Psychiatrists Must Reclaim Substance Abuse Treatment

By Daniel Y. Patterson, M.D., M.P.H.

Prior to the 1970's chemical dependency treatment was the stepchild of health care and, -for that matter, the stepchild of mental health care.

Driven by several factors during the 1970's and 1980's, substance abuse treatment began to be separated from that for mental illness. Congress was a major force, singling out alcohol abuse treatment for increased visibility and funding during that time. The establishment of the National Institute on Alcohol Abuse and Alcoholism removed addictions from the purview of the National Institute of Mental Health, a separation mirrored at the state level by the establishment of separate agencies for mental illness and chemical dependency treatment.

With the driving force of chemical dependency support groups, particularly Alcoholics Anonymous, insurers began to establish somewhat equal but separate health insurance benefits for the treatment of substance abuse. Recovering alcoholics took umbrage at being "lumped in with the mental health crazies" and wanted their treatment separate from that of the mentally ill.

In the late 1970's a separate (mostly for-profit) industry arose for inpatient rehabilitation of alcoholics and other substance abusers. Psychologists and part-time primary care -physicians began to fill the void left by psychiatrists who were glad to delegate this area to these professionals. In time a separate credentialing track developed for the "addictionologist."

With less and less medical oversight, for-profit substance abuse rehabilitation chains began to take liberties with insurance benefits; this was a major factor in stimulating the development of managed behavioral health care organizations (MBHO's), since large employers came to believe that they were paying a high price for inappropriate use of substance abuse benefits.

This artificial separation of mental health and chemical dependency has created major problems in four areas.

• Dual Diagnosis: Dual-diagnosis patients are getting short shrift no matter where they are treated. From the chemical dependency side of the fence, "If you only have a hammer, everything looks like a nail." Clear symptoms and signs of nonchemical dependency disorders are often attributed to chemical dependency problems and are inadequately treated. Alternatively, psychiatrists, psychologists, and master's-level therapists with little experience in chemical dependency treatment often overlook substance abuse problems.



• Administrative Nightmares: HMO's and MBHO's have great difficulty with dual-diagnosis patients and have found dual benefits to be an opportunity for mischief by providers who attempt to revise their diagnosis to maximize their use of both benefits. HMO's and MBHO's have enough difficulty separating medical/surgical conditions from mental health conditions in carveout contracts without adding a third dimension, that is, chemical dependency.



• Artificial Separation of Support Groups: Underpinning the National Alliance for the Mentally III (NAMI), arguably the most potent mental health support group, is the basic premise that there are genetic, biologically based mental disorders that deserve the same attention and insurance coverage that other diseases enjoy. If there were ever a brain disease that was clearly genetic and thus biologically based, it is alcoholism. In spite of this, NAMI has disassociated itself from chemical dependency and its support constituency.



• Parity Legislation: The seeds sewn by those who have fought to keep chemical dependency separate from mental health care have borne bitter fruit. The recently passed National Mental Health Parity Act excludes chemical dependency from this legislation's protection.

I have several recommendations to offer in response to this troubling situation. In my opinion mental health and chemical dependency must be fused at all levels for the better treatment of both.

First, at both the national and state levels, I strongly urge NAMI to include, if not embrace, the chemical dependency support constituency and then use this added strength to argue for "true parity" legislation for all behavioral health care. While waiting for true parity, we should combine mental health/chemical dependency benefits, which would be greater than either separately. With a single set of mental health care benefits, HMO's and national MBHO's can more easily and fairly administer the benefits for all such care.

Chemical dependency deserves visibility at the national and state administrative levels as well, but no more than does schizophrenia, affective disorders, and other psychiatric disorders. A single national agency and statewide agencies advocating for and supporting all behavioral health care would have the visibility and clout to further all behavioral health care interests.

My second recommendation concerns training, credentialing, and roles. For better or worse, psychiatrists are no longer psychotherapists in most urban centers. Psychiatry should never have abdicated its role in chemical dependence treatment. I strongly urge psychiatry residency programs to train residents to diagnose and treat chemical dependency. I urge that psychologists and master's-level therapists should also be better trained in the same area.

I hope as well that primary care physicians who have stepped into the void left by psychiatry will continue to be involved in chemical dependency treatment. Chemical dependency is a chronic disease with multiple medical complications. Patients with that disorder sorely need primary care physicians, but they are often eschewed by those physicians. I hope creative managed care companies can derive a medical case rate capitation or funding mechanism for these often chronically ill patients.

I am frankly opposed to subcertification for chemical dependency treaters. General psychiatrists and primary care physicians should be trained and board certified in their respective specialties, which should include training in the treatment of chemical dependency.

In summary, enough is enough, united we stand (and advance), divided we fall. I strongly urge that we meld mental health and chemical dependency administration and treatment programs at all levels by the new millennium.