Evidence for the biopsychosocial model of suicide: a review of whole person modeling studies using machine learning

Background

Traditional approaches to modeling suicide-related thoughts and behaviors focus on few data types from often-siloed disciplines. While psychosocial aspects of risk for these phenotypes are frequently studied, there is a lack of research assessing their impact in the context of biological factors, which are important in determining an individual's fulsome risk profile. To directly test this biopsychosocial model of suicide and identify the relative importance of predictive measures when considered together, a transdisciplinary, multivariate approach is needed. Here, we systematically review the emerging literature on large-scale studies using machine learning to integrate measures of psychological, social, and biological factors simultaneously in the study of suicide.

Methods

We conducted a systematic review of studies that used machine learning to model suicide-related outcomes in human populations including at least one predictor from each of biological, psychological, and sociological data domains. Electronic databases MEDLINE, EMBASE, PsychINFO, PubMed, and Web of Science were searched for reports published between August 2013 and August 30, 2023. We evaluated populations studied, features emerging most consistently as risk or resilience factors, methods used, and strength of evidence for or against the biopsychosocial model of suicide.

Results

Out of 518 full-text articles screened, we identified a total of 20 studies meeting our inclusion criteria, including eight studies conducted in general population samples and 12 in clinical populations. Common important features identified included depressive and anxious symptoms, comorbid psychiatric disorders, social behaviors, lifestyle factors such as exercise, alcohol intake, smoking exposure, and marital and vocational status, and biological factors such as hypothalamic-pituitary-thyroid axis activity markers, sleep-related measures, and selected genetic markers. A minority of studies conducted iterative modeling testing each data type for contribution to model performance, instead of reporting basic measures of relative feature importance.

Conclusion

Studies combining biopsychosocial measures to predict suicide-related phenotypes are beginning to proliferate. This literature provides some early empirical evidence for the biopsychosocial model of suicide, though it is marred by harmonization challenges. For future studies, more specific definitions of suicide-related outcomes, inclusion of a greater breadth of biological data, and more diversity in study populations will be needed.

The Craft of Generalism clinical skills and attitudes for whole person care

RATIONALE, AIMS AND OBJECTIVES

Generalists manage a broad range of biomedical and biographical knowledge as part of each clinical encounter, often in multiple encounters over time. The sophistication of this broad integrative work is often misunderstood by those schooled in reductionist or constructivist approaches to evidence. There is a need to describe the practical and philosophically robust ways that understanding about the whole person is formed. In this paper we describe first principles of generalist approaches to knowledge formation in clinical practice. We name the Craft of Generalism.

METHODS

The newly described methodology of Transdisciplinary Generalism is examined by skilled generalist clinicians and translated into skills and attitudes useful for everyday generalist person-centred practice and research.

RESULTS

The Craft of Generalism defines the required scope, process, priorities, and knowledge management skills of all generalists seeking to care for the whole person. These principles are Whole Person Scope, Relational Process, Healing Orientation, and Integrative Wisdom. These skills and attitudes are required for whole person care. If any element of these first principles is left out, the resultant knowledge is incomplete and philosophically incoherent.

CONCLUSIONS

Naming the Craft of Generalism defines the generalist gaze and protects generalism from the colonization of a narrowed medical gaze that excludes all but reductionist evidence or constructivist experience. Defining the Craft of Generalism enables clear teaching of the sophisticated skills and attitudes of the generalist clinician. These philosophically robust principles encourage and defend the use of generalist approaches to knowledge in settings across the community - including health policy, education, and research.

