[House Hearing, 117 Congress]
[From the U.S. Government Publishing Office]
AMERICANS IN NEED: RESPONDING TO THE
NATIONAL MENTAL HEALTH CRISIS
=======================================================================
HYBRID HEARING
BEFORE THE
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED SEVENTEENTH CONGRESS
SECOND SESSION
__________
FEBRUARY 17, 2022
__________
Serial No. 117-69
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Published for the use of the Committee on Energy and Commerce
govinfo.gov/committee/house-energy
energycommerce.house.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
62-933 PDF WASHINGTON : 2026
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COMMITTEE ON ENERGY AND COMMERCE
FRANK PALLONE, Jr., New Jersey
Chairman
BOBBY L. RUSH, Illinois CATHY McMORRIS RODGERS, Washington
ANNA G. ESHOO, California Ranking Member
DIANA DeGETTE, Colorado FRED UPTON, Michigan
MIKE DOYLE, Pennsylvania MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois STEVE SCALISE, Louisiana
G. K. BUTTERFIELD, North Carolina ROBERT E. LATTA, Ohio
DORIS O. MATSUI, California BRETT GUTHRIE, Kentucky
KATHY CASTOR, Florida DAVID B. McKINLEY, West Virginia
JOHN P. SARBANES, Maryland ADAM KINZINGER, Illinois
JERRY McNERNEY, California H. MORGAN GRIFFITH, Virginia
PETER WELCH, Vermont GUS M. BILIRAKIS, Florida
PAUL TONKO, New York BILL JOHNSON, Ohio
YVETTE D. CLARKE, New York BILLY LONG, Missouri
KURT SCHRADER, Oregon LARRY BUCSHON, Indiana
TONY CARDENAS, California MARKWAYNE MULLIN, Oklahoma
RAUL RUIZ, California RICHARD HUDSON, North Carolina
SCOTT H. PETERS, California TIM WALBERG, Michigan
DEBBIE DINGELL, Michigan EARL L. ``BUDDY'' CARTER, Georgia
MARC A. VEASEY, Texas JEFF DUNCAN, South Carolina
ANN M. KUSTER, New Hampshire GARY J. PALMER, Alabama
ROBIN L. KELLY, Illinois, Vice NEAL P. DUNN, Florida
Chair JOHN R. CURTIS, Utah
NANETTE DIAZ BARRAGAN, California DEBBIE LESKO, Arizona
A. DONALD McEACHIN, Virginia GREG PENCE, Indiana
LISA BLUNT ROCHESTER, Delaware DAN CRENSHAW, Texas
DARREN SOTO, Florida JOHN JOYCE, Pennsylvania
TOM O'HALLERAN, Arizona KELLY ARMSTRONG, North Dakota
KATHLEEN M. RICE, New York
ANGIE CRAIG, Minnesota
KIM SCHRIER, Washington
LORI TRAHAN, Massachusetts
LIZZIE FLETCHER, Texas
------
Professional Staff
TIFFANY GUARASCIO, Staff Director
WAVERLY GORDON, Deputy Staff Director
NATE HODSON, Minority Staff Director
Subcommittee on Oversight and Investigations
DIANA DeGETTE, Colorado
Chair
ANN M. KUSTER, New Hampshire H. MORGAN GRIFFITH, Virginia
KATHLEEN M. RICE, New York Ranking Member
JAN SCHAKOWSKY, Illinois MICHAEL C. BURGESS, Texas
PAUL TONKO, New York DAVID B. McKINLEY, West Virginia
RAUL RUIZ, California BILLY LONG, Missouri
SCOTT H. PETERS, California, Vice NEAL P. DUNN, Florida
Chair JOHN JOYCE, Pennsylvania
KIM SCHRIER, Washington GARY J. PALMER, Alabama
LORI TRAHAN, Massachusetts CATHY McMORRIS RODGERS, Washington
TOM O'HALLERAN, Arizona (ex officio)
FRANK PALLONE, Jr., New Jersey (ex
officio)
C O N T E N T S
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Page
Hon. Diane DeGette, a Representative in Congress from the State
of Colorado, opening statement................................. 2
Prepared statement........................................... 5
Hon. H. Morgan Griffith, a Representative in Congress from the
Commonwealth of Virginia, opening statement.................... 8
Prepared statement........................................... 10
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 17
Prepared statement........................................... 19
Hon. Cathy McMorris Rodgers, a Representative in Congress from
the State of Washington, opening statement..................... 21
Prepared statement........................................... 23
Witnesses
Lisa Fortuna, M.D., M.P.H., American Psychiatric Association
Member, Vice-Chair of Psychiatry, University of California San
Francisco...................................................... 28
Prepared statement........................................... 30
Jacqueline Nesi, Ph.D., Assistant Professor of Psychiatry and
Human Behavior, Brown University............................... 39
Prepared statement........................................... 41
Amit Paley, M.B.A., CEO and Executive Director, The Trevor
Project........................................................ 49
Prepared statement........................................... 51
Christopher Thomas, Co-Founder, The Defensive Line............... 59
Prepared statement........................................... 61
Elinore F. McCance-Katz, M.D., Ph.D., Former Assistant Secretary
for Mental Health and Substance Abuse.......................... 70
Prepared statement........................................... 72
AMERICANS IN NEED: RESPONDING TO THE NATIONAL MENTAL HEALTH CRISIS
----------
THURSDAY, FEBRUARY 17, 2022
House of Representatives,
Subcommittee on Oversight and Investigations,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to notice, at 11:34 a.m., in
the John D. Dingell Room 2123, Rayburn House Office Building,
and remotely via Cisco Webex online video conferencing, Hon.
Diana DeGette, (chair of the subcommittee) presiding.
Members present: Representatives DeGette, Kuster,
Schakowsky, Tonko, Ruiz, Peters, Schrier, Trahan, O'Halleran,
Pallone (ex officio); Griffith (subcommmittee ranking member),
Burgess, McKinley, Long, Palmer, Dunn, Joyce, and Rodgers (ex
officio).
Also present: Representatives Cardenas, Blunt Rochester,
Latta, and Armstrong.
Staff present: Jesseca Boyer, Professional Staff Member;
Austin Flack, Junior Professional Staff Member; Waverly Gordon,
Deputy Staff Director and General Counsel; Tiffany Guarascio,
Staff Director; Perry Hamilton, Clerk; Fabrizio Herrera, Staff
Assistant; Zach Kahan, Deputy Director Outreach and Member
Service; Mackenzie Kuhl, Press Assistant; Will McAuliffe,
Counsel; Kaitlyn Peel, Digital Director; Chloe Rodriguez,
Clerk; Andrew Souvall, Director of Communications, Outreach,
and Member Services; Kate Arey, Minority Content Manager and
Digital Assistant; Sarah Burke, Minority Deputy Staff Director;
Marissa Gervasi, Minority Counsel Oversight and Investigations;
Brittany Havens, Minority Professional Staff Member, Oversight
and Investigations; Nate Hodson, Minority Staff Director; Peter
Kielty, Minority General Counsel; Emily King, Minority Member
Services Director; Bijan Koohmaraie, Minority Chief Counsel,
Oversight and Investigations Chief Counsel; Clare Paoletta,
Minority Policy Analyst, Health; Olivia Shields, Minority
Communications Director; Alan Slobodin, Minority Chief
Investigative Counsel, Oversight and Investigations; and
Michael Taggart, Minority Policy Director.
Ms. DeGette. The Subcommittee on Oversight and
Investigations hearing will now come to order.
Today the Subcommittee on Oversight and Investigations is
holding a hearing entitled, ``Americans in Need: Responding to
the National Mental Health Crisis.'' Today's hearing will
examine the growing mental health crisis in the United States.
During the COVID-19 public health emergency, members can
participate in today's hearing either in person or remotely,
via online video conferencing. Members, staff, and members of
the press present in the hearing room must wear a mask, in
accordance with the updated guidance issued by the Attending
Physician.
And for members participating remotely, your microphones
will be set on mute for the purpose of eliminating inadvertent
background noise. Members participating remotely will need to
unmute your microphone each time you speak. Please note, once
you unmute your microphone, anything that is said in Webex will
be heard over the loudspeakers in the committee room, and
subject to be heard by the live stream and C-SPAN. All of us
have had that unfortunate experience during the pandemic, so
let's be vigilant.
