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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