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Table of Contents
PERSPECTIVE/VIEWPOINT
Year : 2021  |  Volume : 3  |  Issue : 3  |  Page : 137-140

The Need for a Paradigm Shift to Person-Centered Medicine during Pandemic Times


1 Department of Psychiatry, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala, India
2 Camden and Islington NHS Foundation Trust, London, UK

Date of Submission29-Oct-2021
Date of Decision15-Nov-2021
Date of Acceptance15-Nov-2021
Date of Web Publication23-Dec-2021

Correspondence Address:
Prof. Roy Abraham Kallivayalil
Professor and Head, Department of Psychiatry, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/wsp.wsp_55_21

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  Abstract 


Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has completely changed how the world looks at medicine. Unfortunately, the larger focus has been on the physical health only – epidemiology, clinical features, prevention of transmission, and management and there is very little focus on mental health and stigmatization. The 2019 coronavirus disease (COVID-19) has caused universal psychosocial impact by causing emotional disturbances, economic burden, and financial losses on a massive scale. Effects such as posttraumatic stress disorder, depression, anxiety, obsessive–compulsive symptoms, and insomnia in the post infection period have been reported among COVID-19 survivors. With disease progression, clinical symptoms become severe and infected patients may develop psychological problems. With exponential growth in the number of daily COVID-19 cases since March, 2021, India reported more than 400,000 new cases daily on May 1, 2021. India's COVID-19 surge could have become a regional disaster impacting all of south Asia. However, India has successfully avoided that disaster by strengthening the surveillance systems, imposing travel restrictions, lockdowns, and mandatory travel quarantine for individuals returning from infected areas. These were necessary to control the spread of SARS-CoV-2. The situation in India required urgent, bold measures and close cooperation between India and the global community. Currently, free vaccinations for the whole population are being given. With 1.4 billion people, this is going to be a massive effort. The pandemic and the aftermath need a paradigm shift from our traditional medical care models to one that is person centered. A person-centered model of care will be best solution here and all across the world. This is especially so, when we are fighting a disastrous pandemic.

Keywords: Global mental health, person-centered care, social psychiatry


How to cite this article:
Kallivayalil RA, Enara A. The Need for a Paradigm Shift to Person-Centered Medicine during Pandemic Times. World Soc Psychiatry 2021;3:137-40

How to cite this URL:
Kallivayalil RA, Enara A. The Need for a Paradigm Shift to Person-Centered Medicine during Pandemic Times. World Soc Psychiatry [serial online] 2021 [cited 2022 Jan 23];3:137-40. Available from: https://www.worldsocpsychiatry.org/text.asp?2021/3/3/137/333421




  Introduction Top


“Listen to your patient, he is telling you the diagnosis”

-William Osler

2019 coronavirus disease (COVID-19) pandemic has resulted in extreme devastation to societies around the world. The disease and disability resulting from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection led to more than 4.7 million deaths worldwide by the end of September 2021,[1] he focus currently is on the physical health consequences of infection, the ongoing need to control surges across the world and vaccinations drives. Much has been written about the mental health consequences of COVID-19, especially in the high-income countries (HICs). The pandemic, in addition to the physical and mental health impact, has also exposed the growing health and social inequalities that are particularly relevant in the low- and middle-income countries (LAMIC) where 83% of the global population lives. It has also raised questions about the growing social divide and the need for a pandemic-related paradigm shift for not only the practice of psychiatry but also for the practice of medicine.

This paper will explore the need for this paradigm shift and the relevance of person-centered medicine in tackling the larger impact of this pandemic.


