Download B1_Harvey Mental Health Workshop 2017_FOR

Mastering the Subtleties of the
Mental Health and Substance
Use Screening Workshop
Linda Harvey, MD
Consultant Psychiatrist
Medical Assessment and Policy Team
Immigrant, Refugee, and Migrant Health Branch
Panel Physicians Training Summit
March 27, 2017
National Center for Emerging and Zoonotic Infectious Diseases
Division of Global Migration and Quarantine
Learning Objectives and Agenda
After this session, you should be able to:
Apply the DSM V criteria and the basics of diagnosis
Distinguish the complexities of DUI
Implement the concept of remission
Question I
The consular section refers a 22-year-old
student visa applicant for an exam because
she had an arrest for driving under the
influence (DUI) last year. What is your goal?
A.
B.
C.
D.
E.
Perform the examination
Determine if DSM V criteria are met
Submit DS Forms to Consular Section
Make a classification
Get paid
Goal?
Make a classification
Question 2
During your interview with this applicant, she
asks you what you need to know to determine if
she can study in the United States. Which of the
following is the best answer to her question?
A.
B.
C.
D.
E.
If she has a substance use or substanceinduced disorder
If she continues to drink
Her field of study
Her liver enzyme levels
Her blood-alcohol level at the time of DUI
Information Needed
1)
Evidence of a non-substance-related mental disorder?
 Are DSM V criteria met for diagnosis?
2)
Any substance use?
 Controlled Substances Act (CSA) list?
 Are DSM V criteria met for substance use or substance-induced
disorder?
3)
Associated harmful behavior present?
 Currently, OR
 Past harmful behavior judged likely to recur.
Mental Health Evaluation
1.
Review medical/psychiatric history
2.
Interview applicant
3.
Review laboratory results, if indicated
4.
Mental status evaluation
Mental Health Evaluation:
Medical History Review
1.
Review medical/psychiatric history
• Hospitalization or institutionalization for psychiatric
illness
• History of harmful behavior
• 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
Question 3
Which one of the following is not an example of
harmful behavior?
A.
B.
C.
D.
E.
Suicide attempts
Recurring episodes of self-cutting
DUI
Public intoxication
Destruction of hotel property
History of Harmful Behavior

Prior suicide attempts

Other recurring self injury

Has created serious threat to health or safety of
self and others (DUI, verbal threats)

Substantial damage to property
Additional Records for Review
Police
(criminal)
Military
School
Employment
Mental Health Evaluation:
The Interview
2.
Interview applicant
•
•
•
•
•
Psychiatric symptoms & history
Family history
Social history
History of associated harmful behavior
Use of drugs and medications
*Interview applicant’s family when appropriate
Psychiatric Symptoms and History






Depression (lack of interest in activities,
feelings of hopelessness, guilt)
Anxiety (worries, fears, remembering traumatic
events)
Mania/Hypomania (elevated mood,
racing thoughts, impulsivity)
Psychosis (hallucinations, delusions, paranoia)
Difficulty sleeping
Difficulty concentrating
Reference Tool

Reference Tool 4
provides a list of topics
that panel physicians can
use to guide their mental
health evaluation
interview

Includes four questions
to consider asking
every applicant
Interview Questions




Do you or have you ever had thoughts about harming
yourself and have you ever taken any actions based on these
thoughts?
Do you or have you ever had thoughts about harming others
and have you ever taken any actions based on
these thoughts?
Do you currently or have you ever used alcohol or any
other substances?
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:
Laboratory Results
3.
Review laboratory results, if indicated
• Only if indicated
• Liver enzyme tests do not diagnose alcohol
use disorder
• Urine drug screens should be performed on
case-by-case basis
Mental Health Evaluation:
Mental Status Evaluation







Appearance
Attitude
Behavior
Speech
Thought process
Thought content
Mood and affect