Because members are participating from different locations
at today's hearing, all recognition of members, such as for
questions, will be in order of subcommittee seniority.
And I know we have many of our members of the full
committee who are waiving on today. We welcome you, and your
questions will be in order of full committee seniority after
the subcommittee members have been recognized.
And if any time I am unable to chair the hearing, the vice
chair of the subcommittee, Mr. Peters, will serve as chair
until I can return.
Documents for the record can be sent to Austin Flack at the
email address we have provided to staff. All documents will be
entered into the record at the conclusion of the hearing.
The Chair now recognizes herself for 5 minutes for purposes
of an opening statement.
OPENING STATEMENT OF HON. DIANE DeGETTE, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF COLORADO
The nation has faced a growing mental health challenge for
years, as we all know, which has only been magnified by the
COVID-19 pandemic. Today's hearing is an opportunity for the
subcommittee to continue its bipartisan and long history of
examining ways to support Americans' mental health.
We have prioritized this issue in the Oversight
Subcommittee for many years, under the leadership of both
parties. But now it's more critical than ever that we better
understand the drivers behind the mental health crisis facing
Americans, and explore what must--more must be done to further
the shared goal of supporting their mental health and well-
being.
One in five adults and six youth will experience a mental
health crisis each year. Over the course of the pandemic, in
fact, an estimated 125 million Americans struggled with mental
health issues like anxiety, depression, and other mental health
illnesses. These statistics are, frankly, alarming.
It is clear the COVID-19 pandemic has increased the mental
health challenges that we face as a country, and those whose
lives have been more disrupted by COVID-19 have suffered more
severe mental health consequences.
Just as communities of color have been disproportionately
impacted by the virus itself, so too have people of color
experienced disproportionate rates of mental health challenges.
People with disabilities are now experiencing mental distress
five times as often as adults without disabilities. And
essential workers on the front lines of the pandemic, including
the healthcare workers like those in my home State of Colorado
and around the country, are experiencing burnout and reporting
their own increased mental health struggles.
This committee and Congress have taken steps to address the
surging mental health needs through COVID-19 relief packages
and other critical legislation. But, as we well know on this
subcommittee, our work is long from finished.
The situation is particularly urgent because the Nation's
children are not immune to this crisis. As this subcommittee
heard from experts last fall in our hearing exploring the
impacts of COVID-19 on youth, children are facing an increasing
number of stressors in their lives. And this is also made
evidenced by the staggering increase of behavioral health
visits to emergency departments by children last year. For
example, in 2021 at Children's Hospital here, in Colorado, 70
percent more children came to the ER because of a mental health
crisis than in the very same period in 2019.
Now, there's a reason--a number of reasons--behind this
increase in crisis in children and adults, but we know that
online content plays a part. We are spending a lot more time
online, for good or for bad, and the potential harms of social
media, online misinformation, and cyber bullying are real
threats.
But also, there are real needs to connect with resources
and peers in moments of need. And this too has been evident
over the past few years, as physical distancing has been
necessary to protect our physical health. Virtual connection
proved critical to protecting our emotional well-being, and we
also addressed this in many of our relief efforts.
More must be done to understand the potential benefits, but
while at the same time mitigating the harms because virtual
tools also proved essential for mental health counseling.
Telehealth counseling and healthcare enable millions of people
to connect with providers at a time when need for these
services surged. But we know that access to mental health
services remains an ongoing hurdle for too many people,
particularly children and people in vulnerable communities.
Stigma, high cost, and limited coverage and other systemic
inquiries all pose barriers to care.
Also, worker shortages across the mental health field have
been exacerbated by demands on those frontline workers. The
psychiatric workforce alone within the mental health
professional workforce in the U.S., for example, is only 28
percent of the total population need for psychiatrists.
Hospital emergency departments have experienced dramatic
spikes in the hospitalization of pediatric patients for mental
health reasons, and too often the lack of early screening and
integrated healthcare for kids and adults only increases the
crisis. So that is why resources like the National Suicide
Prevention Lifeline are so crucial.
While efforts are underway to prepare for the expected
increase of calls and texts with the new 988 three-digit
dialing code this summer, anybody struggling today can get help
by calling 1-800-273-8255. And I know Mr. Cardenas is waiving
onto this committee today to talk about this very issue, and I
look forward to that.
I look forward to hearing about other resources that people
can have from the witnesses today, as well as strategies to de-
stigmatize discussions on mental health and emotional well-
being. If we can better understand the drivers behind the
growing mental health epidemic across the country, we can take
more effective action to improve Americans' overall health and
their lives. And we have got to ensure that everybody has
access to this.
[The prepared statement of Ms. DeGette follows:]
Prepared Statement of Hon. Diana DeGette
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Ms. DeGette. With that, I am very pleased now to yield 5
minutes to the ranking member, Mr. Griffith.
OPENING STATEMENT OF HON. H. MORGAN GRIFFITH, A REPRESENTATIVE
IN CONGRESS FROM THE COMMONWEALTH OF VIRGINIA
Mr. Griffith. Thank you very much, Chair DeGette, and I
appreciate you holding this hearing.
This hearing comes at a critical time. Dealing with the
pandemic these last two years has taken a significant toll on
many people, resulting in troubling increases in levels of
mental health issues in the United States. Data from the
Centers for Disease Control and Prevention, CDC, and the
National Health Interview Surveys show American adults are
reporting significantly elevated levels of adverse mental
health conditions, such as anxiety and depression, as well as
increased substance use and suicidal ideations. A growing
number of scientific studies also indicate concerning trends
with respect to our Nation's mental health, and tend to show
that different populations are affected in different ways.
The COVID-19 pandemic has had a major impact on our
Nation's mental health and well-being, exacerbating and
creating increased levels of anxiety and depression for many
Americans. And it is no wonder, as we have faced significant
hardships during the pandemic: individual experiences of severe
or long-lasting COVID-19 cases; loss of loved ones to the
virus; high levels of on-the-job stress and trauma for
frontline and essential workers; job loss and economic
uncertainty for families; and school closures inhibiting both
academic and social development.
Just last week, the U.S. Surgeon General testified the
pandemic has had a devastating impact on the mental health of
America's young people. School closures and lockdowns, in
particular, have been associated with adverse mental health
symptoms. It is important for us to remember that school is not
just where our children are taught reading and math and
science. It is also where our kids socialize, where many find
reliable access to meals, where there are opportunities to
interact with counselors and trusted adults.
Americans deserve a comprehensive approach to public health
that balances COVID-19 mitigation efforts with other
considerations. While it may have been wise to implement
certain policies at the outset of COVID-19, many of them have
been unnecessarily prolonged. Of course, we want to prevent as
many deaths from COVID-19 as possible, but a death by suicide
is just as devastating as death from COVID-19 itself. We must
consider mental health as we evaluate the impact of current
policies, and as we develop policies for the future.
In addition to concerns about the impact of the pandemic on
youth mental health, the Surgeon General noted problems with
access to care. During the COVID-19 pandemic, demand for mental
health services increased substantially, and providers have
reported difficulty meeting demand. This is an area where we
need to work to address--to ensure that individuals have
sufficient access to any care they may need.
The pandemic and the government's response to COVID-19 has
also been a factor in the staggering increase in overdose
deaths. Provisional data from the CDC indicates there were an
estimated 103,306 overdose deaths in the U.S. during the 12-
month period ending April 2021, an increase of nearly 30
percent from the number of deaths reported in the same period
the year before.
We know that mental health and substance use disorders
are--often overlap and are co-occurring. Multiple national
surveys have found that about half of those who experience
mental illness during their lives will also experience a
substance use disorder, and vice versa. Thus, it is critical
that, in addition to addressing our Nation's mental health, we
also examine how to best address the increase of substance use
disorders and overdose deaths throughout the United States.
The mental health of our Nation has been and will continue
to be a top priority of this committee. I look forward to
today's discussion and to learning more about how to best
address the mental health needs of our Nation.
I thank the witnesses for being here today, and being a
part of this important conversation.
[The prepared statement of Mr. Griffith follows:]
Prepared Statement of Hon. H. Morgan Griffith
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Mr. Griffith. And I yield back, Madam Chair.
Ms. DeGette. Thank you, Mr. Griffith. Chair now recognizes
the chairman of the full committee, Mr. Pallone, for his
opening statement, 5 minutes.
OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Chairwoman DeGette.
Today the committee continues its critical work on how to
best support the mental health and well-being of Americans who
have faced ongoing mental health challenges. And of course,
these have been exacerbated by the COVID-19 pandemic.
While the need for mental healthcare is greater than ever,
there are still too many obstacles for people to access that
care. One in five American adults reported that the pandemic
had a significant negative impact on their mental health, yet
only forty-five percent of adults with mental illness were able
to access the mental health treatment they needed in 2020. And
children, particularly children of color, are experiencing
increasing rates of mental health conditions. In fact, in 2020,
mental health emergency department visits rose by 24 percent or
more for children between the ages of 5 and 17.
Americans seeking mental healthcare face a range of
barriers, including stigma and discrimination, workforce
shortages, and concerns over the cost and coverage of care. And
this committee has a long history of addressing these barriers
to care, including ensuring parity for mental health and
substance use benefits to other health benefits. We played a
central role in both the passage of the Mental Health Parity
and Addiction Equity Act and in the expansion of parity to
individual market plans in the Affordable Care Act.
Then, last year, we led efforts to equip the Departments of
Labor, Treasury, and Health and Human Services with new
enforcement tools to strengthen and enforce parity in the
Consolidated Appropriations Act of 2021. This law requires
insurance companies to submit analysis of their coverage of
mental health and substance use disorder benefits to the three
Departments, so that the Departments can then provide an annual
report to Congress on their findings.
Unfortunately, their first report, which was just released,
found that insurance companies are failing to deliver parity
for mental health and substance use disorder benefits, and are
falling short of their obligations under the law. It is
unacceptable that insurance companies are flouting the law.
Clearly, more must be done to strengthen the protections of
mental health parity laws, and we must ensure that Americans'
health coverage includes robust coverage and access to
treatment for mental health and substance use disorder
benefits.
Now, access to mental health has never been more crucial.
Suicide remains the second leading cause of death amongst
Americans aged 10 to 34, and we know that mental health
challenges are often compounded. For instance, roughly half of
Americans experiencing mental illness will also experience a
co-occurring substance use disorder.
Thankfully, we took swift action to help meet the growing
mental health needs of Americans during the COVID-19 pandemic.
Through the Fiscal Year 2021 funding bill, the CARES Act, and
the American Rescue Plan Congress provided $9 billion to
states, tribes, and localities to respond to mental and
behavioral health needs.
And last year the House passed nine additional bills that
were shepherded through this committee that would support the
mental health needs of healthcare providers and students,
address inequities in services, and support access to the
National Suicide Prevention Lifeline and its new 988 dialing
code that launched this summer. And the House-passed Build Back
Better Act would provide an additional 175 million for a range
of mental health, workforce, and community services.
These are crucial steps in the right direction, but our
work is not done. So as we spend more time online on social
media digital platforms, that is going to continue to play a
role in people's mental health, and especially our children. So
we have to do more to understand both the benefits and risks of
this reality with social media, as well.
So let me just conclude by saying the committee is also
working to reauthorize a wide range of substance abuse and
Mental Health Services Administration programs that expire in
September. And as we conduct this work, it is important that we
hear from people experiencing mental health challenges and the
experts.
So I think this hearing is very important today, Madam
Chair, and I want to thank all the witnesses as we look forward
to hearing their experiences and their expertise. With that, I
yield back.
[The prepared statement of Mr. Pallone follows:]
Prepared Statement of Hon. Frank Pallone, Jr.
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Ms. DeGette. Thank you so much, Mr. Pallone. Chair is now
pleased to recognize the ranking member of the full committee,
Mrs. McMorris Rodgers, for 5 minutes.
OPENING STATEMENT OF HON. CATHY McMORRIS RODGERS, A
REPRESENTATIVE IN CONGRESS FROM THE STATE OF WASHINGTON
Mrs. Rodgers. Good morning. Thank you, Madam Chair. Today's
hearing is extremely important. It is long overdue.
COVID has taken a toll, especially on our children. Our
kids are in crisis. A 2020 survey of 3,300 high schoolers found
about a third of them unhappy and depressed. From March 2020 to
October 2020, mental health-related emergency department visits
increased 24 percent for children aged 5 to 11, and 31 percent
for those ages 12 to 17. And we have seen about a two-and-a-
half fold increase in emergency department visits for suicides
and self-harm among children under the age of 18.
Why? Not because of a virus that poses very little risk to
children. The reason--and I want to be very clear about this--
is the government's response to COVID. School closures, forced
masking, lockdowns, and isolation all have driven the severity
of the mental health crisis.
More than 40 public school superintendents from eastern
Washington are calling for an end to the mask mandates on
children. I join in appealing to both Governor Inslee and the
CDC to listen to them. Trust the parents, the children in our
schools who are saying, ``Stop the madness.'' As the schools
wrote, government restrictions are having, ``an exceptional
psychological and social toll on our entire communities.''
It begs the question: Why are elected officials and
unelected public health bureaucrats not responding to their
pleas?
Schools must be open for in-person learning, with no mask.
We must retire this notion of virtual learning. They are not
learning. If a school goes virtual, it is closed. Children need
to be in school to learn, to socialize, to develop emotionally.
Children shouldn't be treated like vectors of disease.
The forced masking, which is undermining the benefits of
being in the classroom, cannot be a condition for in-person
learning anymore. Europe's CDC does not recommend young kids
mask in school. The World Health Organization and UNICEF both
recommend against masking children under five, citing the
safety and overall interest of the child. And when considering
masks for children ages 6 to 11, they actually consider other
factors like the ability to learn and socialize.
I have raised this many times with the CDC Director
Walensky. She is narrowly focused on COVID, which we all know
is a virus that poses a lower risk to unvaccinated children
than some fully vaccinated adults, yet CDC continues to rely on
discredited studies to force a masking agenda. You know, this
week, I asked her, I asked Dr. Walensky what data she is
relying on for the continued forced masking in our schools, and
she cited a flawed Arizona study three times.
What have the experts said of this Arizona study? That it
is so unreliable it should have never been entered into the
public discourse. So why does she refuse to listen? Is it
because of the corrupted relationship with Randi Weingarten and
the teachers' union? I don't know. Is it political? Is she
following directions from the White House?
What I do know is that these guidelines are standing in the
way of what is best for millions of Americans, and is not based
on science or data.
Just this week, just this week we saw tens of thousands of
people enjoy the Super Bowl unmasked in LA. But for the kids in
that same city, they are forced to continue to mask. How can
anyone justify this?
And now, suddenly, we see Democrat Governors and mayors
lifting their mandates. It doesn't seem to be based on science.
Maybe political science.
But just six months ago, the Department of Education,
President Biden's Department of Education, opened civil rights
investigations into five Republican-led states who were
fighting for children to be able to attend school unburdened by
masks. We haven't seen the same action against the Democrat-led
states at this time.
I understand that updated mask guidance is coming. We must
unmask our children. There is no excuse as to why these
restrictions should not--they should be the last to have the
restrictions to be lifted.
You know, I am speaking for millions of Americans and
parents across this country. I speak for them. I speak for my
own son, who is still masked in his school. Children are our
future. We all recognize that. These are bad policies that are
a part of our sacrificing a generation of children and their
future. Let's stop the suffering. Let's stand on the side of
parents and kids, and make sure we get our kids back in school.
And it is best for them, it is best for their mental health, it
is best for our future.
[The prepared statement of Mrs. Rodgers follows:]
Prepared Statement of Hon. Cathy McMorris Rodgers
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Mrs. Rodgers. I yield back.
Ms. DeGette. Chair now asks unanimous consent that Members'
written opening statements be made part of the record.
And without objection, they will be entered.
I would now like to introduce our witnesses for today's
hearing.
Dr. Lisa Fortuna, who is with the American Psychiatric
Association Member, and the vice chair of psychiatry at the
University of California, San Francisco.
Dr. Jacqueline Nesi, assistant professor of psychiatry and
human behavior at Brown University.
Amit Paley, who is the CEO and executive director of The
Trevor Project.
Christopher Thomas, who is the co-founder of The Defensive
Line.
And Hon. Dr. Elinore McCance-Katz, who is the former
secretary for mental health and substance abuse.
I want to thank all of you for appearing before the
committee.