  Psychological and Social Impact of 2019 Corona Virus Disease Top


Large scale calamities, be it traumatic, environmental, or natural are most often accompanied by increase in depression, posttraumatic stress disorder, substance use disorder, other mental and behavioral problems, domestic violence, and child abuse.[2] The COVID-19 pandemic is likely to cause substantial increase in anxiety and depression, substance use, loneliness, and domestic violence, and with schools closed, there is a very real possibility of an epidemic of child abuse.[3] There are documented reports of increase in symptoms of mental distress which is also a possible reflection of normal response of the populations to this unprecedented event. It is all the more important to recognize the acute stress reactions to prevent the development of clinically significant mental health problems. In LAMICs, there is also an added element of the hard to control pandemic due to huge population, the uncertainties and socioeconomic impact, the effectiveness of existing containment strategies, and the impact of hard lockdowns. Some of the policy decisions have had unprecedented effects on the economic and social sectors in LAMICs where the vast population relies on daily wage labor and the threats to this lead to public resistance and often violence.[4] The pandemic has also resulted in an increased risk of development of psychological distress in vulnerable groups such as prisoners, migrants, patients in psychiatric hospitals or social care homes, people with disabilities, or women experiencing domestic violence or abuse. This may be a representation of the preexisting failures in human rights protection which have worsened currently as a consequence of the pandemic.[4]

The COVID-19 pandemic is also expected to have negative impacts on economic and other social determinants of health in the long term, if not tackled with adequate support urgently. This would have a definite impact on mental health problems that are not restricted to only common mental illnesses, which are already a major contributor to the global burden of diseases. Tackling economic stress, job insecurity and unemployment, social isolation, decreased access to community support, barriers to mental health treatment, and exacerbated physical health problems, especially among older adults will also be crucial in the long run. The impact of prolonged school and university closures on children, adolescents, and young adults globally also remains unexplored.

Inequalities in COVID-19 infection and mortality rates are arising as a result of a combination of COVID-19, inequalities in chronic diseases, and the social determinants of health. The preexisting socially patterned factors associated with social determinants of health in noncommunicable and chronic diseases increase the intensity of COVID-19 pandemic. Minority ethnic groups, people living in areas of socioeconomic deprivation, and those in poverty and other marginalized groups generally have a greater number of coexisting noncommunicable diseases, which tend to have a younger age of onset and more severity. Minority ethnic groups in Europe, the USA, and other HICs experience higher rates of the key COVID-19 risk factors including coronary heart disease and diabetes.[5] Threats of the pandemic toward mental health can be observed by systemic social inequities across demographic (e.g., age, ethnicity, caste, religion, and gender), economic (e.g., income, assets, and unemployment), neighborhood (e.g., housing structure or overcrowding), and sociocultural (e.g., social support, social capital, and education) characteristics.[6] In high-income settings, low educational levels and indices of economic and social disadvantage, such as poor or overcrowded housing and homelessness, unemployment, social isolation, and loneliness, are important risk factors for contracting SARS-CoV-2. Since poverty and socioeconomic inequalities are prominent in LAMICs along with the poor coverage of adequately resourced health care, it is plausible to expect mental health problems in large sections of communities across these countries.[4]

It is important to add in additional safety nets for particularly vulnerable groups of the society including older age groups, women, children, and health-care workers and also to take into account the protected characteristics of race, religion, and social class. This further augments the need for approaches in medical care that are person centered in the long run.


  Global Mental Health – What did the Pandemic Teach Us? Top


Global mental health movement can play a pivotal role in responding to the challenges posed by the COVID-19 pandemic. The pandemic has disrupted many commonly held notions about the organization of societies and civic relationships involving both the governments and its citizens. COVID-19 also challenges the prevailing notions of expertise and solidarity. The global health model relies heavily on the assistance provided by the HICs including the US and the UK. The pandemic has exposed gaps in responses and strategies of the HICs and is often described as “sclerotic and delayed at best.”[7] A recent report by Global Health 50/50 showed that 85% of global organizations working in health have headquarters in Europe and North America; two-thirds are headquartered in Switzerland, the UK, and the USA.[8] More than 80% of global health leaders are nationals of HICs, and half are nationals of the UK and the USA.