The Transition to Parenthood in Obstetrics: Enhancing Prenatal Care for Two Generation Impact

Obstetrics, the specialty overseeing infant and parent health before birth, could be expanded to address the inter-related areas of parents' prenatal impact on children's brain development and their own psychosocial needs during a time of immense change and neuroplasticity. Obstetrics is primed for the shift that is happening in pediatrics, which is moving from its traditional focus on physical health to a coordinated, whole child, two or multi-generation approach. Pediatric care now includes developmental screening, parenting education, parent coaching, access to developmental specialists, brain-building caregiving skills, linkages to community resources, and tiered interventions with psychologists. Drawing on decades of Developmental Origins of Health and Disease research highlighting the prenatal beginnings of future health and new studies on the transition to parenthood describing adult development from pregnancy to early postpartum, we propose that, similar to pediatrics, the integration of education and intervention strategies into the prenatal care ecosystem should be tested for its potential to improve child cognitive and social-emotional development and parental mental health. Pediatric care programs can serve as models of change for the systematic development, testing and, incorporation of new content into prenatal care as universal, first-tier treatment as well as evidenced-based, triaged interventions according to level of need. To promote optimal beginnings for the whole family, we propose an augmented prenatal care ecosystem that aligns with, and could build on, current major efforts to enhance perinatal care individualization through consideration of medical, social, and structural determinants of health.

Collegiate Student-Athletes' Perceptions of Patient-Centered Care Delivered by Athletic Trainers

CONTEXT

The health care core competencies indicate that all medical professionals should provide patient-centered care (PCC), which is defined as care that is respectful and responsive to the patient's values and preferences, during each encounter.

OBJECTIVE

To identify collegiate student-athletes' definitions of PCC and measure their perceived level of PCC from an athletic trainer (AT).

DESIGN

Cross-sectional study.

SETTING

Mixed-methods survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 610 (age = 19 ± 1 year) National Collegiate Athletic Association student-athletes completed the survey.

MAIN OUTCOME MEASURE(S)

The survey consisted of 1 open-ended question that prompted the participant to define PCC in his or her own words. The quantitative data were gathered using the Global Perceptions of Athletic Trainer PCC tool, which explores the overall agreement with the AT's use of PCC constructs. Finally, those participants who had received care from an AT completed the validated Patient Perception of Patient-Centeredness instrument. Qualitative analysis was completed through Text IQ technology with a mean sentiment score attributed to each of the coded statements. We calculated descriptive statistics for all quantitative data.

RESULTS

The qualitative analysis revealed 13 topics, with the most used being individual, priority, and best. Other topics were inconsistent with how the medical community has defined PCC. On the Global Perceptions of Athletic Trainer PCC tool, the participants expressed strong agreement (mode = 4) with 12 of the 15 statements. On the Patient Perception of Patient-Centeredness instrument, participants expressed that the AT was completely (mode = 4) patient centered for all dimensions during their most recent encounter. However, PCC behaviors, as defined by the medical community, may not be directly expressed according to collegiate student-athletes.

CONCLUSIONS

Student-athletes defined PCC as individualized and prioritized health care. They perceived that ATs provided care that kept their best interest in mind and practiced PCC during their encounters.

Nondual Awareness and the Whole Person

Integrative Health aims to treat the whole person and to do so within the context of whole systems and practices. We raise questions as to what constitutes the whole person and what must be taken into account to support the creation of optimal well-being. We propose that in order to fully account for the whole person, the transcendent aspects of human awareness, the development of which is the goal of many meditative traditions, must be taken into account. “Nondual awareness” is a term increasingly used in the literature to describe a state of awareness that is characterized by the experience of nonseparation, compassion, and love. Well-being in this state does not depend on anything being experienced per se, but it is rather an innate attribute of living in nonduality. For these reasons, nondual awareness can be considered foundational to the realization of the whole person and achieving the state of optimal well-being.

Disablement Model and Health-Related Quality of Life Classification for Patient-Reported Outcomes Measurement Information System (PROMIS) Instruments

CONTEXT

The National Institutes of Health created a medical research road map that included the development of the Patient-Reported Outcomes Measurement Information System (PROMIS). A key feature of PROMIS was the development of patient-reported outcome measures (PROs) addressing various aspects of health. Understanding disablement dimensions and health-related quality-of-life (HRQOL) domains captured through PROMIS measures will help with instrument selection.

OBJECTIVE

To evaluate the pediatric PROMIS PROs and determine the areas of disablement and HRQOL captured within each instrument.

DESIGN

Descriptive laboratory study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

Twenty-two pediatric PROMIS instruments (19 short forms and 3 profiles).