And I know you are all aware the committee is holding an
investigative hearing, and when doing so has the practice of
taking testimony under oath. Do any of you have an objection to
testifying under oath today?
Seeing no objection, let the record reflect that the
witnesses have responded no.
The Chair then advises you that, under the rules of the
House and the rules of the committee, you are entitled to be
accompanied by counsel. Does any of you wish to be accompanied
by counsel today?
Let the record reflect that the witnesses have responded
no.
And so, if you would, it is always a little different, but
we are--but we do swear witnesses in over Webex. Please raise
your right hand, and--so that you may be sworn in.
[Witnesses sworn.]
Ms. DeGette. Let the record reflect that the witnesses have
responded affirmatively.
And you are now under oath, and subject to the penalties
set forth in title 18, section 1001 of the U.S. Code.
At this time, the Chair will recognize each witness for 5
minutes to provide their opening statement. And as a reminder,
you can see there is a timer on your screen that will count
down your remaining time.
Dr. Fortuna, you are recognized for 5 minutes. And thank
you again for being with us.
STATEMENTS OF LISA FORTUNA, M.D., M.P.H., AMERICAN PSYCHIATRIC
ASSOCIATION MEMBER, VICE-CHAIR OF PSYCHIATRY, UNIVERSITY OF
CALIFORNIA SAN FRANCISCO; JACQUELINE NESI, PH.D., ASSISTANT
PROFESSOR OF PSYCHIATRY AND HUMAN BEHAVIOR, BROWN UNIVERSITY;
AMIT PALEY, M.B.A., CEO AND EXECUTIVE DIRECTOR, THE TREVOR
PROJECT; CHRISTOPHER THOMAS, CO-FOUNDER, THE DEFENSIVE LINE;
AND HON. ELINORE F. MCCANCE-KATZ, PH.D., M.D., FORMER ASSISTANT
SECRETARY FOR MENTAL HEALTH AND SUBSTANCE ABUSE
STATEMENT OF LISA FORTUNA, M.D., M.P.H.
Dr. Fortuna. Thank you. Chairwoman DeGette, Ranking Member
Griffith, and distinguished members of the Energy and Commerce
Oversight and Investigation Subcommittee, thank you for
allowing me the opportunity to serve on today's panel.
My name is Dr. Lisa Fortuna, and I am a professor of
clinical psychiatry and vice chair at the University of
California, San Francisco Department of Psychiatry and
Behavioral Sciences. I also serve as the chief of psychiatry at
the Zuckerberg San Francisco General Hospital, the public
hospital for the city. I thank you for having me here today to
address my issues surrounding the State of our Nation's mental
health. I am testifying today in my capacity as a member of the
American Psychiatric Association.
The COVID-19 crisis, as we know, is exacerbating anxiety,
depression, and other mental health and substance use
conditions. It has likewise unmasked and compounded existing
racial and economic inequities within our healthcare system. I
have seen the results manifest themselves in my leadership
role, but also in my practice.
Earlier in the pandemic, I saw a patient who is a nursing
home aide and a mother. Let's call her Gloria. During the early
days of the pandemic, Gloria was forced to stop working in her
home health job because she was afraid of catching COVID-19 and
getting her children sick. Though Gloria left her job, her
brother, also an essential worker, unfortunately caught COVID,
and required care in an intensive care unit. He was unable to
work for over six months because of his COVID-related
disabilities. And over the course of six months, the same
family experienced six COVID-related deaths in their extended
family due to similar situations.
Gloria's 11-year-old daughter developed severe anxiety
because she was afraid that her mother would catch COVID and
pass away as a result of her job. As Gloria's daughter suffered
from these untreated mental health conditions, Gloria too,
between the stress and the grief of losing family members,
suffered a relapse of major depression.
The stress and anxiety and grief from the pandemic have
very real mental health repercussions for this one family, and
they are not the only ones. And these health conditions also
had a complete domino effect on their economic stability.
Fortunately, Gloria's family was able to reach out to their
primary care doctor, who connected them with a therapist and
psychiatric consultation, and they were able to receive mental
health services through tele-psychiatry, as well as other
social services to help with food insecurity until Gloria was
able to start working again.
The challenges of Gloria and her daughter are,
unfortunately, not unique. As detailed in the December 2021
Surgeon General's advisory on youth mental health, depressive
and anxiety symptoms for youth have doubled during the
pandemic, while emergency room visits for suspected suicide are
likewise increasing at alarming rates.
The mental health crisis for children has become so severe
that last October, as you may know, the American Academy of
Child and Adolescent Psychiatry, the Children's Hospital
Association, and the American Academy of Pediatrics took an
unprecedented step of declaring a national emergency in
children's mental health.
As families like Gloria's continue to grapple with the
direct and downstream effects of the pandemic, we encourage the
committee to pursue policies that promote access to needed
behavioral health services, with particular focus on extended
care to vulnerable populations, including racial and ethnic
minorities, and LGBTQ-plus youth, among others.
As I have laid out and expand upon in my written testimony,
Congress can take several immediate steps to support families
like Gloria and address the ongoing mental health crisis.
One key area, which I will be happy to answer more
questions about, is the importance of telehealth, and how that
has been a godsend to families like Gloria and many others
during the pandemic.
And the APA also has many other recommendations that I
would be happy to talk further about that really are about
increasing access, including extending the telehealth
flexibilities authorized under the COVID-19 public health
emergency, prioritizing health equity and workforce building
programs to address existing shortages in our workforce in
mental health, supporting policies and funding that help
Federal and State enforcement agencies bring insurers into
compliance around parity, apply parity requirements to
Medicare, and ensuring that states and local communities are
prepared for the launch of the 988 crisis line, and further
incentivizing primary care practices for collaborative
integrated care.
So I appreciate the opportunity, and I look forward to
answering any questions about these issues.
[The prepared statement of Dr. Fortuna follows:]
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Ms. DeGette. Thank you----
Dr. Fortuna. Thank you.
Ms. DeGette [continuing]. So much, Doctor. I am now pleased
to recognize Dr. Nesi for 5 minutes.
Doctor, thanks also to you for being with us.
STATEMENT OF JACQUELINE NESI, Ph.D.
Dr. Nesi. Thank you, Chair DeGette, Ranking Member
Griffith, and members of the subcommittee. My name is Dr.
Jacqueline Nesi, and I am a clinical psychologist and an
assistant professor at Brown University. I study the impact of
technology and social media on adolescent mental health.
Our nation is facing a mental health crisis among youth.
Rates of depression, anxiety, and suicide have increased over
the past two decades, and this crisis has only been intensified
since the start of the COVID-19 pandemic. These rising rates of
mental health concerns have coincided with another trend: the
widespread adoption of social media.
Today nearly 97 percent of teens use social media platforms
like TikTok, Instagram, YouTube, and Snapchat. Technology use
has further increased during the pandemic, with adolescents now
spending an average of seven hours per day using screens. These
co-occurring trends of increasing social media use and rising
mental health diagnoses have led to concerns about a potential
link.
Is social media use causing mental health problems?
Unfortunately, the current State of the research does not
provide a simple, definitive answer. What we know is that the
relationship between social media use and mental health is
complex. We also know that serious mental health concerns like
depression, anxiety, eating disorders, and suicide are the
result of a complicated interplay of genetic, developmental,
and social factors, and cannot be attributed to a single cause.
Social media alone does not cause mental illness in teens.
But does this mean that teens' use of social media is
irrelevant when it comes to their mental health? It does not.
Social media plays a central role in our children's mental
health. To date, research suggests that the amount of time
teens spend on social media is less relevant than what teens
are doing online, and which teens are more susceptible to harm.
Social media offers opportunities and benefits for teens,
but it also creates real risks and challenges, especially for
those who are already vulnerable.
In terms of benefits, social media offers adolescents a
forum for social connection, friendship, and creative
expression. It offers critical opportunities for social
support, especially among teens who may not readily have access
to communities of supportive peers in their offline lives, such
as LGBTQ youth. It can also provide education and awareness,
and reduce stigma. For youth struggling with suicidal thoughts,
social media can offer unprecedented opportunities for support,
access to resources, and intervention during a crisis.
Despite these benefits, the potential risks of social media
are significant. Social media provides an endless stream of
photos and quantifiable indicators of social status--likes,
views, comments--which may negatively affect youth self-esteem
and body image. Night-time use of screens has been shown to
interfere with youth sleep. Cyber victimization, or the
experience of being bullied online, is another risk, and is
associated with a range of mental disorders. Youth of color and
LGBTQ youth are also disproportionately likely to be affected
by hate speech online.
