Mental Disorders with Associated Harmful Behavior and Substance-Related Disorders Kishore Desagani, MD General Adult and Forensic Psychiatrist Consultant Psychiatrist Medical Assessment and Policy Team Immigrant, Refugee, and Migrant Health Branch Division of Global Migration and Quarantine Centers for Disease Control and Prevention National Center for Emerging and Zoonotic Infectious Diseases Division of Global Migration and Quarantine
Learning Objectives After this session, you should be able to: Classify applicants with mental disorders and substance abuse Interview applicants for mental disorders and substance abuse Determine when indicate alcohol abuse is present and how it should be classified
Mental Health Evaluation: Role of the Panel Physician Follow Mental Health Technical Instructions Includes using current DSM Examine the applicant Make a decision regarding the diagnosis of a physical or mental disorder, including alcohol and other substance-related disorders Identify any harmful behavior associated with a disorder
Role of the Panel Physician (cont.) Determine the remission status of previously diagnosed disorder Make a decision regarding the classification Refer applicant to mental health specialist when required for diagnostic clarification Role is not to merely summarize the findings of other physicians
Mental Disorder A currently accepted psychiatric disorder, according to the current Diagnostic and Statistical Manual (presently the DSM IV) Generally, a mental disorder is an abnormality in thought, behavior, and/ or mood in an individual that causes significant impairment in one or more areas of important functioning and differs from normal development or culture.
Examples of Mental Disorders Mood Disorders Major Depressive, Bipolar Psychotic Disorders Schizophrenia, Schizoaffective Anxiety Disorders PTSD, Panic, Phobias, Generalized Anxiety Mental Retardation Cognitive Disorders Dementia Personality Disorders Antisocial, Borderline, Paranoid Alcohol abuse or dependence Impulse Control Disorder
Substance Abuse Maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by 1 or more of the following within a 12-month period: Failure to fulfill major role obligations at work, school, or home Substance use in physically hazardous situations Substance-related legal problems Continued substance use despite regular social problems caused by the effects of the substance
Substance Dependence Maladaptive pattern of substance use leading to clinical impairment or distress, manifested by 3 or more of the following occurring at any time in the same 12-month period Tolerance Withdrawal The substance often taken in larger amounts or over longer period than intended A persistent desire or unsuccessful effort to cut down or control Important social, occupational or recreational activities given up or reduced Substance use continued despite knowledge of having persistent or recurrent physical or psychological problems
Components of the Mental Health Evaluation Interview applicant Psychiatric symptoms Past psychiatric history Family history Social history Review laboratory results IF INDICATED Therapeutic drug levels Mental status examination Diagnosis and classification
Mental Health Evaluation: Interviews Interview applicant Psychiatric illnesses History of associated harmful behavior Use of drugs and medications Interview applicant s family when appropriate
Mental Health Evaluation: Interviews Four Questions to Consider Asking Every Applicant: 1) Do you or have you ever had thoughts about harming yourself and have you ever taken any actions based on these thoughts? 2) Do you or have you ever had thoughts about harming others and have you ever taken any actions based on these thoughts?
Mental Health Evaluation: Interviews Four Questions to Consider Asking Every Applicant: 1) Do you currently or have you ever used alcohol or any other substances? 2) Are you currently on any medications or have you ever been on any medications, including herbal supplements, vitamins, or any other substances?
Mental Health Evaluation: Interviews Reference Tool 4 provides a list of topics that panel physicians can use to guide their mental health evaluation interview. Generally, this part of the evaluation should be like a conversation rather than an interview. If interview does not allow you to make a proper diagnosis, please refer the applicant to your consulting specialist.