MAIN OUTCOME MEASURE(S)

Three raters independently reviewed the PROMIS instruments and categorized each question on each instrument according to the World Health Organization's International Classification of Functioning, Disability, and Health disablement model domains (body functions and structures, activity, participation, environmental factors, personal factors) and HRQOL (psychological, physical, social, spiritual, economic) dimensions. A consensus process determined the final question category. The frequencies of disablement model domains and HRQOL dimensions captured by questions on PROMIS instruments were reported.

RESULTS

The most frequently reported disablement model domain was body function and structure, which was captured by questions in 16/22 (73%) pediatric PROMIS instruments, followed by activity (13/22 [59%] pediatric PROMIS instruments) and participation (9/22 [41%] pediatric PROMIS instruments). The most frequently captured HRQOL dimensions were physical and psychological health, both evaluated in 13/22 (59%) of the pediatric PROMIS instruments. The social dimension of HRQOL was assessed in 9/22 (41%) of the pediatric PROMIS instruments.

CONCLUSIONS

Pediatric PROMIS fixed-length instruments captured a variety of disablement domains and health dimensions, but, like most PRO instruments, no single PROMIS instrument captured them all. Clinicians and researchers must consider their goals when selecting PRO instruments, which may require implementing multiple instruments and those beyond PROMIS.

Effects of a Group Protocol on Physical Activity and Associated Changes in Mood and Health Locus of Control in Adults with Parkinson Disease and Reduced Mobility

BACKGROUND

Parkinson disease (PD) is a degenerative nervous disorder that affects motor functioning. Although physical activity is beneficial, it often is reduced, and psychosocial issues persist such as low mood and perceptions of loss of control over health.

OBJECTIVE

To determine the extent to which a community-based physical activity/self-regulatory skills intervention affects overall physical activity and changes in psychosocial factors in adults with PD and in adults with reduced mobility without PD.

METHODS

Existing participants (N = 45, mean age = 71 years) of community-based PD group movement classes, who also participated in an individualized 6-session protocol for exercise support that emphasized self-regulation through barriers, completed validated self-report surveys. Participants' mean length of movement class participation was 11.8 months at the time of survey administration.

RESULTS

Mixed-model repeated-measures analysis of variance indicated significant improvements in physical activity, self-regulation, exercise self-efficacy, negative mood, and task social cohesion but not internal health locus of control. Improvement in social cohesion was significantly greater in the PD group (n = 27) than in the non-PD (n = 18) group. Changes in exercise self-efficacy mediated a significant relationship between changes in self-regulation and physical activity. Changes in social cohesion mediated a significant relationship between changes in physical activity and mood. Changes in mood and social cohesion had a reciprocal, mutually reinforcing relationship. For the PD group, length of program involvement predicted vigor change (r = 0.52, p = 0.006).

CONCLUSION

The intervention demonstrated positive effects on physical activity and psychosocial factors in adults with PD and with reduced mobility. Effects on social cohesion were important. Such programming should be considered as an adjunct to traditional medical treatment.

Reference Values for the Pediatric Quality of Life Inventory and the Multidimensional Fatigue Scale in Adolescent Athletes by Sport and Sex

BACKGROUND

Effective use of patient-rated outcome measures to facilitate optimal patient care requires an understanding of the reference values of these measures within the population of interest. Little is known about reference values for commonly used patient-rated outcome measures in adolescent athletes.

PURPOSE

To determine reference values for the Pediatric Quality of Life Inventory (PedsQL) and the Multidimensional Fatigue Scale (MFS) in adolescent athletes by sport and sex.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A convenience sample of interscholastic adolescent athletes from 9 sports was used. Participants completed the PedsQL and MFS during one testing session at the start of their sport season. Data were stratified by sport and sex. Dependent variables included the total PedsQL score and the 5 PedsQL subscale scores: physical functioning, psychosocial functioning, emotional functioning, social functioning, and school functioning. Dependent variables for the MFS included 3 subscale scores: general functioning, sleep functioning, and cognitive functioning. Summary statistics were reported for total and subscale scores by sport and sex.

