Mental Health

Background

The purpose of the adjustment of status examination is to identify health-related conditions that render an applicant inadmissible (Class A). The Immigration and Nationality Act (INA) provides three grounds of inadmissibility related to substance addiction or abuse, or physical or mental disorders that affect behavior. They are:

• Current physical or mental disorder with associated harmful behavior.
• Current physical or mental disorder with a history of associated harmful behavior if the harmful behavior is likely to recur or lead to other harmful behavior in the future.
• Drug (substance) abuse or addiction (medically identified as a "substance use disorder") of any of the substances listed in Section 202 of the Controlled Substances Act (Appendix C).

Thus, medical screening for physical and mental disorders with associated harmful behaviors and substance use disorders among persons applying for adjustment of status in the U.S. is an essential component of the immigration process. Because such conditions are challenging to diagnose and treat, these Technical Instructions provide a method for recording findings from the medical examination and guidance for the civil surgeon on classifying applicants. The Technical Instructions use uniform criteria for diagnosis consistent with current medical knowledge and standards of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders Fifth Edition, Text Revision (DSM-5-TR).

The instructions in this document supersede all previous Mental Health Technical Instructions, updates to the Technical Instructions, memoranda and letters to civil surgeons, and memoranda and letters to international refugee resettlement organizations.

For questions about these Technical Instructions, please contact the Immigrant and Refugee Health Branch of the Division of Global Migration Health (DGMH), Centers for Disease Control and Prevention (CDC), at civilsurgeons@cdc.gov. For more information pertinent to these instructions and the required medical examination for applicants for U.S. adjustment of status visit: Technical Instructions for Civil Surgeons.

Key Concepts

"V" Coded Condition

"V" coded conditions listed in the DSM are not diagnoses but are used in clinical practice settings when the focus is on a behavior that is not due to a mental disorder. Because these "V" coded conditions are not mental disorders, they cannot be used in determining if a person has an inadmissible (Class A) health-related condition, regardless of whether there is an associated harmful behavior. However, treatment might be recommended for behaviors associated with "V" coded conditions.

Physical Disorder

Physical disorders are clinically diagnosed medical conditions where the focus of attention is physical manifestations. Only physical conditions that are included in the current version of the International Classification of Diseases (ICD) will be considered for the purpose of this portion of the overseas medical examination.

Physical disorders are rarely associated with harmful behavior. However, it may happen in delirious or confused states due to metabolic disturbances, hypoglycemia, some psychomotor epilepsies and in the aftermath of generalized seizure disorders.

Physical disorders that have associated harmful behaviors, either current or likely to recur, are inadmissible (Class A) conditions.

Physical disorders that do not have associated harmful behaviors or that have a history of associated harmful behaviors that have been judged unlikely to recur are considered Class B conditions.

Mental Disorder

Mental disorders are health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination). The current version of the DSM is an authoritative source on the classification of mental disorders and must be followed for this portion of the overseas medical examination. For the purpose of these Technical Instructions, "mental disorders" do not include substance use disorders. Substance use disorders are addressed separately, below.

Mental disorders that have associated harmful behaviors, either current or likely to recur, are inadmissible (Class A) conditions.

Mental disorders that do not have associated harmful behaviors or that have a history of associated harmful behaviors that have been judged unlikely to recur are considered Class B conditions.

Substance Use Disorder

The DSM diagnosis for substance use disorders is used in this portion of the overseas medical examination to determine "drug abuse" and "drug addiction."

The essential feature of a substance use disorder is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems. Diagnoses of substance use disorders are to be made in accordance with existing medical standards as determined by the current edition of the DSM. There are 11 criteria for substance use disorders listed in the DSM, grouped into four primary categories: impaired control, social impairment, risky use, and physical dependence. A detailed list and additional commentary on the 11 criteria for substance use disorders can be found in the DSM-5. The civil surgeon must assess each of the 11 criteria in determining whether an individual has (or has ever had) a substance use disorder and at least 2 criteria must be met in order to make a diagnosis. In other words, if an applicant's substance use does not meet at least 2 of the DSM substance use disorder criteria, they are considered "No Class."