Mental Health Evaluation: Psychiatric Symptoms Elicit current and past history: Depression low mood, lack of interest in activities, hopelessness, energy, appetite, sleep, concentration, suicidal/homicidal ideations, guilt Anxiety worry, fear, remembering bad/traumatic events, obsessive thoughts
Mental Health Evaluation: Psychiatric Symptoms (cont.) Mania/Hypomania Elevated mood, grandiosity, pressured speech, racing thoughts, impulsivity, increased goal directed activities, sleep, energy Psychosis Hallucinations, delusions, paranoia
Mental Health Evaluation: Psychiatric Symptoms (cont.) Impulse control Failure to resist aggressive impulse Paraphilias History of sexually dangerous behaviors
Mental Health Evaluation: Medical History Review Review psychiatric history for: Hospitalization or institutionalization for psychiatric illness History of harmful behavior Danger to self or others Diagnosis of mental disorder with which harmful behavior may be associated or in which harmful behavior is an element of the diagnostic criteria Drug use Past or current psychiatric medications prescribed
Mental Health Evaluation: Medical History Review (cont) Review psychiatric history for harmful behavior Prior suicide attempts Other recurring self injury Substantial injury by the individual or others (including driving while intoxicated) Substantial damage to property
Mental Health Evaluation: Medical History Review (cont) Review other records, if available: Police Military School Employment
Laboratory Testing Random screening for drugs is not part of routine medical examination for applicants Panel physicians should make an individual decision based on history, behavior, and physical appearance Random screening for drugs on short notice can aid diagnosis and classification (in special cases) Therapeutic levels of prescribed mood stabilizers (Depakote, Lithium, Tegretol) indicates adherence Do not order liver enzymes to evaluate alcohol use
Mental Health Evaluation As part of the physical exam, perform a Mental Status Examination that assesses: Orientation & cognition Appearance Behavior Mood & affect Thought process &content Speech & language Insight & Judgment
Diagnosis and Classification Evaluation should determine: Diagnosis DSM criteria Classification- Class A or B determination is based on presence of harmful behavior TI require panel physician to refer to mental health specialist if panel physician unable to make diagnosis or classification Fraud prevention must occur at specialist s office (check applicant s ID)
Diagnosis and Classification CDC available to provide advice and consultation to panel physicians or Consular Sections CDC consultant psychiatrist conducts review of cases on regular basis or as needed A request for an advisory opinion of diagnosis and classification may be made through the Consular Section to IRMH/CDC consultant psychiatrist
Specialist Referral What are the requirements for a mental health specialist? Must have mental health expertise; CDC does not specify type of specialist(psychologist, psychiatrist) Should NEVER be someone who already provides ongoing care to the applicant CDC suggests panel physician use the same MH specialist for all cases to develop rapport and experience What should the panel physician include in the referral to the mental health specialist? State the reason(s) for referral Indicate that the evaluation should address The determination of a mental disorder diagnosis and Information regarding harmful behavior Table 4 of the 2010 TI provides referral information
Specialist Referral What is the mental health specialist required to do? Serve as referral when a panel physician is unable to make a diagnosis or classification Follow fraud prevention procedures Provide a written report of findings and diagnosis No specific forms for the specialist s report What should the panel physician do after receiving the mental health specialist s report? Provide a classification based on specialist s findings Include full specialist s report with the DS forms in the medical record provided to the Consular Section
Classifications Summary Class A Current evidence according to DSM criteria of mental disorder, alcohol abuse, or substance abuse Associated harmful behavior or history of harmful behavior judged likely to recur Class B Current evidence according to DSM criteria of mental disorder, alcohol abuse, or substance abuse and No currently associated harmful behavior and no history of harmful behavior that is judged likely to recur EXCEPTION: Substances on Controlled Substances Act (CSA) and DSM criteria for abuse or dependency regardless of whether or not there is harmful behavior: Class A