RESULTS

Among 3574 males and 1329 female adolescent athletes, the PedsQL scores (100 possible points) generally indicated high levels of health regardless of sport played. Mean PedsQL total and subscales scores ranged from 82.6 to 95.7 for males and 83.9 to 95.2 for females. Mean MFS subscale scores (100 possible points) ranged from 74.2 to 90.9 for males and 72.8 to 87.4 for females.

CONCLUSION

Healthy male and female adolescent athletes reported relatively high levels of health on the PedsQL subscales and total scores regardless of sport; no mean scores were lower than 82.6 points for males or 83.9 points for females. On the MFS, males and females tended to report low effect of general and cognitive fatigue regardless of sport; mean scores were higher than 83.5 points for males and 83.8 points for females. Clinically, athletes who score below the reference values for their sport have poorer health status than average adolescent athletes participating in that sport. Scores below reference values may warrant consideration of early intervention or treatment.

Expanding the Palliative Care Domains to Meet the Needs of a Community-Based Supportive Care Model

Background:

Whole person care is appropriate for seriously ill persons. The current framework of palliative care domains in the National Consensus Project (NCP) Guidelines for Quality Palliative Care offers an opportunity to reassess the domains of care delivered at home, earlier in the course of illness.

Objective:

This qualitative study was used to test the applicability of a proposed, expanded set of domains. The results were used to inform a home-based, upstream model of supportive care for serious illness.

Methods:

Quotes relating to the experience of late-life serious illness were derived from transcripts of 12 semi-structured group interviews conducted with patients, family, and professionals. Quotes originally coded to the NCP domains of palliative care were then coded to the proposed domain set, which included new categories of family/caregiver, legal/financial, and legacy/bereavement domains.

Results:

A total of 489 quotes were assigned to the proposed expanded set of domains. One hundred one (19%) coded to the family/caregiver domain, 28 (5%) to the legacy/bereavement domain, and 27 (5%) to the legal/financial domain. Ninety-seven (87%) of the 111 quotes coded to family/caregiver had been initially coded to the NCP social aspects of care. Family/caregiver themes included challenges, rewards, insights, and family growth.

Conclusion:

The preponderance of family-related issues suggests that including the family domain may promote recognition and support of family caregivers and the services they provide. Although this study provides some support for including the legacy/bereavement and legal/financial domains, additional research is needed to determine whether there is a basis for including them in the domain structure.

How to Create a Successful Lifestyle Medicine Practice

A lifestyle medicine (LM) practice aims to treat the whole person, with a focus on addressing the root lifestyle causes of disease. Creating a practice in LM comes with an array of challenges. Utilizing different payment systems and practice models, such as cash, traditional insurance, Direct Primary Care model, or concierge systems, allows for the incorporation of more LM services and ensures sustainability in the practice. One must develop a sound business model and aim to keep costs low. Optimizing coding, taking advantage of additional LM services, and expanding service formats to group visits or telemedicine are all creative ways to incorporate and develop LM practices. Anticipation of new challenges and flexibility in practice models and payment systems allows one to be successful in starting or transitioning to an LM practice.

The problem with science-the context and process of care: an excerpt from remodelling medicine

The goal of science is truth through knowledge. But medicine's truth is not altogether the same as science's truth.Science works with ideas, imagination and intuition, but essentially has to do with facts. Medicine has also to deal with meaning.This is not an argument for less science in medicine, but for more and better science; better in the sense of better attuned to 'the rest of life'.Truthfulness is a core principle of medical practice and medical science.But a kind of untruthfulness is common in day-to-day clinical practice.The fundamental untruth is the illusion of certainty.The inexcusable untruth is to reduce the patient's problem to it to its narrow biomedical parameters and to allow the patient as a person to vanish from our gaze.Science fails medicine by the narrowness of the scope of things it is willing to investigate. Important areas of medicine have been neglected as a consequence.The medical research culture must change if it is to promote science for understanding alongside science for manipulation. We need to be unsparingly critical of the distinction between useful science and wasteful science."Medical knowledge is not knowledge acquired primarily for its own sake (but) for a specific purpose-the care of the sick."(1.)