Psychiatrists Should Be Involved in Assessing MH Status of U.S. Immigrants

In a letter to the Centers for Disease Control and Prevention (CDC) last month, APA asked the agency to continue employing psychiatrists to review the mental status of aliens seeking to enter the United States or to adjust their legal status.

Currently, the Immigration and Nationality Act (INA) blocks admission of aliens with a physical or mental disorder that “may pose or has posed a threat to the property, safety, or welfare of the alien or others” or of those who are determined to be “drug abusers or addicts.”

Individuals ruled inadmissible may appeal such decisions to a review board convened by the CDC. In the past, when the appeal involved a mental health issue, the CDC required that the review board include a board-certified psychiatrist.

The CDC’s newly proposed regulation is less specific. Among other things, it calls for “at least one medical officer who is experienced in the diagnosis and treatment of the physical or mental disorder, or substance-related disorder for which the notification was made.”

The CDC’s rationale for this change is that it would be easier and more efficient to convene a review board. Changes to the CDC rule would also end the requirement that medical officers be physicians in the U.S. Public Health Commissioned Corps, expanding the pool from which psychiatrists could be drawn.

“Nonpsychiatric physicians do not have the expertise to perform the necessary dangerousness-based risk assessments and cannot ensure that the determination of inadmissibility is valid,” APA CEO and Medical Director Saul Levin, M.D., M.P.A., wrote in a letter to CDC Director Thomas Frieden, M.D., M.P.H. “Psychiatrists are both the highest qualified physicians and the highest qualified mental health clinicians to ensure the validity of the type of determinations that rest in the relevant statute.”

The goal, said Levin, quoting the CDC’s own words, should be “to meet the needs of the alien.”

While medical reasons to exclude foreign travelers to the United States are mostly based on the active presence of communicable diseases, the psychiatric criteria are much more vague and appear to conflate mental illness with dangerousness, said Steven Kenny Hoge, M.D., chair of APA’s Council on Psychiatry and the Law.

“Presumably, someone who was dangerous but did not have a mental illness could be permitted to enter the country,” Hoge told Psychiatric News.

Even before the CDC issued its proposed regulations, the council was already examining how the criteria had been applied in the case of several people stopped at the Canadian border, said Hoge.

In Levin’s letter to the CDC, he expressed his concerns over the CDC’s maintenance of policies and language that stigmatizes people with mental illness by assuming that aliens with mental illness were likely to be violent.

“The inadmissibility framework does not address those aliens who may be dangerous and have never been diagnosed with a mental illness,” he said.

In addition, the use of the terms “drug abuser” and “drug addict” in the regulations are outmoded and discriminatory and should be replaced with terms more compatible with current behavioral or medical standards, said Levin. However, those changes must be made legislatively by the Congress.

APA did applaud the CDC’s recently proposed change to make explicit the use of the “most recent edition” of the Diagnostic and Statistical Manual for Mental Disorders as the standard for defining drug abuse, drug addiction, and mental disorders. Some reviewers had been using earlier editions of the DSM, with obsolete definitions of disorders.

The CDC is now evaluating all the comments received about the proposed regulations. ■