INCONSISTENCIES IN MENTAL ILLNESS & SUBSTANCE DISORDERS CONTRIBUTES TO FRAUD
By Mickey Skidmore, AMHSW, ACSW, MACSW
On 28 Sept 2017 two Australian news outlets published stories with sensational headlines. The Sky News article was entitled: “Ice use increases mental illness.” Similarly, an ABC News article was entitled: “Mental illness among drug users rises in latest National Drug Strategy Household Survey.” While there is an element of truth in their reporting, the assertion they attempt to make is over-simplified and misleading.
The source for both of these stories comes from a 2016 National Drug Strategy Household Survey recently released by the Australian Institute of Health and Welfare (AIHW). The articles note that the rates of mental illness were particularly high for methamphetamine and ecstasy users, and attributed the soaring mental illness rates to people using one of the most potent forms of methamphetamine — ICE.
In this month’s “perspective” I would like to unpack these assertions a little more thoroughly; provide some basic and fundamental psycho-education about mental illness and substance abuse; and offer an alternative narrative to better explain this data.
I began this essay by acknowledging there were some elements of truth to these reports. So let’s tease out these assertions from both a clinical and research perspective. First of all, as a practicing clinician of more than 30 years, I am aware of no research that supports the view that illicit drug use or psychoactive substance misuse “causes” any mental health disorder. Using ICE, ecstasy or heroin does not cause Schizophrenia, Schizoaffective Disorder, or Bipolar Illness. (The reverse is also true: illicit drug use is not a symptom of these conditions, nor do they “cause” psychoactive substance misuse). There is increasing research that suggests or hypothesises that heavy marijuana use may be the trigger or catalyst for the onset of schizophrenia for some individuals who already have predisposition for this condition. But such literature is far from making statements of causality.
The DSM-V includes diagnostic criteria of substance abuse disorders in the classification of mental disorders; however, among professionals in the field there remains ongoing debate about whether substance abuse disorders should be viewed as a distinct and separate category rather than included in the group of mental disorders. Only in the broadest sense of the DSM-V classification would illicit drug use be viewed or considered a mental illness. In this context, there is an element of truth to in these news articles. There is little doubt or disagreement that ICE use would often result in a delirium that may also include psychotic symptoms. This would be another way to acknowledge an element of truth in these news reports.
In Australia these two classifications of disorders are dealt with distinctly, in particular from a legal standpoint. Theoretically, individuals with substance abuse disorders may not be detained under the Mental Health Act as there is a different legal threshold that is required. Furthermore, Australia utilises the ICD classification system to label behavioural disorders over the DSM. In either classification system, illicit drug use would not be considered a mental illness per se, but rather a substance abuse disorder.
So, this brings us to the alternative narrative that many people are unaware of, and frankly would be (or should be) shocking to learn. Every day people present to Liverpool Hospital where there is unequivocal, straight-forward evidence that they injected heroin or used significant amounts of ICE. When they present they are often exhibiting psychotic symptoms or a delirium. In such circumstances, these individuals are often insight-less, agitated, aggressive and generally uncooperative or unwilling to voluntarily accept efforts to stabilise them. In such circumstances the Mental Health Act protects doctors legally who admit patients that are delirious or floridly psychotic — even if the cause of the psychosis is illicit drug use. However, there are two larger issues at play, that are unsettling — and have been ignored for some time now.
First, an alarming number of admitting doctors in such scenarios literally alter the language and nomenclature of their documentation to suggest these patients may be suffering from a mental illness instead, so they can be admitted and detained under the Mental Health Act.
In such instances the documentation may mention the possibility of ruling out schizophrenia or an underlying psychotic illness which results in a label becoming generalised and attached to them and utilised over and over in future presentations. Such a patient may present in the ED acknowledging that they injected 2 points of ICE the day before, but the documentation will read: patient presents with a relapse of his psychotic illness in the context of methamphetamine use. Most competent clinicians would acknowledge that if one were to inject 2 points of ICE that it would not be surprising that they may exhibit psychotic symptoms. However, based on this scenario there is no evidence of a relapse of psychotic illness. Rather the evidence suggests an exacerbation of psychotic symptoms resulting from methamphetamine use or a substance-induced psychosis.
