Toward A Bio-Psycho-Social-Eco Model of Psychiatry

© Korn V.@stock.adobe.com

Earth provides enough to satisfy every man’s needs, but not every man’s greed. – Mahatma Gandhi

My epiphany came a dozen or so years ago, soon after my third grandchild was born. I was sent to the corner grocery for some supplies. As I was checking out, the clerk asked: “Paper or plastic”? Usually, my answer came quickly, but not this time. I froze. Finally, I muttered “neither,” grabbed the items, and left, shaken.

Later that day, I wondered what had happened? What was the right answer? Did my professional work as a community psychiatrist have anything to do with this community interaction?

The answer to plastic or paper was easy to find out. Bring your bag was obviously the best for the environment. But the relevance of psychiatry was unclear. Other than immediately following a natural disasters, psychiatrists tend not to think about our natural environment much. Sure, I had heard a little about global warming and climate change, but we psychiatrists and organized psychiatry did not seem concerned at that time, even if human behavior was the main causative factor.

Yet, if this experience had something to do with my grandchildrens’ future, I needed to keep looking. I learned from the other mental health disciplines such as psychology, which were already trying to help. Slowly, but surely, other psychiatrists and psychiatry joined in. I founded the informal Psychiatrists for Environmental Action & Knowledge (PEAK), which later morphed into the Climate Psychiatry Alliance (CPA). We now know that the climate and many other environmental problems are indeed of psychiatric relevance.

About a generation ago, there was a call for psychiatrists and organized psychiatry to pay attention to how our ecology affected health and mental health. We even prayed for it at the American Psychiatric Association (APA) Annual Meeting in 1985 when the psychiatrist and minister E. Mansell Pattison offered a prayer to open the meeting.

This focus on ecology followed a focus on the subject by the American Psychiatric Association in the late 1970s. During that time, the APA established a Task Force to examine what we knew about the relationship of the environment to mental health and illness, using the term “ecopsychiatry.” Interest then waned and several decades passed when nothing much happened. About 10 years ago, spurred by societal attention to climate change, ecology got the attention of psychiatry once again.

A model for our times

Our traditional model for psychiatry and general medicine is the bio-psycho-social one. However, this model has had its limitations. It has not prevented psychiatry from becoming dominated by biology, as in the criticized bio-bio-bio revision of the model.¹ Nor has it included such aspects as the spiritual, which would goes beyond the psychological to beliefs of meaning that cannot be (yet) verified by science.

Occasionally, there is confusion about whether to use the term ecology or environment. Ecology is generally broader, referring to the relationships of organisms, including humans, to the environment in which we live. That is why I use the term ecology (eco), as in ecopsychiatry and the recommendation to have a bio-psycho-social-eco model of medicine.

Climate change

Climate change, or climate instability, or climate crisis-whichever term is used-has recently had the most extensive coverage because of its detrimental effects on our ecology. Like all the major ecological threats to our mental health, there is a two-way street between humans and the environment in a kind of ongoing feedback loop. Indeed, in the Torah, there were two different genesis stories that predated the development of different groups of people: one in which humans were masters of the environment for their own use, the other in which humans were shepherds of the environment.

Climate change is somewhat unique in that its major effects will be seen in the future-when our children or their children come of age. This is particularly difficult for our minds to appreciate and address, given our evolutionary tendency to pay attention to immediate dangers and problems. Nevertheless, there are already concrete repercussions (eg, stronger and more frequent storms, more droughts and wildfires).

Given our understanding of how patients recognize and respond to chronic mental illness, we should have a particular expertise in helping people respond to real or perceived threats of climate change. Such patients can deny that such problems exist and prioritize other problems first. We can help our patients understand that optimism is essential to avoid feeling helpless in the face of environmental threat.

Pollution

The environmental problem that is perhaps the most similar to climate change is air pollution. However, air pollution has different causes and brain repercussions, and it has the potential to be redressed more quickly. Despite federal clean air standards, risk continues. Air pollution has been found to be toxic to the brain. An increased prevalence of psychiatric symptoms was seen in adolescents exposed to nitrogen dioxide and nitrogen oxides released by diesel vehicles.² Prenatal and infant exposure to pesticides increases the risk of autism spectrum disorders.³ Moreover, air pollution may be responsible for brain diseases such as autism in children and dementia in older adults.⁴

Toxins. Toxic causes of mental illness are often overlooked. The consequences of the unprecedented number of substances that have been released into the atmosphere are not yet fully understood. However, the potential toxicity to the brain from heavy metals, pesticides, plasticizers, and other compounds is likely to be the underlying factor responsible for cognitive dysfunction, memory disturbance, and subtle alterations in mood and/or behavior. For example, higher than normal levels of lead have been linked to brain damage.⁵

Noise pollution. Probably the most studied urban variable on health is noise. The ear picks up the sound wave and transmits it to the temporal lobe for interpretation, and the brain determines whether that sound is unwanted, unpleasant, or disturbing. Noise can trigger a strong stress response. Loud noise has been linked to an increased prevalence depression and anxiety.⁶

Chronic noise can impair a child’s development, including the acquisition of cognition and language skills.⁷ When the noise causes hearing damage and job loss, a secondary outcome is often depressive and/or traumatic symptoms. Psychiatrists know how important it is to have sound-proof offices; however, people in general seem to have an ambivalent attitude toward noise.