For the purpose of this evaluation, substances will be considered as belonging to one of the two following categories:

• Controlled Substances Act (CSA) substances – include any substance listed in Schedules I through V of Section 202 of the CSA. (See Appendix C.) Substance use disorders (of any severity) involving a CSA substance are inadmissible (Class A) conditions and do not require additional evidence of associated harmful behavior.
• Non-CSA substances - include alcohol and all other psychoactive substances not found in the CSA. Substance use disorders (of any severity) involving a non-CSA substance must also be assessed for associated harmful behavior. Those with associated harmful behaviors, either current or likely to recur, are inadmissible (Class A) conditions. Those without any associated harmful behaviors are considered Class B conditions and are not inadmissible.

Harmful Behavior

A harmful behavior is defined as an action associated with a mental or physical disorder, or a non-CSA substance use disorder that is causing or has caused any of the following:

• Serious psychological or physical injury to the applicant or to others (e.g., a suicide attempt or child abuse).
• A serious threat to health or safety (e.g., driving while intoxicated or verbally threatening to kill someone).
• Major property damage.

Mental disorders most associated with harmful behavior include:

• Mood disorders.
• Anxiety disorders that include post-traumatic stress disorder, panic disorders, and phobias.
• Personality disorders that include antisocial, paranoid, and borderline personality disorders.
• Sexual disorders that include paraphilia.
• Schizophrenia and other psychotic disorders.

However, the following are excluded from the above definition of "harmful behavior" for the purpose of this examination:

• Harmful behaviors that are the direct result of an applicant's environment – if the harmful behavior would likely cease completely if the applicant was removed from the current environment, that harmful behavior is not considered for the purpose of these instructions.
• Nonsuicidal self-injury – if it is determined that the harmful behavior is being inflicted toward the applicant themselves and is not life threatening or indicating an intent to die, but rather an attempt to cope with emotional pain, sadness, anger and stress (e.g., superficial cutting, scratching, burning), that harmful behavior is not considered for the purpose of these instructions.
• Harmful behaviors resulting from an applicant's significant intellectual disability (regardless of the cause) – if the harmful behavior is done as a means of expressing frustration, such as hitting, biting or head-banging and not with any intent to harm, that harmful behavior is not considered for the purpose of these instructions.

Thus, for the remainder of this document, the term "harmful behavior" is referring only to those behaviors that meet the above definition, applying the listed exclusions.

As discussed above, a CSA substance use disorder alone is an inadmissible condition (Class A) and does not require the additional presence of harmful behavior to be considered inadmissible.

Applicants with harmful behaviors not associated with a physical or mental disorder or a non-CSA substance use disorder may be rendered inadmissible under criminal grounds as determined by [an adjudicating officer of] the U.S. Citizenship and Immigration Services (USCIS). However, only harmful behaviors associated with a physical or mental disorder or non-CSA substance use disorder are relevant for the determination of medical ineligibility; neither harmful behavior nor the physical or mental disorder or non-CSA substance use disorder alone makes an applicant medically inadmissible.

Mental Health Examination

Overview

As part of the history and physical examination of the applicant, the civil surgeon must:

• Identify and diagnose any physical or mental disorder or substance use disorders.
• Identify any harmful behaviors associated with physical or mental disorders or non-CSA substance use disorders.
• Determine the likelihood of recurrence of prior harmful behaviors.
• Determine the remission status of any disorders previously diagnosed.

For most applicants, this can be completed in one appointment. However, for some applicants, multiple appointments or consultations with a mental health specialist may be needed to make an accurate diagnosis (see referral section below).

