On Friday, Hathaway of BBH said in an e-mail that most of the alleged deficiencies resulted from state surveyors' unfamiliarity with its electronic records and that the audit was not based on the complete record.
But Hepburn, a psychiatrist, said he was "very concerned" about BBH for reasons that go beyond billings. Patients suffer harm if they continue using illicit drugs while seeking treatment for substance abuse, mental illness or both problems, he said. Patients also suffer, he said, if they are misdiagnosed as mentally ill and given medicine they don't need.
"In the end, it actually works against the individual, because they now have a psych diagnosis and they're now on psychiatric medications, and that follows them wherever they go."
The BBH campus sprawls across two large brick buildings on West Pratt Street, next to the B&O Railroad Museum. On a recent day, dozens of people smoked cigarettes and milled around the clinic's courtyard, a short walk from neighborhoods awash in drug dealing. In the parking lot sat a fleet of white BBH vans bearing the company motto: "Turning Lives Around."
Inside, counselors led group therapy sessions for scores of patients. A brief tour last year showed clusters of patients engaged in classroom discussions.
BBH is a magnet for down-and-out addicts in a city teeming with them. The city's substance abuse authority, Baltimore Substance Abuse Systems Inc., admitted more than 16,000 people for treatment last year at providers across the city but says that twice as many went without needed care and that residential slots are in especially short supply.
As of the summer, BBH was treating about 800 patients, with nearly 150 living in its rental housing. Its chief executive declined requests for interviews. He agreed to answer questions in writing and replied to about a quarter of the more than 40 questions submitted by The Sun in June.
Dr. Nicholas Scotto, BBH's chief doctor, called the newspaper last month to elaborate on the organization's practices. "We're helping a lot of people, doing a lot of good for these people, that often nobody wants to help," he said.
In an earlier statement, Hathaway summed up his philosophy for tackling a person's drug problem and underlying mental illness at the same time.
"Treating only the addiction does not address the psychiatric disorder, which may lead to abusing drugs again to manage the depression," the company's chief executive wrote. "Conversely, treating the depression without addressing the drug addiction is a recipe for disaster, because there is a pharmacological component in addition to a psychotherapeutic component to managing depression."
The phenomenon of mentally ill drug addicts is well established in medical literature, where it is called "co-occurring disorders." But many experts say a minority of addicts in any population will be actively suffering from a psychiatric disorder not brought on by drug use.
Dr. Christopher Welsh, 46, an addiction psychiatrist at the University of Maryland Medical Center who focuses on heroin abusers, said fewer than half the addicts he treats use drugs to ease the effects of freestanding mental problems. These can include bipolar disorder, marked by extreme mood swings, and schizophrenia, a brain disorder that can cause paranoia.
Most are not mentally ill, Welsh said. "Substance abuse is often an independent disorder. You don't need another disorder to explain it. It happens in and of itself."
Feeling miserable, as addicts often do in the throes of addiction or withdrawal, is not enough to support a psychiatric diagnosis. The state stresses that the public mental health system should not pay for psychiatric treatment if someone has a "substance-induced" mental condition, that is, one caused by drug use and likely to fade with sobriety and drug counseling.
"If everything in your life is falling apart, you feel horrible, but that doesn't mean you have clinical depression," said Alice Jonas, a psychiatric nurse who runs Union Memorial Hospital's intensive outpatient program in North Baltimore. "There are people who, if you get them sober, completely off drugs and alcohol — oh, my God, a couple months go by, and there is no sign of what anybody could call depression or mood changes. They're good to go."
By contrast, a freestanding mental condition persists even after the person gets off drugs, she said. "Three months later, they still have their bipolar disorder or major depression. There is a very serious overlying mental illness."
One in eight drug abusers nationwide had a serious mental illness in 2008, according to the most recent available statistics from the federal Substance Abuse and Mental Health Services Administration. It defines serious mental illness as one causing major "functional impairment, which substantially interferes with or limits one or more major life activities." The agency excludes all "substance use disorders" from the tally.