Mental Disorders (Includes Alcohol Abuse/Dependence)
Mental disorder Harmful behavior (for this examination) Definitions Currently accepted psychiatric disorder, according to the current DSM Dangerous action or series of actions that has Resulted in psychological or physical injury to the alien or another person OR Threatened the health or safety of the alien or another person OR Resulted in property damage
Mental Disorder Classifications Determined by 2010 MH TI Key element: the diagnosis of mental disorders must be made according to the current Diagnostic and Statistical Manual (DSM) Class A Current evidence of mental disorder AND Associated harmful behavior or history of harmful behavior judged likely to recur Class B Current evidence of mental disorder AND No currently associated harmful behavior and no history of harmful behavior that is judged likely to recur
Alcohol
In 2011, there were nearly as many alcoholrelated vehicular deaths as cases of tuberculosis in the United States. TB cases: 10.521 Alcohol-related vehicular deaths: 9,878
In 2011 alcohol-impaired driving deaths represented 31% of all driving fatalities (NHTSA*) *National Highway Traffic Safety Administration Video http://www.ktla.com/videobeta/b918f066-7000-48d8-8a65-51fe4a0b0bb1/news/ktla-witness-says-drunk-mom-left-4- year-old-at-crash-scene-don-guevara-reports
What is the Difference Between Alcoholism and Alcohol Abuse? Alcohol abuse is a pattern of drinking that results in harm to one s health, interpersonal relationships, or ability to work (DSM IV). Manifestations of alcohol abuse include the following: Failure to fulfill major responsibilities at work, school, or home. Drinking in dangerous situations, such as drinking while driving or operating machinery. Legal problems related to alcohol, such as being arrested for drinking while driving or for physically hurting someone while drunk. Continued drinking despite ongoing relationship problems that are caused or worsened by drinking. Long-term alcohol abuse can turn into alcohol dependence. Source: http://www.cdc.gov/alcohol/faqs.htm
What is the Difference Between Alcoholism Alcohol Abuse? (cont) Dependency on alcohol, also known as alcohol addiction and alcoholism, is a chronic disease (DSM IV). The signs and symptoms of alcohol dependence include: A strong craving for alcohol Continued use despite repeated physical, psychological, or interpersonal problems The inability to limit drinking Alcoholism is not a medical term Source: http://www.cdc.gov/alcohol/faqs.htm
CAGE CAGE screening tests for alcohol abuse or dependence: Have you ever felt you should cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you ever felt bad or guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)? Developed by Dr. John Ewing, University of North Carolina at Chapel Hill
Alcohol Abuse Classified as Mental Disorder not Substance Abuse (needs associated harmful behaviors for classification) Diagnosis made using DSM criteria for abuse Classified as Mental Disorder Must determine if associated harmful behavior is present or if in past, is likely to recur (see Figure 2 in 2010 TI) If panel physician unable to make diagnosis or classification, the panel must refer to specialist
Alcohol Abuse TI applies to immigrants and refugees Complete medical exam (minus vaccinations) needed for NIVs if they require medical evaluation for alcohol abuse Need BOTH mental disorder diagnosis and associated harmful behavior to be Class A
Alcohol Abuse (cont.) Evaluation for alcohol abuse is required for those applicants with A single alcohol related arrest or conviction within the last 5 years OR Two or more arrests or convictions within the last 10 years
Mental Disorders (Includes Alcohol Abuse) Class A Current evidence according to DSM criteria of mental disorder (includes alcohol abuse) Associated harmful behavior or history of harmful behavior judged likely to recur Class B Current evidence according to DSM criteria of mental disorder (includes alcohol abuse) and No currently associated harmful behavior and no history of harmful behavior that is judged likely to recur
Substance Abuse and Addiction (Dependence)
Substance Abuse and Addiction (Dependence) Panel physician responsibilities Interview and examine applicant Review records Determine if there is current or past nonmedical use of a psychoactive substance Determine if DSM criteria met for abuse/dependence If yes, determine whether substance listed in Section 202 of the Controlled Substances Act (CSA); see Appendix C of 2010 TI