Medical History and Psychiatric Evaluation

The civil surgeon should obtain and consider as much information as possible regarding the applicant's medical and behavioral history. At a minimum, the civil surgeon should do the following:

1. Complete a thorough history to include (but not limited to) questions about:
   1. The applicant's history of diagnosed mental or physical disorders.
   2. The applicant's use of CSA and non-CSA substances and prescription medicines, both currently and in the past.
   3. The applicant's current or past behaviors that are or were harmful to self or others.
2. Conduct an activities assessment and mental status examination that assess at a minimum:
   1. Orientation
   2. Mood and affect
   3. Speech and language
   4. Thought process and content
   5. Behavior
3. Review other relevant records (if available), such as police, military, school and employment, and any historical medical records, that might provide a history of harmful behavior or substance use.
4. Ask family members for information about the applicant regarding social dysfunction, as well as any school, occupational or law enforcement problems.

If any associated harmful behaviors are identified, the civil surgeon should then do the following:

1. Determine whether the behavior is current or in the past.
2. Decide whether any past harmful behavior is unlikely to recur. Past harmful behavior is considered unlikely to recur if both of the following are true:
   1. The underlying physical or mental disorder or non-CSA substance use disorder is either in remission or is reliably controlled by medication or other effective treatment; AND
   2. It has been at least 12 months since the harmful behavior occurred. However, clinical judgement must be used to determine if this is enough time to make such a decision (See "Remission" section).

Under most circumstances, applicants will not require additional psychological or neuropsychological testing. Projective instruments, such as the Rorschach test, may not be useful given the added administrative and time burden; however, particularly when harmful behavior is present, these tests may be used to aid in making a diagnosis.

For applicants who demonstrate cognitive impairment such as dementia or intellectual disability, the civil surgeon may estimate the degree of impairment by assessing the applicant's (1) level of knowledge and (2) ability to carry out functions of daily living (e.g., learning, communication, and routine activities). Any available reports of cognitive, development, intelligence testing, or neuropsychological testing in the medical record should be included with the civil surgeon's report. However, the civil surgeon is not required to routinely send such applicants for additional psychological tests and should not do so unless a medical inadmissibility is suspected.

Laboratory Testing for Substances

Civil surgeons should not routinely subject whole populations of applicants to laboratory testing such as urine drug testing. Instead, the civil surgeon must evaluate the individual applicant's history, behavior and physical appearance when determining if laboratory testing should be performed. (See Table 1)

However, there are two circumstances in which laboratory testing for CSA substances is required as part of the mental health examination:

• When a civil surgeon defers a diagnosis or classification of a CSA substance use disorder for 3 to 6 months, random laboratory testing for CSA substances on short notice (i.e., 24 to 48 hours after notification) to the applicant is required to aid in the determination of diagnosis and classification. Civil surgeons must perform a minimum of three tests during the 3-to-6-month period.
• When determining remission from a CSA substance use disorder, random laboratory testing for CSA substances on short notice (i.e., 24 to 48 hours after notification) to the applicant is required to aid in this determination by confirming the absence of substance use. Civil surgeons must perform a minimum of four tests over a 12-month period.

If laboratory testing for the CSA substance associated with the substance use disorder is not routinely available, please contact civilsurgeons@cdc.gov for additional instruction.

Laboratory testing for alcohol use disorders is largely non-specific and as such, civil surgeons are not permitted to use these tests in place of standard diagnostic screening tools. However, laboratory testing can be used along with clinical judgement as an additional piece of clinical information to confirm a suspected diagnosis and to document remission for alcohol use disorders (see remission section below). Although not required for the medical examination, several laboratory alcohol "biomarkers" can be used including:

• Liver enzymes: a ratio of aspartate aminotransferase (AST): alanine aminotransferase (ALT)>2:1 is suggestive of alcohol-induced liver disease.
• Gamma-glutamyltransferase (GGT): elevated levels can suggest excessive alcohol use. GGT levels of >30U/IL can reflect alcohol consumption of >4 drinks per day.
• Carbohydrate-deficient transferrin (CDT): considered more specific than GGT alone for chronic excessive alcohol use with few factors causing false positives. It can be used to distinguish heavy alcohol use from social drinking. When used in combination, GGT-CDT, can further improve the detection of excessive alcohol consumption.
• Urine test for alcohol metabolites: ethyl glucuronide (EtG) and ethyl sulfonate (EtS) are minor metabolites of ethanol and can be detected for up to 5 days in urine, although these tests will have higher accuracy for the first 24 hours after use. Test sensitivity is highest in heavy drinkers.

