Enhancing a Biopsychosocial Approach

Part of the Evidence in Action series by Palmer College of Chiropractic

The concept of caring for the whole patient is not new. As early as the 5th century BC, Hippocrates described the importance of attending to the person behind the disease rather than the disease itself.1 Socrates also explained that one should not attempt to cure the body without the mind, as the two are inextricable.2

During much of the 20th century, the biomedical model, which focuses on tissue or system-level disease, dominated western health care aided by provider specialization.3 However, as Hippocrates described, psychological, social and physical elements variously combine and contribute to a person’s health.4-6 Assessing and addressing all three components (i.e., biological, psychological and social conditions) contributing to health is called a biopsychosocial approach.6 For clinicians whose practice is biomedically oriented, moving toward a biopsychosocial approach means increasing psychological and social awareness to inform relevant clinical activities. This leads to the question: What resources identify activities that address psychological and social conditions contributing to health?

A Resource

An article authored by Thomas and colleagues7 contains recommendations pertinent to a wide range of health care professionals promoting psychological and social awareness as a way to implement a biopsychosocial approach. The authors suggest a need for providers to take action because:

  • Mental conditions are a leading cause of work loss
  • One-third of those with a long-term health condition also experience a mental health problem
  • Some psychological and social factors impede clinical outcomes
  • The impact of mental illness can be potentially devastating, leading to self-harm or loss of life

Recommendations to bolster psychological and social aspects of clinical care include:

Knowing the Warning Signs of Psychological Conditions

Patients with anxiety and/or depression might:

  • frequently request sick notes
  • complain of fatigue
  • report back pain
  • report frequent headaches
  • report or exhibit mood changes
  • be experiencing stressful life transitions

Talking with patients about home, work and relational stressors can help identify patients in need of in-office treatment or other management.

Implement Screening

Use screening tools to detect the psychological and mental health conditions that can be associated with present or future pain. Several screening tools are available. We recommend considering:

  • Patient Health Questionnaire-9 (PHQ-9): A nine-question instrument that measures depression severity and includes one question that identifies risk for suicidal thoughts or self-harm.8
  • Generalized Anxiety Disorder Scale (GAD-7): A seven-question instrument that measures anxiety.9
  • Fear-Avoidance Beliefs Questionnaire (FABQ): a 16-question instrument that measures pain –related fear of work and physical activities.10
  • Pain Catastrophizing Scale (PCS): A 13-question instrument that measures catastrophic thinking.11
  • STarT Back Screening Tool (SBT), a nine-item instrument that categorizes risk for persistent disabling pain.12

Support Early Intervention

When a mental health condition is detected, early intervention is warranted.13 Thomas and colleagues suggest that early intervention for some mental health conditions in children can lead to improved educational, behavioral and social outcomes both at home and school.14 Authors explain that early intervention for depression and anxiety results in less impact on relationships, family and work,14-16 and early intervention for harmful drinking results in improved physical, mental and social wellbeing.14,17 Timely screening can identify which patients may benefit from early intervention through in-office treatment and which may require prompt referral or co-management.

Establish Interdisciplinary Collaboration

Establish a professional network that includes:

  • Mental health professionals
  • Drug and alcohol rehabilitation agencies
  • Community resources, such as local homeless shelters and employment agencies

Establishing effective referral pathways and communication networks with mental health professionals and other community agencies will help ensure important psychological and social components of health are addressed when in-office activities are insufficient.

Integrate Mental Health Promotion at Work

Check in with patients:

  • Routinely talk with patients about mental and social well-being, especially those experiencing life cycle transitions, loss, grief or other stressors.
  • Promote in-office mental health and wellness.
  • Display mental health promotion posters; place in-office fliers promoting community resources.
  • Lead by example through appropriate self-care and a balanced work-home lifestyle.
  • Promote a balanced lifestyle among staff.