Substance Abuse and Addiction (Dependence) Non-medical use of substance on CSA and DSM criteria Class A Non-medical use of substance not on CSA and DSM criteria If insufficient data provided Must assess for associated harmful behavior to determine if Class A or Class B May defer for additional information or abstinence to be established (see Figure 2 of 2010 TI) Panel physician should refer to specialist if unable to determine diagnosis or classification (see Table 4 of 2010 TI)
Drug Classes in Section 202 of the CSA (Not All-Inclusive) Cannabinoids Phencyclidine (PCP) and Related Substances Hallucinogens Amphetamines and Related Substances Cocaine and Related substances Sedative, Hypnotic, or Anxiolytic Substances (Tranquilizers) Opioids and Related Substances
Definitions Substance Abuse/Dependence Includes 2 groups 1. Nonmedical users of any drug currently listed in Section 202 of the Controlled Substances Act 2. Nonmedical users of any drug currently listed in Section 202 of the Controlled Substances Act
Definitions Nonmedical users of any drug currently listed in Section 202 of the Controlled Substances Act Must meet DSM criteria for abuse/dependence diagnosis For CSA, click on Appendix C of the 2010 TI at www.cdc.gov/immigrantrefugeehealth/exams/ti/p anel/technical-instructions-panel-physicians.html No associated harmful behavior required for Class A
Includes alcohol Definitions (cont.) Nonmedical users of any drug currently listed in Section 202 of the Controlled Substances Act Must meet DSM criteria for abuse/dependence diagnosis Determination of Class A or B classification Same as for mental health or physical condition For Class A, there must be current associated harmful behavior, or a history of harmful behavior judged likely to recur
Remission (Class B) Definitions (cont.) DSM criteria for full, sustained remission Includes no use of a drug listed in Section 202 of the CSA for 12 months Includes no use of a drug NOT listed in Section 202 of the CSA for 12 months (includes alcohol) See Table 2 of 2010 TI Panel physician/specialist must also use clinical judgment in determining if 12 months is sufficient time period
Substance Abuse and Addiction (Dependence) Notes No waiver available for immigrants IRMH/CDC not involved in waiver for nonimmigrant visa applicants (NIVs)
Substance Abuse and Addiction (Dependence) Notes (cont.) Classification For substances on CSA, non-medical use and DSM diagnosis Class A Substance Abuse/Dependence For substances NOT on CSA (includes alcohol), non-medical use, DSM diagnosis, and associated harmful behavior Class A Mental Disorder with Associated Harmful Behavior
CDC Review of Individual Applicant Substance Abuse/Dependence CDC available to provide advice and consultation to panel physicians or Consular Sections CDC consultant psychiatrist conducts review of cases on regular basis or as needed A request for an advisory opinion of diagnosis and classification may be made through the Consular Section to IRMH/CDC consultant psychiatrist
Key Concepts Harmful behavior not associated with specific mental or physical disorder is not considered inadmissible under health-related grounds, but may be inadmissible under criminal grounds as determined by DHS/USCIS Alcohol Dependence or abuse is considered same as mental disorder and requires associated harmful behavior to be classified as medically inadmissible condition
Travel Clearance and Validity 12 months from time evaluation is complete Applicants that do not have a Class A or Class B mental health or substance related disorder 6 months from time evaluation is complete Applicants who have a Class A or Class B classification for a physical or mental disorder or a substance related disorder Applicants who do not travel within the clearance period will need to restart the mental health screening process
Waivers Applicants who are Class A for a mental disorder with associated harmful behavior may be eligible for a Class A waiver Most applicants with substance abuse or addiction are ineligible to apply for a Class A waiver Applicants with a substance abuse diagnosis now in remission and reclassified as Class B do not need to apply for a waiver CDC reviews Class A waiver requests and supporting medical documents, to ensure applicant has been properly diagnosed and classified, and an appropriate U.S. health care provider identified. DHS adjudicates waiver request and makes decision regarding whether to grant waiver
Thank You Questions?