Other laboratory testing depends on the availability of laboratory services and the clinical judgment of the civil surgeon. For instance, laboratory testing to identify underlying medical conditions causing psychiatric manifestations may be necessary before making any diagnoses. However, specialized laboratory testing, such as dexamethasone suppression tests or challenge administration of various pharmaceuticals, is usually not indicated.

Therapeutic levels of prescribed anticonvulsant medications, antipsychotic medications, or other medicines used in psychiatry (such as lithium levels) might also be of value to the civil surgeon or mental health specialist in:

• Determining the applicant's adherence to a prescribed course of treatment.
• Possibly changing or adjusting the applicant's medications, and therefore contributing to remission of illness and reduction of associated harmful behavior.

Civil surgeons must know the reliability and validity of the laboratory tests and laboratory methods used during the medical evaluation. All laboratory testing for substances must be done using materials licensed by the U.S. Food and Drug Administration. Rapid testing or semi-quantitative testing may be used for the screening test; however, gas chromatography/mass spectrometry (GC/MS), performed at a reference laboratory, must be used as the confirmatory test. Positive and negative controls must be used with any testing and only test kits that are for medical diagnosis and treatment must be used. Forensic testing is minimally regulated and will be labeled "not for medical diagnosis and treatment." Therefore, it should not be used because it is not sensitive enough for medical purposes.

Referring the Applicant to a Specialist

Referral to a mental health specialist is not a requirement for this examination. However, after reviewing the applicant's medical history and performing a psychiatric evaluation, the civil surgeon might feel that a more specialized psychiatric examination is indicated to determine if an applicant has a mental or physical disorder with associated harmful behavior, or a substance use disorder involving a CSA or non-CSA substance (See Table 2). In these cases, the civil surgeon should have a previously identified mental health specialist who can carry out a full psychiatric evaluation. Civil surgeons should only refer cases to a specialist to confirm or rule out a suspected inadmissibility (Class A condition) and only when the civil surgeon is unable to make a diagnosis or determination regarding associated harmful behavior utilizing their own level of expertise.

Virtual evaluations by a mental health specialist are acceptable for this portion of the mental health examination only and no other portion of the U.S. adjustment of status for U.S. permanent residency medical examination.

Deferring a Diagnosis/Classification

If the civil surgeon is unable to determine whether an applicant has an inadmissible (Class A) condition, the civil surgeon may defer diagnosis and classification for 3 to 6 months to obtain additional medical evidence.

As noted above, in cases where a diagnosis or classification is deferred for a suspected CSA substance use disorder, random testing for substances on short notice to the applicant is required to aid in the determination of diagnosis and classification. Civil surgeons must perform a minimum of three tests during this period.

In cases of deferment for a suspected mental or physical disorder or non-CSA substance use disorder with associated harmful behavior, civil surgeons may use this time to obtain additional records, communicate with family members, obtain relevant laboratory testing, or refer to a specialist for a more detailed evaluation.

For applicants with deferred diagnosis and classification, the civil surgeon must have medical rationale for the deferment and must clearly explain to the applicant what is required during the next 3 to 6 months for the civil surgeon to be able to diagnose and classify. The civil surgeon should also ideally write these instructions in a document that is signed by the applicant.

Referring a Case to DGMH

If an applicant has been referred to a mental health specialist for psychiatric evaluation and the civil surgeon still needs assistance in determining the diagnosis and classification of a suspected inadmissibility (Class A condition), DGMH may be consulted to provide additional assistance.

Civil surgeons should only consult DGMH in situations where, after their own examination and evaluation by a mental health specialist, they are still unable to make a final determination on diagnosis or classification.

To submit a case to DGMH for review, a copy of all pertinent medical information should be sent via secure files to civilsurgeons@cdc.gov.