Though Thomas and colleagues do not present evidence demonstrating improved outcomes from some of their recommendations, such suggestions are consistent with a biopsychosocial approach. Changing activities to enhance a biopsychosocial approach can be daunting, but small changes can be potentially meaningful. A possible first step is using screening tools. Another important step is establishing or strengthening relationships with mental health professionals, which can streamline management, co-management and referral decisions. A step to promote social health can include pointing patients toward community-based organizations. These and other activities have the potential to improve mental and social health, and promote healthier communities.

Dr. Vining is associate professor and senior research clinician at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, Iowa.

Dr. Khan is a clinical research fellow at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, Iowa.


  1. Alcauskas M, Charon R. Right brain: reading, writing, and reflecting: making a case for narrative medicine in neurology. Neurology. 2008;70:891-4.
  2. Plato, Charmides. Plato: The Collected Dialogues. New Jersey: Princeton University Press, 1989:103.
  3. Shi L, Singh D. Delivering Health Care in America: A Systems Approach. 6th ed. Burlington, MA: Jones & Bartlett Learning, 2015.
  4. Weiner BK. Spine update: the biopsychosocial model and spine care. Spine.(Phila.Pa.1976.) 2008;33:219-23.
  5. Lindau ST, Laumann EO, Levinson W et al. Synthesis of scientific disciplines in pursuit of health: the interactive biopsychosocial model. Perspect.Biol.Med. 2003;46:S74-S86.
  6. Engel GL. The clinical application of the biopsychosocial model. Am.J.Psychiatry. 1980;137:535-44.
  7. Thomas S, Jenkins R, Burch T et al. Promoting mental health and preventing mental illness in general practice. London.J.Prim.Care.(Abingdon.) 2016;8:3-9.
  8. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J.Gen.Intern.Med. 2001;16:606-13.
  9. Spitzer RL, Kroenke K, Williams JB et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch.Intern.Med. 2006;166:1092-7.
  10. Waddell G, Newton M, Henderson I et al. A fear-avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993;52:157-68.
  11. Sullivan MJL, Bishop Scott R, Pivik J. The pain catastrophizing scale: development and validation. Psychological Assessment 7(4), 524-532. 1995.
  12. Hill JC, Dunn KM, Lewis M et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum 2008;59:632-41.
  13. Rivero EM, Cimini MD, Bernier JE et al. Implementing an early intervention program for residential students who present with suicide risk: a case study. J.Am.Coll.Health. 2014;62:285-91.
  14. Knapp M, McDaid D, Parsonage M. Mental Health Promotion and Prevention: the Economic Case. 2011. 5-2-2017.
  15. Callander EJ, Lindsay DB, Scuffham PA. Employer benefits from an early intervention program for depression: a cost-benefit analysis. J.Occup.Environ.Med. 2017;59:246-9.
  16. Zhang M, Rost KM, Fortney JC et al. A community study of depression treatment and employment earnings. Psychiatr.Serv. 1999;50:1209-13.
  17. Kaner EF, Beyer F, Dickinson HO et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane.Database.Syst.Rev. 2007;CD004148.

Editor’s Note:

ACA’s Editorial Advisory Board also recommends the following resources for those who are interested in learning more about the biopsychosocial approach to patient care:

  • Marin TJ, Van Eerd D, Irvin E, Couban R, Koes BW, Malmivaara A, van Tulder MW, Kamper SJ. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane Database of Systematic Reviews. Issue 6. Art. No.: CD002193.
  • Pincus T, Kent P, Bronfort G, Loisel P, Pransky G, Hartvigsen J. Twenty-five years with the biopsychosocial model of low back pain-Is it time to celebrate? A report from the twelfth international forum for primary care research on low back pain. Spine (Phila Pa 1976). 2013;38(24):2118-2123.
  • Newell D et al. Contextually aided recovery (CARe): a scientific theory for innate healing. Chiropractic & Manual Therapies, 2017;25:6.