Clinical implications

The health and mental health consequences of these environmental changes are becoming clearer. Given that the adverse effects of environmental change threaten our basic psychological needs of safety and security, how could that be otherwise? Moreover, once we realize our own role in these environmental changes, some guilt, conscious or unconscious, is inevitable.

All these adverse environmental effects may show up in the clinician’s office. Patients can run the gamut from being apathetic to being overreactive to environmental change. Those who are apathetic are a particular challenge and require a sensitive clinical response. The ecologically astute clinician will look for denial of risk, a focus only on immediate problems, or an attitude of passivity.

Another clinically challenging group are “environmental activists.” They may become overly frustrated with a lack of progress, leading to existential despair. This despair does not call for medication, but rather meaning-based psychotherapy that is used in other tragic situations. Treatment interventions include mindfulness and cognitive behavioral therapy to help patients accept adverse events and to stay engaged in activities that give their life meaning. At both individual and community levels, transformational resilience can be supported by the clinician. At the societal level, psychiatrists can help bridge the conflicts between conflicting points of view on climate change.

Getting out into nature can help concentration and decrease anxiety. Taking time to be in gardens is often calming and refreshing. Biophilia, that is, the love of nature and living things, seems to be part of human nature. Similarly, hortophilia, the desire to interact with and tend to nature, also seems to be ingrained in us. When outdoor exposure is particularly difficult, being able to look outside into nature or bringing nature inside with plants and flowers can be helpful. When the clinician’s office decor reflects an appreciation for nature, it can be both soothing and provide a model for the patients.

Conclusions

Taken together, the environmental factors in addition to climate change-air pollution, toxins, noise-seem to have detrimental psychological repercussions. Although the climate is receiving the most attention right now in psychiatry and society, that is only one of the harmful environmental processes impairing health and mental health. There is overlapping brain damage from environmental poisons, including agricultural pesticides that become ingrained in our food, microscopic particles of carbon and other pollutants in the air, and lead in the water.

Humans have played an essential role in these harmful developments. Virtually all the major categories of mental disorders, including ADHD, MDD, and anxiety disorders as well as psychotic conditions, seem to have an associated increase in prevalence. New syndromes are being described and named, such as ecological grief and eco-anxiety. The environment, like genetics, involves conjoined and complex networks of many interacting elements that influence mental processes that can lead to mental disorders. This exosome research is still in its infancy, but promising. Most of the environmental risks are highest among the poor, including those from climate change, dwindling social resources, and any future nuclear disasters.⁸

We can hope that we are moving beyond the time when psychiatrist leaders thought that environmental risks were irrelevant to the everyday practice of patient care. The everyday ongoing relevance of environmental changes must change our conception of disaster. Instead of focusing on acute disasters, we must pay attention to slowly developing disasters, ranging from a nuclear disaster to global warming. Indeed, by now, paying attention to our ecology is an ethical priority.

Ecology consists of the relationship of humans and the environment. At least in the US, virtually all the major ecological problems are human made by for-profit corporations, primarily by fossil fuel industries. With the international relationships between psychiatrists around the world, we have the potential to work together globally to improve the environments in which we live. The World Psychiatric Association is the logical organization to help coordinate such a challenge.

More articles in the Climate Change series, here.

Disclosures:

Dr Moffic is retired from clinical work and his tenured professorship at the Medical College of Wisconsin in 2019, but he continues to write, his latest book is Combating Physician Burnout: A Guide for Psychiatrists. He is on the editorial board of Psychiatric Times.

References:

1. Sharfstein S. Big pharma and American psychiatry: the good, the bad, and the ugly. Psychiatric News. August 19, 2005 [Epub].

2. Newbury J, Arseneault L, Beevers S, et al. Association of air pollution exposure with psychotic experiences during adolescence. JAMA Psychiatry. 2019;76:614-623.

3. Von Ehrenstein OS, Ling C, Cui X, et al. Prenatal and infant exposure to ambient pesticides and autism spectrum disorder in children: population based case-control study. Br Med J. 2019;364:1962.

4. Finch C. The Role of Global Air Pollution in Aging and Disease. London, UK: Academic Press; 2018.

5. Zagorski N. Environmental pollutants are pervasive, persistent in their damage. Psychiatric News. November 16, 2018 [Epub].

6. Beutel M, Junger C, Klein EM, et al. Noise annoyance is associated with depression and anxiety in the general population: the contribution of aircraft noise. PLoS One. 2016;11:e0155357.

7. Novotney A. Silence, please. Am Psychol Assoc Monitor. 2011;42:46.

8. Diamond J. The global peril of inequality. National Geographic. December 2018;17-20.