Remission

Remission must be considered in three contexts (see Figure 2):

1. General mental or physical disorders.
2. CSA substance use disorders.
3. Non-CSA substances use disorders (e.g. alcohol use disorders).

For general mental or physical disorders, the determination of remission must be made based on both of the following criteria:

• The disorder must be under control by one or more of the following: medication, therapy or natural history of the disorder; AND
  
• It has been at least 12 months since the last occurrence of associated harmful behavior.

For CSA substance use disorders, the determination of remission must be made based on both of the following criteria:

• At least 12 consecutive months during which the applicant does not meet any DSM criteria for a substance use disorder, with the exception of craving; AND
• Full abstinence from use. Abstinence must be verified by a minimum of four random laboratory screenings on short notice for CSA substances over a 12-month period. If laboratory testing for the CSA substance associated with the substance use disorder is not routinely available, please contact civilsurgeons@cdc.gov for additional instruction.
  • The 12 months of CSA substance sustained remission can begin prior to the medical exam if the civil surgeon can document the applicants' remission efforts. This requires corroborating the applicant's responses with input from family members, therapists, support groups, rehabilitation facilities, etc. and documentation of at least one negative random laboratory screen. Otherwise, the 12 months of sustained remission begins at the first negative laboratory screen performed as part of the medical exam.
  • When used for achieving sustained remission of an opioid use disorder, agonist therapy such as methadone or buprenorphine, should not be considered a CSA substance.

For non-CSA substance use disorders (e.g. alcohol use disorders), full abstinence from use is not required to determine remission. However, in lieu of full abstinence, both of the following must be met:

• At least 12 consecutive months during which the applicant does not meet any DSM criteria for a substance use disorder, except craving. AND
• At least 12 months since the last occurrence of associated harmful behavior.
  • The 12 months of non-CSA substance sustained remission can begin prior to the medical exam if the civil surgeon can document the applicants' remission efforts. This requires corroborating the applicant's responses with input from family members, therapists, support groups, rehabilitation facilities, etc. Otherwise, the 12 months of sustained remission begins at the time of the medical exam.

For alcohol use disorders, although not required, some laboratory monitoring for can be useful to confirm a reduction in use. See the above laboratory section for more details.

If an applicant claims to have previously met the above listed criteria for remission from any Class A disorder, but has no objective documentation to corroborate their account, the civil surgeon must defer for 3-6 months and follow the requirements outlined in the "deferring a diagnosis/classification" section above.

Class A Applicants

For applicants who are found to be inadmissible (Class A), civil surgeons must explain what is expected in order for them to meet criteria for remission as a means of overcoming their inadmissibility. If treatment is indicated, civil surgeons should also provide information regarding recommended treatment options. Civil surgeons should ideally write these instructions in a document that is signed by the applicant, confirming that they understand what has been explained to them.

After applicants submit their completed Form I-693 to USCIS and it has been reviewed by an officer, USCIS will issue a request for evidence (RFE) to confirm that remission has been met. The applicant should then return to the civil surgeon to have their remission documented on a new Form I-693.

Applicants who are found to be Class A for a mental disorder with associated harmful behavior or a non-CSA substance use disorder with associated harmful behavior are eligible to apply for a Class A waiver of inadmissibility. However, applicants who have been determined to be Class A for a substance use disorder involving a CSA substance are not eligible for a waiver and therefore, must complete the required criteria for remission before reapplying for admission.

Please see "Waivers" section below for more information.

Additional Concepts to Consider

Marijuana (i.e., Tetrahydrocannabinols (THC))

Despite several U.S. state governments legalizing marijuana or some of its derivatives, including derivatives with > 0.3% THC, it is still considered a CSA substance by the United States Drug Enforcement Agency (DEA).

As is true for all CSA substances, applicants admitting occasional use or having one positive urine drug test alone does not make an applicant inadmissible (Class A). To be considered Class A, they must meet at least 2 of the 11 DSM criteria for a substance use disorder. The topics of deferment, remission, and laboratory testing for CSA substances are detailed above.