When it comes to suicide-related social media content, the
dangers can be profound. Exposure to harmful suicide-related
content has been shown to increase risk for self-injury over
time. In extreme cases, youth may even encounter messaging that
actively encourages suicide or self-harm.
But evidence-based guidelines exist for safer social media
posting about suicide. Safe posts about suicide should provide
messages of hope and recovery, include links to resources, or
indicate that suicide is preventable. In contrast, harmful
posts about suicide are those that glamorize, sensationalize,
or romanticize suicide, those that trivialize it or blame it on
a single cause, those that describe it as desirable, and those
that provide details about methods or locations of attempts.
More research is urgently needed to determine exactly how,
when, and for whom social media is more harmful than helpful.
But one overarching conclusion can be drawn from the
current body of work: social media is central to the mental
health of young people.
Addressing the youth mental health crisis must be a multi-
faceted effort, and ensuring access to services is a key
component. Nearly half of adolescents with mental disorders do
not receive needed treatment, with those numbers even higher
among youth of color. Improving access to mental healthcare,
such as through schools and primary care facilities, is vital.
Helping youth use technology and social media in healthier ways
must also play a role.
Legislators, social media companies, researchers, and other
stakeholders can work together to maximize the benefits of
social media for youth, while minimizing the risks. We can
educate youth on the dangers of hate speech and bullying. We
can help youth protect time for activities outside of screens.
We can provide youth the opportunities to personalize their
social media experiences, and give parents the tools to ensure
their child's safety. And we can guide youth toward helpful
resources and content, and limit access to harmful content.
Thank you.
[The prepared statement of Dr. Nesi follows:]
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Ms. DeGette. Thank you so much, Doctor.
I am now very pleased to introduce Mr. Paley for 5 minutes.
Mr. Paley, you are recognized.
STATEMENT OF AMIT PALEY, M.B.A.
Mr. Paley. Subcommittee Chair DeGette, Ranking Member
Griffith, and members of the subcommittee, thank you for the
opportunity to testify today. My name is Amit Paley, and I am
the CEO of The Trevor Project, the world's largest suicide
prevention and mental health organization for LGBTQ young
people. We offer free 24/7 crisis services for LGBTQ youth, and
The Trevor Project last year served more than 200,000 calls,
chats, and texts.
This is not a partisan issue. Any time we talk about the
national mental health crisis, we need to all remember how
deeply it impacts young people, and these past two years of the
pandemic have only created new struggles. America's young
people need Congress to act.
More than 1.8 million LGBTQ young people seriously consider
suicide every year in the United States, and CDC data shows
that LGBTQ young people are more than four times more likely to
attempt suicide than their peers. We estimate that at least one
LGBTQ young person attempts suicide every 45 seconds in the
United States. LGBTQ young people are not inherently prone to
suicide because of their sexual orientation or gender identity.
They are placed at significantly increased risk because of how
they are mistreated and discriminated against in society.
According to our 2021 national survey of 35,000 LGBTQ young
people across the country, 70 percent said their mental health
was poor most or all of the time during the COVID-19 pandemic,
but nearly half could not access the mental healthcare that
they need.
The Trevor Project is on the front lines of the national
mental health crisis, and our counselors hear every single day
from young people who have been negatively impacted by the
COVID-19 pandemic, by recent politics, and a wide range of
instances of anti-LGBTQ victimization.
But we have also seen rays of hope in the midst of this
crisis. The Trevor Project is proud to have helped lead the
effort to pass the National Suicide Hotline Designation Act in
2020, which established 988 as the new 3-digit code for the
National Suicide Prevention Lifeline. This legislation was
passed successfully due to overwhelming bipartisan cooperation
and a unified focus on suicide prevention. Many of you
championed the bill. The Trevor Project appreciates your
leadership, and we are excited to work with you all to fulfill
[inaudible] lifesaving promise.
SAMHSA has invested nearly $850 million in strengthening
local crisis call center capacity and efforts to scale up the
lifeline. And Congress is poised to appropriate $7.2 million
for specialized services. However, time is running short.
Formal agreements and funding have yet to be finalized, and it
is not clear that essential specialized services will be ready
for LGBTQ young people in July.
In particular, it is crucial that 988 specialized services
include establishing an integrated voice response option, which
would enable LGBTQ young people to be transferred to groups
like The Trevor Project, where we have our own specially and
highly trained counselors. This would also help take some of
the burden off of the National Lifeline call centers, as call
volumes are expected to dramatically increase.
I urge this subcommittee to utilize its oversight authority
to ensure that congressional intent is being followed, and that
the Administration is providing the funds promised, and taking
all actions necessary to address the needs of all Americans,
including LGBTQ young people, as quickly as possible.
I want to conclude with a final statistic, that having just
one accepting adult in an LGBTQ young person's life can reduce
their risk of suicide by 40 percent--4-0, 40 percent. All of us
here today, each of you, can be that person, and can help save
lives. We each have the power to make the world a more
accepting place, and to show our children, all of them, that
they are deserving of love and respect, and that they are not
alone.
Subcommittee Chair DeGette, Ranking Member Griffith, and
members of the subcommittee, thank you for hosting this hearing
and for your time today. The Trevor Project looks forward to
continuing to work with Congress and the Administration in
addressing the national mental health crisis and supporting our
most marginalized young people.
[The prepared statement of Mr. Paley follows:]
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Ms. DeGette. Thank you so much, Mr. Paley. I met with some
of my providers here in Denver the other day, and had a
roundtable, and they gave that same statistic. One adult in
someone's life can save them from suicide. So I think that is a
good call to action that we should all follow.
Now I am really pleased to recognize Mr. Thomas for 5
minutes for your opening statement. Thank you, Mr. Thomas.
STATEMENT OF CHRISTOPHER THOMAS
Mr. Thomas. Good morning, Subcommittee Chair DeGette,
Ranking Member Griffith, and members of the subcommittee. My
name is Chris Thomas. I am the son of a high school dropout,
and the first in my family to attend and graduate from college.
I am here today as a survivor of 60 years. I am a survivor of
sexual and racial abuse, as well as violence, poverty, and
trauma. Unfortunately, along with my wife, Martha and my son
Solomon, I am also a suicide loss survivor of my daughter,
Ella.
In the face of this most profound loss and treacherous
grief, my wife of 37 years, Martha, a middle school teacher
with decades of experience, my son, Solomon, who was in his
sixth year of playing in the NFL, and my niece, Ray, who
possesses extensive social work and public policy experience,
are speaking out today and every day about how we live. We are
turning pain into purpose through our creation of The Defensive
Line, with the vision of a world where no young person of color
dies by suicide, the second leading cause of death for young
people under the age of 24.
For young people of color, suicide [inaudible] and be a
leading cause of death. The Defensive Line seeks to make a
difference by reducing the stigma from sharing ours and other
stories of loss and hope, by increasing connection to mental
health services in schools with a majority of students of
color. We pursue this work through two programs: storytelling
and advocacy, and suicide prevention workshops.
Reducing the stigma of mental health, mental illness, and
suicide can only be combined discussing these challenges and
what they look like in real people. We believe, by sharing our
story publicly, we give these hard things faces, personalities,
and relatability. Our suicide workshop aims to create solutions
and enhance resource connections, referrals for youth.
We believe teachers and coaches play an essential role in
young people's lives, and have the unique opportunity to see
signs of suicide risk or mental health challenge before it gets
to a point of crisis, which is why they are our focus.
Schools have resources for students, and we want to help
everyone understand how they can play role in supporting young
people's access to those resources.
Our workshops also focus on ways teachers may be creating
unsupportive environments for some students through their own
implicit bias by overlooking students of color's mental health
needs because they look different.
The Defensive Line's mission is to end the epidemic of
youth suicide, especially for young people of color, by
transforming the way we communicate and connect about mental
health. The Defensive Line was established in May 2021. Its
genesis centers around the death, the impulsive suicide, of my
daughter, Elizabeth Thomas.
