Dual Diagnosis: Reality, or Fraud?

People go to a lot of trouble to get insurance companies to cover expensive addiction treatments for their loved ones – and so do the doctors and other staff offering treatment. A recent article on nj.com covered this phenomenon well, and in fact they might’ve covered it too well for their purposes. The headline reads:

Insurance companies frustrate N.J. families seeking addiction treatment

And the theme of the piece is that while people quibble with insurance companies over paying for treatment, their children are dying of addiction. I’d take issue with that, since I don’t think treatment programs actually work , I don’t think their children would’ve actually been saved (unfortunately, and tragically). The article is filled with great quotes from people who’ve tried desperately to get insurance to provide treatment, and in the process we get clues to solving another part of the treatment success rate puzzle.

Gene Heyman Ph.D. has done a fantastic job of presenting the truth about addiction and treatment in his 2009 book Addiction: A Disorder of Choice (see this post citing some of his work). Essentially, he shows through several wide scale epidemiological studies that most people do get better, they do it without treatment, and that going to treatment doesn’t raise your chances of success. Looking at all of that, it’s clear that treatment is like a sugar pill – it does nothing, and to the degree that it’s said to be effective, it’s really just taking credit for changes that already would’ve likely taken place without the treatment.

Alas, some of the studies actually show that people have a higher rate of relapse once they’ve been to treatment (I know nobody wants to hear that, but it’s true).

Why Are Remission Rates So Different in the Clinic and General Population Studies?

The finding that addicts in treatment were more likely to relapse than those not in treatment often triggers the following exchange: “Those in treatment were more addicted.” “What do you mean by more addicted?” “They used drugs longer.” What is missing here is an account of why those in treatment used drugs longer. This has not been studied much, most likely because it has been widely believed that addicts in treatment did better than those not in treatment.

Heyman tries to explain this, and after successfully dismissing several explanations for it, he settles on the idea that “comorbidity” is to blame for the higher rates of relapse among rehab patients as opposed to those addicts who don’t receive treatment.

…it has proved easy to find individual differences that are correlated with differences in treatment history. The most important is that addicts in treatment are much more likely to suffer from additional psychiatric disorders than those not in treatment.

…According to the few studies that directly compared clinic and nonclinic drug users, those in treatment were much more likely to suffer from additional psychiatric and other medical disorders. Psychiatric and nonpsychiatric medical problems create barriers. They make it less likely for drug users to become involved in viable alternatives to drug use. Hence, the clinic drug addicts remain heavy drug users for much longer than the nonclinic heavy drug users.

That is, more of the people who go into treatment programs have other mental health problems in addition to substance dependence – what us laypeople know as “dual diagnosis” – than those who don’t get treatment. So, the reason these people can’t quit is because they’ve also got depression, bipolar, or various anxiety and personality disorders, and these conditions keep them from getting their lives off the ground.

That makes enough sense, yet it never struck me quite right. When I went for treatment I was diagnosed with 3 of the 4 conditions listed above. And when I finally made a concerted effort to change I actually stopped getting treatment, and those problems disappeared (please, don’t anyone take this is a recommendation to stop psychiatric treatment). What’s more, when I started working to help treatment center failures, I found that many of them had the same experience. It seemed that too many of us were also diagnosed with all manner of mental illnesses when we went for help with addiction. And now that brings us back to the nj.com article (link to full article) about parents’ struggles to get insurance companies to pay for addiction treatment. Let’s look at some quotes:

Denise Mariano and her son Michael had been at Princeton House since 9:30 in the morning. It was now after 5 p.m. and the doctors at the in-patient rehabilitation facility were still fighting with Mariano’s insurance company. Michael was going through withdrawal. Denise was desperate.
The doctors, according to his mother, told Michael he’d have better luck with the insurance company if he had a dual diagnosis: a drug addict who was also mentally unstable.
Would he, they asked, be willing to say he was going to harm his mother or himself. If Michael was mentally unstable, they could admit him, Denise said. And his insurance would cover that.
Michael refused. The 18-year old from Roxbury was a drug addict using as many as 40 bags of heroin a day, but not a sociopath.

…

Princeton House would not comment on this specific case. Its policy prohibits doctors from asking patients to make false statements, but health care experts say scenes like this have become far too common as heroin use booms among New Jersey youth.

…

Dozens of interviews with parents, addicts, doctors, social workers, psychologists and policy makers reveal many patients are ready to commit insurance fraud to be admitted to in-patient rehabilitation programs.

…

It is often beneficial, others say, to lie about how much heroin is used because the more used, the harder it is for an insurance company to deny coverage.

…

Silverman had taken her son to Kennedy Memorial Hospital in Cherry Hill, which had a detox center. Her son, she said, told the staff that he was using two or three bags of heroin a day.

A nurse pulled Alice aside. That wasn’t going to be enough to get him a bed, she whispered, according to Alice. He needed to say he was doing eight or nine bags a day, or that he was suicidal.

Before we decide that comorbidity is to blame for the higher relapse rates among treated addicts, we’ve got to figure out what proportion of those diagnoses are fraudulently made in order to secure funding for treatment. While I’m not here to claim that any particular person’s mental health problems are not real, I still know from personal experience that my diagnoses were useless, and I know from many other people that in the long run, they didn’t really deserve the dual diagnosis either, and here in this article we have some recent documentation of claims that outright fraud is being encouraged by health care professionals. People are being told that to get free addiction treatment, they need to fake other mental illnesses as well. I’ve heard this firsthand from many parents I’ve spoken with as well. But keep in mind, bald faced fraud isn’t the only way that illegitimate dual diagnosis may happen, for as many people who have been willing to openly recommend the faking of symptoms, there are probably many more treatment center workers who simply trump up their diagnoses without ever mentioning it (and of course there are those who are overzealous and simply see disease and dysfunction in everyone they meet).

I have a different thesis on why people may do worse once they’ve been to treatment programs for addiction though, and I’m certainly not the first to come up with it (I think that Heyman even considers it as well, among others who are more sure of it):

When people go to treatment programs for addiction, they are taught in no uncertain terms that they are broken, powerless, out of control, and will struggle with this for the rest of their lives.