Double Trouble

Dual Diagnosis in Tompkins County

Beth Jenkins has two problems.


First, out of the 24.6 million Americans with serious mental disorders, more than a fifth suffer from a substance use problem as well.

What’s more, only 8.5 percent of those Americans are treated for both psychological disorders and addictions, according to a 2005 survey conducted by the Department of Health and Human Services. Fifty-three percent, or 2.8 million Americans, receive no treatment at all.

While Jenkins does not suffer from either condition, as executive director of the Mental Health Association in Tompkins County, her duties focus on educating mental health professionals, as well as addiction counselors, on how to deal with patients living with dual diagnoses, the co-occurrence of mental and substance use disorders.

If Tompkins County, with a population that numbers just above 100,000, is in line with national statistics, then it is home to a little more than a thousand residents that suffer from substance use and mental disorders. If the 100,000 residents of Tompkins Country are in line with national statistics, more than a thousand suffer from both substance use and mental disorders.

The department’s survey, which was released by the Substance Abuse and Mental Health Services Administration, found that only about a third of Americans suffering from both ailments receive treatment for their psychological states alone, and more than half receive no treatment at all.

At the local level, Jenkins says Tompkins County benefits from what she calls a movement between mental health and addiction recovery services to provide appropriate treatment for dual diagnoses.

“There’s a lot of coordination and collaboration in this community,” she says. “So we’re fortunate that people are very much aware or this issue and are willing to look a ways to meet the needs of individual who come before them.”

In New York state, medical insurance can only pay for individuals’ primary diagnoses. Jenkins added that it has been practically impossible for someone who has had a mental illness to be treated for a substance use disorder as well.

“It’s not a problem with the therapists,” Jenkins said. “It’s primarily a problem with the payers — insurance companies, Medicaid, Medicare, those types of things.”

Diagnoses also often reveal only a patient’s most pressing problem at the time of treatment.

“Clearly, if you have someone who is depressed and suicidal, you’d want to treat the depression first,” she said. “If you have someone who is just depressed and has a substance use problem that prevents them from being able to address their depression, then obviously you’d have to treat the substance abuse problem first.”

On a national scale, and in communities where awareness isn’t as acute as in Tompkins County, the problem lies in not only covering the cost of treatment coupled but also with professionals that are only trained in one field.

“You can only charge one service,” Jenkins said. “And people who are trained in mental health are necessarily trained in addictions, and people who are trained in addictions aren’t necessarily trained in mental health.”

Jenkins also noted a strong correlation between past trauma and individuals with both mental health and substance use problems. Post-traumatic stress disorder can lead to an increased risk for substance use and psychological disorders.

Despite being aware of the financial roadblocks that hinder treating substance use disorders and mental health simultaneously, Jenkins was still certain of the best method of treatment.

“The best approach is a holistic approach,” she says. “That is not how it’s being done, and I’m not sure which one to say is better to treat first.”

Covering dual diagnoses

Shane Jaynes, the dual recovery coordinator at the Tompkins County Mental Health Department, has more than a decade of experience treating patients with dual diagnoses. Jaynes is charged with the daunting task of streamlining the integration of services between addiction treatment centers and mental health care providers.

“My job is to make those two things work better and be more seamless on behalf of the people who have co-occurring disorders,” he says.

To Jaynes, third-party insurance providers don’t treat substance use disorders as they would mental disorders, when the two conditions have been proven to come hand-in-hand in many cases. What’s more, coverage plans cater to physical healthcare (i.e. accident coverage and physical illnesses) rather than mental ailments. This disparity hinders many with dual diagnoses to find the right balance between addiction counseling and mental health care and, sometimes, forces some to choose one or the other when it comes time for payment.

For those without any kind of health insurance coverage, options are slim. According to the 2004 census, the number of uninsured U.S. residents number at 45.8 million, up from 45 million in 2003 and 39.8 million in 2000. Fortunately for residents of Tompkins County, centers like the Ithaca Free Clinic offer those without insurance — usually, the unemployed and the working poor — the chance for treatment. Residents suffering from mental disorders and substance use problems are no exception.

Still, the Ithaca Free Clinic is only a start. The complete, holistic recovery process still remains out of reach for most people with co-occurring disorders.

“They’re able to go to things like the Free Clinic and begin to get some amelioration of their symptoms,” Jaynes says. “It’s a great model. I certainly support it. I know many people who have benefited from it. It’s not enough, but it’s in the right vein.”

Addiction and mental disorders: neurological roommates

To makes matters harder for mental health professionals like Jenkins and Jaynes, those outside the industry separate mental disorders and substance use problems into two different categories. Jaynes, however, says that substance abuse issues should be considered no different than mental disorders.

“When we talk about mental illness, were talking physically about neural anatomy, brain-based disorders,” he says. “The same is true in substance abuse. We know about things like the liver and the heart, things like that. But essentially addictions, just like other forms of mental illness, are brain-based disorders.”

In an anatomical sense, there is no difference between mental disorders and substance use problems. The different degrees of substance use disorders — substance abuse, addiction and chemical dependency —can then be seen as mental disorders in and of themselves. According to Jaynes, they even share “common real estate” in the brain. The same neuro-transmitters implicated in mental illness are used in addiction problems, and vice versa.