Ella was born April 19, 1993. She was our first-born, and
was born with a huge personality. From the womb she had
determination, wit, and feistiness. Ella was never just another
person in the room. Ella had that rare quality that we call
presence. It is called charisma, as well, but it is always
associated with leadership. She gave until she could give no
more. On the day Ella took her own life, a police officer
handed my wife her phone to show the last text that she sent
before she died. Two of her friends were struggling with
depression, and she was helping them save their own lives.
After losing Ella to suicide, my family and I learned about
suicide prevention. What we wish we had known prior to losing
her--what we want others to know. There are signs a person
experiencing suicidal crisis may show, such as giving away
prized possessions. About a week before Ella took her life, she
came to me and said, ``Dad, you can take care of my dog,
Mickey.''
As we speak, this Thursday, February 17, 2022, there will
be 17 people under the age of 24 that will die by suicide. That
equates to 119 people that will die by suicide every week,
nearly what about Boeing 737 holds. I have to believe, if a
plane went down every week in America, Congress would take--
work together and create immediate solutions to address the
issue. Let's do that for suicide prevention.
We started this work because we felt compelled to speak
when so many were silent. The Defensive Line is an answer to
the challenges of accessing mental health resources for young
people. We are the bridge to resources. We believe everyone has
a role in ending the suicide epidemic. Everyone can have a
better understanding of the warning sign to look for and learn
how to engage with others to have hard conversations. If people
don't know when someone needs help, how can they get them help?
We believe mandating, standardizing, and funding K-through-
12 suicide prevention curriculum, with a mandated annual
certification for educators would play a significant role in
preventing suicide deaths.
Our love is with Ella forever. We will work to ensure what
happened to Ella doesn't happen to others. But we can't do it
alone. We hope you will join us in this Defensive Line to
protect, defend, and ensure the health and wellness of the
brilliant future for our young people.
Thank you for this extraordinary honor. Ella would be
proud. Thank you.
[The prepared statement of Mr. Thomas follows:]
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Ms. DeGette. Thank you so much, Mr. Thomas, for sharing
your powerful story, and for your testimony today. It means a
lot to this committee.
I am now really pleased to recognize Dr. McCance-Katz for 5
minutes for your opening statement, Doctor.
STATEMENT OF ELINORE McCANCE-KATZ, M.D.M., Ph.D.
Dr. McCance-Katz. Members of the subcommittee, thank you
for the opportunity to speak about the current mental health
crisis in the United States.
The COVID-19 pandemic has caused unprecedented stressors to
be experienced by the American people. Mitigation strategies
put in place to try to reduce disease and death related to
viral infection were important, but unfortunately lacked a
balanced approach that considered all health and mental health
needs of people. Millions lost their employment and their
income, experiencing great financial stress. All experienced
the inability to participate in so many activities that give
meaning to our lives. Millions contracted this illness, and
hundreds of thousands died, contributing to fear, anxiety, and
depression.
As we emerge from the pandemic, these situations have
resulted in what is now a mental health crisis, one that for
many is fueled by substance abuse and addiction. I believe
that, to a great extent, this could have been avoided. I say
this because there existed a literature that told us the mental
health costs of isolation and quarantines.
This review of scientific studies published just prior to
the start of COVID-19 mitigation programs in the United States
told us that people experienced mental health effects following
as little as nine days of isolation. For healthcare workers
studied after required isolation periods following exposure to
an infectious agent, quarantine was the factor most predictive
of the development of symptoms of acute stress disorder,
anxiety, irritability, and reluctance to work.
As an aside, this study also laid the foundation for what
we are seeing today: an exodus of healthcare workers over the
course of this pandemic. For some, alcohol abuse was found to
be long-term, as much as three years after quarantine. Many
subjected to such restrictions remained reluctant to re-engage
in normal life activities following quarantine. For example,
ongoing avoidance of public spaces. The most severe symptoms
were in those with the history of psychiatric disorder. And the
longer the quarantine, the more severe the symptoms.
As we look to understand the current situation, SAMHSA's
National Survey on Drug Use and Health showed that substance
use disorders fully doubled in 2020 from pre-pandemic 2019
data, a 100 percent increase. Although SAMHSA caveats the
findings because of updating the system to use current
diagnostic criteria, it is important to note that this survey
is a household survey, which means it does not capture data
from some groups that we know have high rates of substance use
disorders: the homeless, those incarcerated, people living in
institutions. So the National Survey on Drug Use and Health
potentially underestimates the extent of substance abuse issues
in our country.
As a further indicator of the severity of illicit drug use
issues nationally, one only need to look at the substantial
increases in deaths from drug overdoses in 2020 relative to
2019, an increase of nearly 30 percent, year over year.
Further, there was a 20 percent increase in alcohol sales
during lockdowns relative to 2019. That is at-home drinking,
often in isolation.
The data on increases in substance use and misuse is
important because of the intersection of substance use and
mental disorders. Co-occurring disorders--that is, simultaneous
occurrence of mental and substance use disorders--are
increasingly common. Substance abuse induces changes in the
brain that are often associated with depression, anxiety, and
psychosis. Those with preexisting mental illness or
vulnerability to mental illness who use substances will
experience more severe episodes. Combined stressors of social
isolation and disease-related fears occurring in the context of
large increases in illicit drug and alcohol availability have
contributed to an upsurge in substance use and mental
disorders.
I want to emphasize that legislation passed by Congress to
address the pandemic was key to maintaining mental healthcare
when our healthcare system was essentially closed. For example,
making medical care available by telehealth, including use of
the telephone, preserved access and ongoing care, while
reducing stigma, particularly for drug users needing treatment.
The ability to make FDA-approved medications for opioid use
disorder more easily available saved lives.
It is my hope that Congress will permit these innovations
to stay in place with guardrails to diminish risk of fraud.
Designing systems where patients have an option for hybrid
telehealth and in-person visits should become permanent.
As our country opens up again, we must make treatment
resources available to those in great need. Fully addressing
the brain diseases that are mental and substance use disorders
require psychiatric medical treatment. And knowing this, we
must take immediate action to reconstitute the behavioral
health workforce necessary to provide psychiatric and social
services to help Americans recover from these illnesses.
In the future I think it is a certainty there will be more
pandemics. As a Nation, we should review actions taken over the
past two years, determine what has been effective and what has
not. We should learn from our experiences, make behavioral
health a national priority. Recognize that consideration of
behavioral health needs must be part of any pandemic response,
and prepare now for the next pandemic. Thank you.
[The prepared statement of Dr. McCance-Katz follows:]
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Ms. DeGette. Thank you so much, Doctor. I appreciate it.
It is now time for members to ask questions, and I want to
reiterate, since all of the witnesses are appearing remotely
today, let's make sure that everyone in the hearing room and
online has their microphones on mute unless they are asking
questions. Chair will now recognize herself for 5 minutes.
As we have heard from the testimony from all of our
wonderful witnesses today, there is no single problem with
mental health in this country. And so therefore, there is no
single solution. Congress has made a lot of investments. We
need to look at a multi-faceted way to support Americans'
health and well-being.
And so, given the range of experts and experiences among
the witnesses today, I want to ask you--you can think about it
while the others are answering--what key action you think
Congress should take to address this crisis.
Mr. Paley, I am going to turn to you first. Briefly, what
do you think is the most important action Congress can take now
to address the mental health crisis in America?
Mr. Paley. I think one of the key actions that Congress can
take is making sure that all Americans have access to care and
support when they need it.
There are a wide range of ways to do that, but one that I
want to highlight is making sure that 988 is fully funded and
fully prepared, because we know that it is a critical lifeline
for so many Americans who often don't know where else to turn
when they are considering suicide or experiencing a mental
health crisis.
And it is important that we make sure not only that it is
available to all Americans, but that those most marginalized
and most at risk, including veterans, including LGBTQ young
people, have specialized services available.
Ms. DeGette. And they need to know about it, too.
Dr. Nesi, what about you?
Dr. Nesi. Yes, so my expertise is as a psychologist, and
really the science behind social media. So, you know,
commenting on specific policy is probably outside of my domain.
But I will say that I think there are steps we can take
when it comes to social media to better serve youth. Just to
that I will highlight I think that there is a lack of
information and, really, awareness among the public about these
issues. And so educating the public, including parents,
teachers, teens themselves on safer and healthier ways to
engage with social media, I think, is critical.
I also think there are difficulties in conducting research
on this topic, and that we need more research to better
understand these issues.