The COVID-19 pandemic has shown that the public health responses to the pandemic were not directly dependent on the income status of the countries. There are definitely lessons that can be learned from some LAMICs in Asia and Africa where the pandemic was managed much better than some of the HICs.[9],[10] The pandemic has exposed the lie that expertise is concentrated in, or at least best channeled by, legacy powers and historically rich states.[7]

There is a need for a paradigm shift in the way global mental health functions. This has to change from seeing LAMICs as data collection sites or test beds to a view which promotes equitability and mutually beneficial partnership with the HICs. Insights from LAMICs will be vital for promoting mental health during the COVID-19 pandemic.[4] There is already a change in envisioning of global mental health owing to the substantial research generated from the LAMICs which are locally developed.[11] Addressing the bias that research generated from LAMICs is of low quality in terms of strength and evidence requires HIC researchers, funders, and journal editors to embrace a position of humility, alongside challenging enduring colonial attitudes built into the education of LAMIC professionals.[12] The transfer of knowledge has to be bidirectional and meeting the challenges posed by the COVID-19 pandemic would require this fundamental shift in global mental health.


  Person Cantered Medicine – The need for a Paradigm Shift Top


The historical roots of person-centered medicine may be traced to the personalized and holistic notions of health in the earliest Eastern and Western civilizations including the Andean ones, in which personal health was conceived as a harmonious balance among the internal, social, and ecological worlds.[13] Ayurveda, the ancient system of medicine in India, was also very much person centered emphasizing on healthy lifestyle, health promotion, and personalized treatment. The focus of social psychiatry over the years has broadened to promote greater understanding of the interactions between individuals and their physical and human environment (including their society and culture), and the impact of these interactions on the clinical expression, treatment of mental and behavioral problems, and disorders and their prevention. The definition of person-centered medicine and the ethos of social psychiatry have in them the potential answers needed in a post COVID era. This would also require a paradigm shift in the way we practice medicine and especially psychiatry to ways that consider the person and the context, in which the illness arise over biological reductionism.

There are multiple reasons why this paradigm shift is going to be challenging despite the relevance it holds, especially in the current era. The growing influence of pharmaceutical industry and the main stream research in biological psychiatry which is funded by pharmaceutical companies continues to impede the progression of person-centered models of care. There continues to be an overreliance on drugs, which are considered quick and easy, despite having evidence for psychosocial interventions which are effective. The traditional models of care and biological reductionism fail to acknowledge the relevance and importance of social determinants of health. This is particularly relevant in the post-COVID era where the pandemic has exposed the growing inequalities and relevance of social determinants of health. The overemphasis on disease and cure has led to neglect of the preventive and promotive aspects of health which is a vital part of person-centered practice. Therefore, there are number of challenges in implementing person-centered care owing to the availability of resources and corporatization of medical care. This all the more makes a case for investments in approaches that are sustainable and oriented to a person as a whole than treatment of the symptoms alone.

Systematic consideration of psychological and social factors requires the application of relevant social sciences, just as consideration of biological factors requires the application of relevant natural sciences. Both the natural and social sciences are “basic” to medical practice. In other words, psychological and social factors are not merely epiphenomena: they can be understood in scientific ways at their own levels as well as in regard to their biological correlates. Psychiatry is well equipped and can lead the way to this paradigm shift in practice of medicine.


  Conclusion Top


Over the last few months, COVID-19 has resulted in unending grief, social isolation the over, and also exposed structural and social inequalities in systems around the world. It also gives an opportunity to reflect and rebuild for the better. In the years ahead, there is a fundamental need for conversations and investment to shift toward person-centered care. This shift should be based on locally sourced and culturally accepted models of care and treatment which are often ignored. The challenge ahead is vast, but there is a definite opportunity to rebuild better in the years to come.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Kallivayalil RA, Enara A. Utilization of Primary Health-Care Infrastructure in Tackling COVID-19. Indian J Soc Psychiatry 2020;36:Suppl S1:89-90. Available from: https://www.indjsp.org/article.asp?issn=0971-9962;year=2020;volume=36;issue=5;spage=89;epage=90;aulast=Kallivayalil#ref2. [Last accessed on 2021 Sep 24].  Back to cited text no. 10
    
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Mezzich JE, Kallivayalil RA, Bennegadi R, Botbol M, Christodoulou G, Cozman D, et al. Articulating social psychiatry and person-centered medicine: Conceptual bases and international implications for COVID-19. World Soc Psychiatry 2020;2:58.  Back to cited text no. 13
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