Prescription Drugs

Substances used for clinical care in medical practice are not prohibited. Prescription drugs taken in accordance with a prescription do not amount to a substance use disorder. However, misuse of prescription drugs could indicate a substance use disorder. If that is suspected, further investigation would require a full evaluation by the examining physician with particular attention to whether illicit drugs are being used, because use of illicit drugs is a risk factor for the abuse of prescribed CSA substances.

Sexually Dangerous People

Not all sexually dangerous people have behaviors attributable to a mental disorder. Likewise, not all people diagnosed with a paraphilic disorder will demonstrate harmful behavior. As stated in the Mental Disorder and Harmful Behavior sections above, there must be an underlying diagnosable mental disorder with associated harmful behavior – either current, or likely to recur – to be considered a Class A condition. Of note, harmful behaviors do include the viewing of child pornography because children are at least indirectly harmed, or at worst directly harmed, during the making of such imagery.

To achieve remission for a Class A paraphilic disorder, applicants must still meet the same remission criteria outlined above for other mental disorder, with the exception of pedophilic disorder. Research has demonstrated that individuals diagnosed with pedophilic disorder do not reliably benefit from treatment programs, and thus can never truly reach a point where there is no risk that they will act on their desires. As a result, remission for pedophilic disorder is not achievable and any applicant diagnosed with pedophilic disorder must remain medically classifiable as Class A for the remainder of their lives.

Screening Results and Classifications

The mental health screening is complete when all required aspects of the medical examination have been finalized, including the report of the specialist and laboratory test results, if indicated

Applicants may have more than one classification. For instance, an applicant can be Class A for both a mental disorder and a CSA substance use disorder. However, applicants cannot be classified as both Class A and Class B for the same physical, mental, or substance use disorder (see Figure 1).

Mental Health and Substance Use Disorder Classifications

There are three categories of mental health and substance use disorder classifications, listed below:

No Class A or Class B Classification

• Applicants with no diagnosis of physical, mental or substance use disorder.
• Applicants with occasional use of a substance (CSA or non-CSA), but who do not meet criteria for a substance use disorder.
• Applicants with harmful behavior that is not associated with any diagnosable physical, mental, or substance use disorder.

Class A Classification

• Applicants diagnosed with a current physical or mental disorder with associated harmful behavior.
• Applicants diagnosed with a non-CSA substance use disorder (e.g. alcohol use disorder) with associated harmful behavior.
• Applicants diagnosed with a CSA substance use disorder.

Class B Classification

• Applicants diagnosed with a current physical or mental disorder with no associated harmful behavior.
• Applicants diagnosed with a non-CSA substance use disorder (e.g. alcohol use disorder) without a history of associated harmful behavior.
• Applicants diagnosed with physical or mental disorder with a history of associated harmful behavior now in remission.
• Applicants diagnosed with a CSA substance use disorder, now in sustained remission.
• Applicants diagnosed with a non-CSA substance use disorder with a history of associated harmful behavior, now in remission.

DSM Diagnoses and Classifications

Waivers

Applicants with a Class A physical or mental disorder or non-CSA substance use disorder with associated harmful behavior can petition for a Class A waiver. The applicant should complete Form I-601 and submit directly to USCIS. After submission, DGMH reviews the waivers and supporting medical examination upon request by USCIS to provide an opinion regarding the case. DGMH's review of the waiver and supporting medical examination documentation ensure the applicant has been classified properly and that an appropriate U.S. health care provider is identified for the applicant to continue treatment after adjudication. However, only USCIS has the final authority to adjudicate the waiver request.

Individuals seeking adjustment of status who are diagnosed with CSA substance use disorders are not eligible for a waiver.

Please note that civil surgeons should not instruct applicants to apply for Class A waivers as a universal next step when found to be inadmissible (Class A). Waivers are a costly and lengthy process and can often exceed the time it would take to achieve remission. Instead, civil surgeons should emphasize to applicants that the best pathway towards overcoming a Class A condition is to work towards, and eventually meet criteria for remission.