So those are the two things I can----
Ms. DeGette. Great, great, thank you so much. That is
helpful.
Dr. Fortuna, how about you? What one thing do you think
Congress can focus on to really help address this crisis in a
meaningful way?
Dr. Fortuna. I think--yes, we know it is multi-factorial,
but I would say the--one of the key issues is access, and that
has to come through different interventions and venues.
So for example, that is why the APA--and I am completely
behind this, as well--is the importance of telehealth access
and mental health services wherever individuals reside. More
mental health services within their communities that are
culturally competent, and responsive, and accessible to all
people. So that includes in primary care, in schools, where
kids are all the time, and that we can rapidly have them have
access to either in-person or telehealth services.
So I think expanding and making sure that there is access,
and also including the workforce is critical.
Ms. DeGette. Yes, yes, workforce is important.
Dr. McCance-Katz, what about you, briefly?
Dr. McCance-Katz. Yes, thank you. I would say that, if
Congress would preserve and expand the Certified Community
Behavioral Health Clinic program, that is an evidence-based
practice of integrated care. It includes mental health,
substance use disorders, and physical healthcare in one
setting.
But importantly, it includes 24/7 crisis intervention
services. People in mental health crisis should not be seen in
emergency departments. It is not the right setting. It causes
them to not get treatment, to be further stigmatized, and to
spend many days languishing often. So these kinds of services
are directed toward people in great need.
Voice. It is also--the impetus is on----
Ms. DeGette. OK, we need to have everybody mute now. Thank
you.
Thank you so much, Doctor.
Mr. Thomas, I am going to finish with you because, as a
parent, you have seen this firsthand. So here you have your
opportunity to talk to people who are making the public
policies.
Voice. Yes, I think it will----
Ms. DeGette. What do you think we can do--after this person
mutes--what do you think we can do to make sure that we can
prevent suicides like the terrible, terrible death of your
daughter?
Mr. Thomas. Thank you for
[inaudible]. I agree with everything everyone else has
said, but I think the key thing is mandating and standardizing
and funding K-through-12 suicide prevention curriculum.
There are some states that you can just show a 5-minute
video, and it ticks the box for suicide prevention. That is the
critical part, mandating, and funding. This was a key piece, as
well as developing awareness and legislative platforms to
generate a public discussion and normalizing the conversation
about suicide, as well as mental health. Because the more we
talk about it, the more we normalize it, and the more it helps
us create culturally competent care--access culturally
competent care, which is an important piece.
Ms. DeGette. Thank you so much. I now am pleased to
recognize the ranking member for 5 minutes, Mr. Griffith.
Mr. Griffith. Thank you very much, Madam Chair. I just want
to quickly respond to something that Chairman Pallone mentioned
in his opening statement. He referenced a Department of Labor
finding that insurance companies are out of compliance with a
law that requires them to deliver parity for mental health
benefits, and we all want that.
But it is true that all the comparative analyses were
initially insufficient. Initially. But my understanding is that
the DoL has yet to give plans the guidance they need in order
to be in compliance. And it is not just me. Secretary Walsh
agrees. The Department of Labor has said they will issue a
notice of proposed rulemaking to provide that additional
guidance to payers by July of this year. The need for this
guidance is acknowledged in the very report that the chairman
referenced.
I look forward to reviewing the new regulations before
concluding that the current authorities are intentionally
insufficient, that--they are trying, I hope. And if they
aren't, they will have to do something.
Dr. McCance-Katz, there has been a lot of discussion among
members of our committee about the mental health of school-aged
children. That said, there has not been nearly as much
conversation in the public discourse about the impact of COVID-
19 restrictions on younger children and babies. But I am seeing
growing evidence that their cognitive development may be
affected by prevalent use of masks by caregivers, as is likely
to be the case for babies and young children spending their
days at daycare or preschool.
What is the role of face-to-face interaction in the normal
development of infants and toddlers?
Dr. McCance-Katz. So from the time that a baby is born,
they make facial recognition with their caregivers. It is
important to attachment between the caregiver and the baby.
Babies learn facial processing, so they learn to recognize who
their caregivers are. And they, from a very early age, start
with social and emotional development that is based on
interaction, being able to look at the face of the caregiver,
and the caregiver at the face of the infant.
I think it is--it would be important to educate parents and
caregivers about the need to interact with these very young
children without masks. I know that we now have rapid testing
available. We can use rapid testing to assure that the risk of
COVID is very diminished. But it is important that families and
caregivers in daycare centers, for example, and nurseries be
able to also interact with babies and young children without
masks.
Mr. Griffith. And isn't it true it is not just the
interaction, and knowing that the folks care for them, and
seeing those facial expressions that--and that is very
important. But isn't it also true that it affects their ability
on verbal skills, and motor skills, and overall cognitive
skills when the people that they are with a big part of the day
are masked?
Dr. McCance-Katz. It--yes, it is a concern. There is
emerging research that indicates that children born during the
course of the pandemic, when compared to children born earlier,
have those kinds of deficits, and it is something that I think
is not fully understood. And the literature is young, but we
need to pay attention to that. It could very well be something
to be concerned about for our children.
Mr. Griffith. And Dr. McCance-Katz, you referenced hybrid
telehealth, and we all know that telehealth has been important
during this. But you referenced hybrid telehealth, and I think
I know what that means, but can you tell the folks back home?
What does that mean, and why is that important that we have
that?
Dr. McCance-Katz. So what I am recommending is to keep
telehealth in place, but to make it available in a number of
ways.
So when we--when CMS defined telehealth originally, they
talked about audio-visual platforms. Well, millions of
Americans don't have access to audio-visual platforms. They
either can't afford to have an internet connection in their
home, or they live in rural areas. And it is estimated about 25
percent of Americans living in rural areas do not have
broadband access, and so the telephone----
Mr. Griffith. And they need contact----
Dr. McCance-Katz [continuing]. Becomes extremely important.
Mr. Griffith. There you go.
Dr. McCance-Katz. So----
Mr. Griffith. And look, that is a lot of people in my
district. And I am running out of time, so I hate to cut you
off. I would love to have more discussion, but that is a lot of
people in my district. So we need to make sure it is not just
the audio and visual, but also the audio, so that people can at
least have somebody they can talk to when they are having
mental health issues. I appreciate that.
I will say we also need more on substance abuse, and I want
to commend Delegate Sam Rasoul, who is leading the charge in
my--he is just outside of my district, but leading the charge
in my district for expansion by the State of Virginia at the
Catawba Hospital for Substance Abuse Disorders. And I
appreciate that.
And I yield back, Madam Chair.
Ms. DeGette. Thank you so much. Chair now recognizes Mr.
Pallone for 5 minutes.
Mr. Pallone. Thank you, Chairwoman DeGette. As I mentioned
in my opening statement, despite congressional efforts that our
committee led in 2019 to strengthen the enforcement of the
Federal parity law, a recently released report found that
insurance companies are still failing to deliver parity for
mental health and substance use disorder benefits. So let me
start with Dr. Fortuna.
In your testimony you State that--and I quote--``Achieving
full compliance with the parity law's requirements is
essential, given the need to access and maintain coverage for
mental health and substance use services.'' So, Dr. Fortuna,
can you briefly discuss why mental health parity is so
essential for patients, particularly in light of COVID-19, and
some of the challenges they face in accessing services and care
for behavioral health during COVID-19?
Dr. Fortuna. Yes, thank you very much for that question.
Yes, parity of mental health is critical.
You know, the laws have been put in place, essentially, to
ensure that when individuals are experiencing a mental health
crisis or a psychiatric disorder that requires treatment, that
they are able to access that in equal ways, as they would if
they were having a major medical crisis or medical condition
that needs to be treated.
Often in our field we find that often people are rejected
by insurance companies of being able to have adequate services
because they are psychiatric. For example, being in an
inpatient unit, and being said that no longer days will be
covered because they have to be discharged because they are not
getting better. And we wouldn't do that for any other medical
condition, right, that you are not getting better, so you are
discharged, or for substance use disorders that are not
covered.
So for Americans to actually be able to access the services
that they need, we have to consider psychiatric illnesses
equally as important and necessary to receive treatment and to
have the adequate coverage. Without coverage, people cannot
receive care.
Mr. Pallone. But as I said, we know that, you know, the
parity law, the insurance companies are not, you know, acting
in accordance with it. So what additional steps do you think
are necessary to close the gaps that exist between coverage for
mental health services and general medical care?