Chemicals such as dopamine and serotonin are also essential to both conditions. MDMA, the pure form of the drug ecstasy, produces euphoria by causing a large amount of serotonin to release into the body. Dopamine, on the other hand, plays a large role in the limbic system, which is highly incorporated in the brain’s interpretation of pleasure. During recreational drug use or sexual intercourse, dopamine is what causes the subsequent pleasurable feelings.

Dorm daze

At many higher-education institutions across the nation, an anxiety-filled lifestyle coupled with drinking and drug use has become the accepted environment.

Tompkins Country is home to a vibrant college community with Cornell University, Ithaca College and Tompkins County Community College adding more than 26,000 residents to its population. With the students comes a culture of self-medication when it comes time to relieving stress caused by classes or other collegiate issues, Jenkins said.

The Mental Health Association has worked closely with Ithaca College and Cornell by educating the schools’ health officials on specially targeted issues, like the correlation between mental health and substance use disorders.

“The colleges are not blind to this,” she says.

She adds that the correlation can be attributed to the fact that these people have academic pressures coupled with the alcohol-soaked party culture attached to college life.

“Sometimes students decide to drink too many beers on a Friday night because they’re relieving their stress,” Jenkins said. “And some of it is self-medicating. If you have depression you might, instead of taking anti-depressants, self-medicate with alcohol, marijuana or some other substance.”

A survey report by the Substance Abuse and Mental Health Services Administration in 2002 found that “excessive episodic drinking” was prevalent among young adults aged 18 to 24. About 1 in 10 were found to be heavy drinkers, while 2 in 5 could be considered binge drinkers whether or not the young adults was enrolled in college. The report defined binge drinking as consuming more than five drinks on the same occasion on at least one day in the past month, while heavy drinking as consuming the same amount on each of five days in the past month. The rate of alcohol dependence was found to be higher among college students than nonstudents.

Michael M., a 22-year-old senior at Ithaca College, says he consumes about 30-50 drinks in a typical week. At the most, that’s seven drinks a day. But M.’s fun is not spread thinly across the week — he usually fits those drinks into a three-day span of Thursday, Friday and Saturday, bringing the average up to, at the very most, 17 drinks per night. At the very least, it’s 10 drinks a night and more than 120 in a given month.

While the senior says he drinks to relieve stress from a week’s worth of work, he rejects the term self-medication.

“I can go a weekend without drinking and not go crazy,” he says.

One Ithaca College sophomore, who asked not to be named in this article, says he spends about $100 on marijuana a week and smokes two to three times a day. The reason behind his habit is to relieve stress, but he says he doesn’t see it as self-medication.

“I wouldn’t say that,” he says. “‘Cause if there’s a three-day period where I can’t smoke or whatever, it’s not that big of a deal.”

To Jenkins, however, that’s exactly what it is. Whether it’s relieving weekly stress or drinking away a deep depression, any substance used to alleviate a condition or mental illness without a prescription is considered self-medication.

Out in the open

With more and more access to over-the-counter drugs coupled with the availability of alcohol, it’s becoming harder and harder for many sufferers of mental illness to stay clean. The deinstitutionalization movement of the 1970s and 1980s caused thousands of Americans with mental disorders to leave institutions and enter community-based programs, where a trip to the liquor store could be as easy as walking down the street.

Outside the walled-off institutions were temptations of illicit drugs and alcohol, and many blame the movement for a sharp rise in homelessness. Since then, advocacy groups have emerged, like Tompkins County’s Mental Health Association, to help the mentally ill re-enter society. The goals of these professional organizations revolve around educating the public about mental health issues as well representing the mentally ill on local, state and national levels.

For substance use disorders, professional advocacy groups are almost nonexistent, Jaynes says. The largest provider of support for abusers of alcohol is Alcoholics Anonymous, which is apolitical, informal and run by non-professionals. A.A. has taken measures to remove itself from acting as anything other than an informal support group. Alcoholics and drug addicts lack the networks of community- and nation-based advocacy centers that the mentally ill enjoy, Jaynes says. Addicts and alcoholics also suffer from others’ misconceived perceptions. While A.A. has done much in the way of promoting alcoholism as a disease, the stigmas attached to it are reluctant to fall off any time soon.

“For a variety of reasons, alcoholism is historical associated with moral failure — degeneracy, I guess you might say — the criminal and legal system, instead of with the health care system,” Jaynes says.

As a result, Jaynes says, media portrayals and common perception of addictions are skewed at times, adding one more roadblock to bringing the problem of dual diagnoses to the public. Addictions are often attempts at self-medication gone too far, and should then be seen as either a symptom of mental illness, or a psychological disorder itself.

“It makes it hard then to talk about the overlap as its own emerging, unique identity,” he says. “It’s sort of like having a broken leg and a fever at the same time. We see them as very different entities.”

Crossing over

Bridging the gap between substance use and mental disorders has been trying work for Jenkins and Jaynes. Most of the time, addicts with mental disorders just want help, not public attention. Those suffering from dual diagnoses do so discreetly — in their homes, on the street — with only a slight number receiving adequate care.

Those fighting for people with dual diagnoses do so modestly, as well, in nondescript offices with small, cardboard signs no bigger than a normal-sized piece of paper. For them, tackling the two problems — substance use and mental disorders — has turned into vocation.