Second, and perhaps most importantly is the issue of an approved facility to appropriately treat such conditions. The mental health wards of Liverpool Hospital have been accredited as in-patient mental health facilities — not as an in-patient substance abuse facility. Make no mistake. I have no doubt, and have full confidence that the physicians who work in these wards are adequately trained to treat any condition identified in the DSM or ICD. However, I have serious doubts if the mental health service has been properly accredited to provide such treatment in their facility. There is no question these individuals require treatment. However, they should be receiving treatment at an accredited substance abuse facility rather than a mental health or psychiatric service not designed or intended to treat such conditions.
Such practices raises a host of professional and ethical concerns:
-When there is clear, direct and overt misrepresentation such as this, a case could easily be made for fraud. In a mental health budget that is already taxed and limited, it could be argued that this practice is tantamount to a gross misuse of allocated resources — at the highest level (Skidmore, 2020).
-While doctors perhaps rationalise such actions as the lesser evil in managing complex risk factors, and perhaps think this is a clever “work-around”, it pushes the limits of the Mental Health Act — and may be a violation of the intent of the legislation. (It is also quite baffling to me that Mental Health Tribunals do not enforce this better and look the other way. They too are complicit in this fraudulent activity as well).
-None of the wards of the Liverpool MHU are designed or intended to provide substance abuse treatment. At face value this would seem to be clinically inappropriate (both for the substance abuser and the genuine mental health patients the ward was intended for) and ethically questionable. However, it becomes even more problematic when the doctors cavalierly allow such patients to have (unescorted) leave; as these patients frequently use illicit drugs while on leave (thereby undermining their treatment) and/or bring illicit substances back on to the ward and provide them to other patients (compromising the safety of other patients and putting them at undue risk).
-I conservatively estimate that nearly 50% of the patients admitted to the wards of Liverpool MHU fit this scenario, thereby blocking availability of treatment to high numbers of legitimate mental health patients waiting for admission in the ED.
The reader should not be fooled or distracted by disingenuous arguments or diagnostic debates about which diagnosis is primary or which one occurred first. I am referring to the straight-forward presentations where illicit drug use is clear, undeniable and undebatable. I recognise that there are patients who also present with co-existing conditions (which actually results in a third category).
There are a range of possible solutions to addressing what has become an alarming status quo. At a larger, macro level the solutions rest largely with our politicians to acknowledge this and provide a pathway to (a) revisit and adjust the legal manner in which it deals with psychoactive substance abuse conditions and the Mental Health Act; (b) provide clinically appropriate and specifically tailored inpatient treatment wards to deal with substance abuse conditions; or (c) at the very least, identify specified dual-focused wards for patients with co-existing conditions. Continuing to look the other way, or making weak excuses to further justifying these practices only serves to further jeopardise psychiatric patients in the mental health wards, and give politicians a pass for their responsibility to properly address this.
Additionally, at the organisational level, the executive psychiatric leadership of Liverpool hospital must implement clear criteria for admission to the inpatient psychiatric service (along with clear exclusionary criteria) and insist that it be consistently adhered to across the SouthWest Sydney LHD. This is the glaring self-inflicted action (or inaction) that underscores these many of these professional and ethical concerns as well as contributing to a range of other noteworthy systemic challenges as well.
These changes need to take root and be firmly established before there can be a significant push and commitment to cease this massive fraud that is being carried out at Liverpool Hospital (and perhaps other hospitals in NSW as well) at the taxpayers expense.
- DSM-V. American Psychiatric Association.
- Skidmore, Mickey. “Train Wreck” 2020.