety and perceived stress; poor attention, concentration, and memory; and more impulsive or reckless behavior.

Okay, I realize that we’ve covered a lot of ground here, but I wanted to really help you understand and appreciate that there is a long and extensive list of biological factors that must be taken into consideration when someone is struggling with symptoms of a mental illness.  These factors include underlying physical illness; vitamin deficiencies and poor diet; a family history of mental illness; prescription medications that have side effects negatively impacting mental health; alcohol, drug, and tobacco use; and inadequate and/or unrefreshing sleep.  Each of these biological factors have the potential to predispose, trigger, perpetuate, or worsen mental illness.

Folks, let’s make it our business to understand mental illness and those who struggle against mental illness.  I’m Dr. K, and this has been Mental Health | Plain Speak.  And remember, “Be kind, for everyone you meet is fighting a hard battle.”