Please also note that civil surgeons cannot provide guidance on the likelihood or timeframe of a waiver being approved. If applicants have questions or concerns regarding the waiver process, they should be advised to reach out to USCIS.

Documentation

Civil surgeons should indicate pertinent information relating to physical or mental disorders and substance use disorders and assign any Class A or B classifications on Form I-693, Part 8.

For applicants who are referred to a mental health specialist for psychological or laboratory testing, the civil surgeon is required to attach the original specialist's report or the testing result to the I-693. The report from the specialist and all testing results must be provided in English.

For applicants evaluated for a substance use disorder, the civil surgeon or mental health specialist is required to clearly document which of the 11 DSM criteria were met and include this in their report.

For applicants with a Class A finding, civil surgeons must provide detailed notes in the remarks section of Form I-693 indicating whether the applicant is planning to follow the required steps, as indicated by the civil surgeon, to meet criteria for remission, or apply for a waiver from USCIS, if eligible.

The civil surgeon should attach to the I-693 any other documents provided for review regarding diagnosis or classification of a physical or mental disorder, or substance use disorder for an applicant.

USCIS may reject incomplete documentation and send a Request for Evidence (RFE) to the applicant.

Appendices

Appendix A: Glossary of Abbreviations

Appendix B: Useful Resources

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Diagnostic and Statistical Manual of Mental Disorders | Psychiatry Online

Appendix C: Controlled Substances

Schedules I through V of Section 202 of the Controlled Substances Act. Found in Part 1308 of Title 21 Code of Federal Regulations.

Figures

Figure 1. Classification Algorithm for Suspected Substance Use Disorder, or Physical or Mental Disorder

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Figure 2. Classification Algorithm for Evaluating Remission after a Class A Determination:

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Tables

Table 1. Indications for Laboratory Drug Screening

Include (but are not limited to) –

• History of any substance abuse or dependence with a specific substance listed in Schedules I through V of Section 202 of the Controlled Substances Act (see Appendix C).
• Applicant-provided information that appears to contradict information provided by family members or from other records such as police, military, school and employment.
• Unexplained gaps of time in the applicant's past schooling or employment.
• Evidence of unreliable or false information given during the interview or examination.
• Any demeanor, presentation, or findings that the examining physician associates with substance abuse or dependence, such as motor ability and interpersonal skills; deepened skin coloring, needle scarring, or skin ulcers along the veins in the arms or legs; a hard or bumpy liver.
• Evidence or appearance of intoxication with any substance during the examination; disturbed behavior that might be associated with a substance-related disorder.
• Follow-up on an initial positive drug screen.
• Monitoring remission.
• Deferring diagnosis/classification after confirmed or suspected substance use.

Table 2. Referring Applicant to a Mental Health Specialist

The civil surgeon may refer the applicant to a mental health specialist if after interview, review of records, and examination, they are unable to –

• Arrive at a probable diagnosis of a current mental disorder with associated harmful behavior.
• Arrive at a probable diagnosis of current CSA substance use disorder according to DSM criteria.
• Arrive at a probable diagnosis of current non-CSA substance use disorder with associated harmful behavior.
• Arrive at a probable diagnosis for past episodes of mental disorder or determine that previous difficulties in functioning were the result of a mental disorder that is associated with harmful behavior.
• Rule out the presence of a mental disorder or non-CSA substance use disorder that may be associated with known episodes of harmful behavior.
• Determine if harmful behavior has been associated with a known physical or mental disorder.
• Determine if harmful behavior has been associated with a known non-CSA substance use disorder.
• Determine if any prior associated harmful behavior is likely to recur.
• Determine if any diagnosed physical or mental disorders that were associated with harmful behavior are under control.
• Determine if any diagnosed non-CSA substance use disorders that were associated with harmful behavior are in remission.
• Determine if any diagnosed CSA substance use disorders are in remission.
• Determine the likelihood of maintaining remission or effective control of diagnosed physical or mental disorders that affect behavior.