Our recent two-part series about the problems and the proposed solutions of dually diagnosed patients, prompted the following letter from a visitor to the About Alcoholism / Substance Abuse site.

I have enjoyed much of the discussion of "dual diagnosis," but I would like to sound a warning bell about the new eagerness of physicians to find treatable (read 'treatable with pills') psychiatric "diseases" in alcoholics, addicts, and related individuals.

The economic reality is that organized medicine has lost control of the addictions field and all the fees and revenues they gained from it. In the past, the family physician, the drying out farm, the "specialist" in alcoholism wielding Valium and the other medications have all played a prominent and profitable role in the addictions.

More recently, these medical players have been shouldered aside by psychiatrists, and more recently yet, the psychiatrists have been shouldered aside by the addiction counselors. Only a few short years ago, physicians -- including psychiatrists -- made enormous amounts of money by being the physician of record in all manner of addiction treatment centers.

Surprise! A New Interest Develops

Setting aside the question of whether there was ever any solid reason for psychiatrists to be active on addiction treatment units in the past, it has become clear that there is now no more room for the psychiatrist to offer expensive "services" on the inpatient units, and no more room for the psychiatrists to offer similarly high revenue "services" on the outpatient and follow-up phases of addiction treatment itself. Physicians in general, and psychiatrists in particular have additionally lost immense amounts of money as HMOs have cut into their personal profits.

But wait! These physicians have now announced a new-found interest in the diagnosis and treatment of "dual diagnosis," "co-existing" psychiatric disease in recovering people. And the "treatment" for this newly found problem may begin simultaneously with the treatment of the primary addiction, at which point of course no one really has much realistic chance of being able to determine how much of an addicted person's distress is part of the addiction itself and how much is part of some concurrent psychiatric disease.

Different Brand of Alcoholics?

Alcoholics are alcoholics, and those we see these days are probably pretty much unchanged now from those that have filled the addiction treatment units for years. If these dual diagnosis ideas are so powerfully important and such a major issue in the treatment of addictions, why didn't the psychiatrists who were so active on treatment units five, ten, fifteen, or even twenty years ago come up with these ideas then?

I suspect that the answer is that they didn't need the revenue that stems from dual diagnosis work then, but they surely do need it now that they have been appropriately displaced by treatment teams of an addictions counselor and an internal medicine specialist.

How many perfectly normal people are currently receiving psychiatric "treatment," primarily pills dispensed on a five or ten minute visit every month or two, that are completely unneeded? What sort of "psychiatric treatment" consists of these pills and these pills only? How many perfectly normal people have we heard announce that they have "a chemical imbalance" that was diagnosed in the earliest stages of their recovery?

"Pills Only" Treatment?

HMOs themselves represent another pressure in favor of "pills only" psychiatric treatment for addicted and for other persons simply because "pills only" treatment is cheaper to the HMOs than are other forms of counseling and therapy aimed at helping people to make positive changes in their own lives.

Are "pills only" really the treatment of choice and to be preferred over individual counseling, couples' counseling, group therapy, assertion training, and all the other valuable treatment techniques available to all of us if appropriate?

Beware of Trends, Fads

My reading of Bill Wilson's words on this point is that he specifically advocated psychiatric or psychologic treatment where appropriate and it is certainly true that AA's publications include a pamphlet indicating that some recovering people can and do need special treatment, including medication. But it is reasonable to ask whether or not everyone who is receiving medication is being treated with the right form of psychiatric treatment, with the right medicine for the right period of time for the right reasons?

It is wise to guard against the possibility that addicts of all varieties and physicians in all their varieties might work against each other and might sometimes even use each other for their own purposes?

It wise to ask ourselves what protections we need to put into place to increase our chances of getting the best possible medical care, including psychiatric and psychological care. In medicine, as in all areas, we need especially to be beware of trends, fads, and the hottest "NEW! NEW! NEW!" product, service, or discovery, and the current "dual diagnosis" material needs to be included in this scrutiny?