Suicidal/homicidal
thoughts
Perceptions
Cognition
Insight
Judgement
THE DIAGNOSTIC
AND STATISTICAL
MANUAL OF
MENTAL DISORDERS
(DSM-5)
Substance Use Disorder Criteria
Impaired control
1.
2.
3.
4.
Use larger amounts over time
Desire to reduce use
Spend time obtaining, using, or recovering from effects of substance
Craving
Social impairment
5. Failure to fulfill obligations at work, school, or home
6. Continued use despite problems caused by substance
7. Stops doing activities
Risky use
8. Use when physically hazardous
9. Continued use despite problems
Pharmacologic
10. Tolerance
11. Withdrawal
Question 4
Which of the following is included in the
criteria for diagnosing a substance-use
disorder?
A.
B.
C.
D.
Use of a substance for at least 1 year
Enjoys using the substance
Uses substance alone
Uses substance despite problems
Substance-Induced Disorder Criteria
Disorders that have been caused by the use of a substance:
• Intoxication
• Withdrawal
• Other substance/medication-induced mental
disorders:
o Psychotic disorder
o Depressive disorders
o Anxiety disorders
o Sleep disorders
o Sexual dysfunctions
o Delirium
Question 5
A 23-year-old football player reports taking
hydrocodone prn for recurrent knee pain since an ACL
repair 2.5 years ago and shows you his prescription.
His father is a prominent surgeon in your community.
He was arrested 3 months ago for petty theft. Upon
exam, he appears anxious and is sweating profusely.
Before leaving, he asks you for a prescription for pain
pills. What is his classification?
A.
B.
C.
D.
Class A
Class B
Class B Other
No Class
Prescription Drug Use

Patients can meet criteria for substance-use or
substance-induced disorder for prescribed
substances and be Class A despite having
a prescription
Severity

Mild
• 2-3 symptoms met

Moderate
• 4-5 symptoms met

Severe
• ≥6 symptoms met
Question 6
An applicant meets two criteria for a
substance-use disorder, so they are No
Class.
A.
B.
True
False
Severity

Mild
• 2-3 symptoms met

Moderate
• 4-5 symptoms met

Severe
• ≥6 symptoms met
Question 7
A 52-year-old business woman uses marijuana.
She is well respected in your community. She is
very functional and smokes marijuana a few
times per week. Prior to her recent divorce, she
only used marijuana once per week. Now she says
she “can’t make herself stop.” What is her
classification?
A.
B.
C.
D.
Class A
Class B
No Class
Defer for more information
Question 8
A 55-year-old applicant reports increasing
alcohol use over the past year, needing to
drink more to get the desired effect,
drinking while driving, but wanting to
drink less. All other history is negative. The
applicant has:
A.
B.
C.
Mild substance-use disorder
Moderate substance-use disorder
Severe substance-use disorder
Question 9
What is the classification of the previous
applicant?
Class A
B. Class B
C. No Class
D. Need more information
A.
Question 10
You diagnose a 43-year-old male applicant
with a substance-use disorder. What else do
you need to know to make a classification?
A.
B.
C.
D.
E.
If the substance is a controlled substance
If there is a risk of harmful behavior
Whether or not he is in remission
A and B
A and C
Recap
You can make the classification for any applicant
if you know:
1. If DSM-5 criteria are met for:
• Substance-use disorder
• Substance-induced disorder
2. If harmful behavior is present or judged likely to
recur
When does an applicant need a mental
health evaluation?
Is the issue substance use or alcohol related?
Yes
No
Are ≥2 DSM criteria met for substance use disorder?
or
Is DSM criteria met for substance induced disorder?
Yes
No
Is the substance on the
Controlled Substances Act?
Yes
Class A
Is DSM criteria met for
a diagnosis?
No Class
No
Yes
Is current harmful behavior present or
has there been previous harmful
behavior that is judged likely to recur?
No
Yes
No
Class A
Class B
Basics of Remission

DSM-5 defines sustained, full remission as a period of
at least 12 months during which no substance use or
mental disorder-associated behaviors have occurred.

The panel physician/consultant must use clinical
judgment in determining if 12 months is an acceptable
period of time for an applicant to demonstrate
sustained, full remission.

The time period should be based on the reliability of
the evidence provided
Basics of DUI
Alcohol is not on the CSA list – therefore, it is
treated the same as a mental disorder:
1. Go through the 11 criteria for diagnosis (DSM5)
2. Does it meet at least two of the criteria?
3. If no – No Class
4. If yes – must look at harmful behavior
5. No harmful behavior – Class B
6. Harmful behavior – Class A
Case Studies
Thank you
[email protected]
http://www.cdc.gov/panelphysicians
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
Visit: www.cdc.gov | Contact CDC at: 1-800-CDC-INFO or www.cdc.gov/info
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the
Centers for Disease Control and Prevention.
National Center for Emerging and Zoonotic Infectious Diseases
Division of Global Migration and Quarantine