I mean, what should we be doing in Congress or otherwise in
response to this report that shows that the enforcement is not
there the way it should be?
Dr. Fortuna. Yes, I mean, I think Congress should
definitely support states to be able to have the resources that
they need to be able to evaluate, investigate insurance
companies, ensuring that they are in compliance with the parity
laws. We think that that is essential at the APA.
In addition, there are some insurance, like Medicare and
components of Medicare, that are not covered by the parity law.
And that also, therefore, does not allow this protection over
people who are particularly vulnerable with disabilities. So,
you know, so advancing that in the Medicare population, as
well, would be something that would be very important to also
include and extend.
Mr. Pallone. Well, thank you. I know there is not a lot of
time left, but I want to ask Mr. Thomas--and my condolences to
you and your family for your loss. And, you know, what--the
work you have done through Defensive Line is really saving
lives, in my opinion, by helping de-stigmatize mental health
issues.
So from your personal experience and your foundation,
what--you know, obviously, we are having discussions like the
one we are having today to help de-stigmatize mental health.
Again, is there anything else you would suggest to help de-
stigmatize mental health and encourage people to seek help?
Mr. Thomas. Yes, I--thank you for the question, and I
really believe it is a focus on whole health, and making sure
that we have the right care, the right access for people.
I know that for, like, my son Solomon, physical strength as
an NFL player, but when my daughter Ella passed away, he went
through his own mental health crisis, and it took extraordinary
care and attention from his employer, the 49ers, and my wife,
Martha, to recognize he was in pain. And he had to fight his
way through the stigma to understand that it was OK for him to
go seek help, and understand therapy and meditation and
journaling were all ways to help him through the process.
So I think having discussions, platforms, communications in
school and universities about the importance of whole health,
and the fact that it is OK to not be OK, and it is OK to be
vulnerable, and it is OK to not have this toxic mentality and
masculinity, that that is going to be a key part of it.
And because I know that, for sure, if my wife, Martha, and
I had seen the signs that AFSP puts up on talk--behavior, we
might have been able to help prevent Ella's passing.
Mr. Pallone. Thank you so much.
Thank you, Madam Chair.
Ms. DeGette. Thank you so much. Chair now recognizes Mrs.
McMorris Rodgers for 5 minutes.
Mrs. Rodgers. Thank you, Madam Chair. Thank you, everyone,
for being with us.
Dr. McCance-Katz, I have some questions for you. In early
2021 we started hearing some experts ringing the bell about the
impact of school closures. And we heard some that were saying
that the mental health crisis caused by school closures would
be worse than the pandemic of COVID-19. Two years into this
pandemic, I would love to hear your thoughts on that.
Dr. McCance-Katz. Thank you very much for that question. I
have to say that, in my role as assistant secretary, I was, you
know, ringing that bell, if you will, from the very beginning,
with the decisions to have extended lockdowns in the country,
and to have extended school closures.
I think it is really important to note that children have
been relatively unaffected by COVID-19, relative to other parts
of our population. If we look at deaths from COVID, the great
majority, about 74 percent, are in people over 65. We have had
well over 800,000 deaths. We have had less than 800 deaths in
children. And while every death is a tragedy, relative to other
age groups and risk groups, children have fared very well with
the virus.
If we compare that, if we compare those numbers, children
aged 5 to 19 had suicide rates in 2019 that were 3.4 times as
high as the 2-year number of total COVID deaths of children in
that age group. So this is--I think this makes the case for
just how devastating the social isolation of the extended
periods of isolation have been for our children.
Mrs. Rodgers. Thank you.
Dr. McCance-Katz. And it was very predictable.
Mrs. Rodgers. As I mentioned in my opening statement, the
CDC and Director Walensky continue to cite a discredited
Arizona study as the basis for forcing children to mask in
schools, and there has been an Atlantic article that has
showcased the problems with this study.
I wanted to ask if you were familiar with this study, and
why you believe CDC continues to rely upon this study when it
is--we have very little data or science to highlight or
underscore the benefit of masking in schools.
Dr. McCance-Katz. Well, I am familiar with the study, and I
think that the study has a couple of major problems,
methodologically. One is there were differences in the
observation periods for the different schools. And the second
is that there was no consideration of vaccination rates amongst
children and staff in the schools. And that can bias, in terms
of COVID outbreaks and the appearance of COVID outbreaks in
schools.
It is really--I don't know why CDC touts this study. I
can't speak to that. I would just say that it is concerning
that this study is being used as kind of the study that they go
by, when they have another study that they funded that had over
90,000 children in it in Georgia that showed that masks were
not a significant factor in COVID outbreaks in those schools.
Mrs. Rodgers. Thank you.
Dr. McCance-Katz. So I just don't----
Mrs. Rodgers. Well----
Dr. McCance-Katz. Yes, thank you.
Mrs. Rodgers. I appreciate that insight. I have one final
question that I wanted to ask, and--because it is not only the
masking in schools where we see, it seems like, cherry picking
of data. The CDC has highlighted its data on a number of
children between ages 5 and 11 who died from COVID over 2020,
2021. However, the CDC's own data from 2019, pre-pandemic,
showed that three times as many children from ages 5 to 11 died
from homicides that year, relative to the number of COVID
deaths in the age group.
So I wanted to ask, do you think the numbers of homicides
in children will change over the course of the pandemic?
And do you think school closures play a role?
Dr. McCance-Katz. Well, I think that this really
underscores one of the real tragedies of the COVID mitigation
responses and closure of schools, because schools are the
source of mandatory reporters for children that are suspected
to be victims of abuse and neglect. Homicides in children aged
5 to 11 are likely to be children who were abused. And so this
underscores one of the true tragedies of the extended school
closures.
And no, I do not think those numbers are going to go down.
I think they are going to go up.
Mrs. Rodgers. Thank you. Thanks for being with us. And
thank you, everybody. My time is expired.
I yield back, thanks.
Ms. DeGette. Thank you so much. Chair now recognizes Ms.
Kuster for 5 minutes.
Ms. Kuster. Thank you, Madam Chairwoman. I appreciate it. I
very much appreciate the topic of this important hearing.
Life during the COVID pandemic was truly stressful. I had
a--someone yesterday that I was with from New Hampshire tell me
that it is almost as though the entire country has experienced
an adverse childhood experience over the past two years, and I
think it is no wonder Americans are reporting increased
symptoms of anxiety and depression.
Some of the testimony that has been cited, evidence that
has been cited, I think it is the fear of catching the disease
that really was at the heart of it. And I think that spilled
over to children, as well. I think a lot of children did just
fine with masking, but I want to hear more, and learn more
about it.
Even before COVID-19, our communities were battling an
addiction crisis. And that is why in 2015 I founded the
bipartisan Addiction and Mental Health Task Force to address
this evolving epidemic. We were finally making progress, but
COVID-19 has pulled back the curtain on the depths of that
crisis, and substance use and overdose deaths continued to
rise, exacerbated by an ongoing epidemic affecting millions of
Americans.
Just yesterday I spoke with our Granite State YMCAs and
learned that they are partnering with the local hospital in
Nashua, New Hampshire, to bring more mental health services
into the community. And this is just one example of the types
of programs we need to support our communities because,
unfortunately, the number of overdose deaths continues to
climb. More than 100,000 Americans a year now die from drug
overdose, a 30 percent increase over 2019. And sadly, this
increase is infecting--affecting some communities harder than
others.
A recent NIH-funded study found that opioid or stimulant
deaths among Black Americans has risen at more than three times
the rate among non-Hispanic, White people, especially in
eastern states. So, Dr. Fortuna, you have researched the co-
occurrence of substance use disorder and comorbid mental health
conditions. How has the pandemic affected the substance use
epidemic in this country, particularly in marginalized
communities?
Dr. Fortuna. Thank you for that question. It--we--as you
have mentioned, the COVID-19 pandemic has completely
exacerbated and escalated substance use problems that we are
seeing in our community.
Just in San Francisco, which I can speak to very
intimately, is--in our homeless population, which we serve as a
public hospital, there have been more deaths due to overdoses
as compared to COVID-19, which we were very worried about in
our homeless population. It has doubled to tripled the rates of
death. Where we were having maybe 60 deaths a week at one point
during the pandemic, they were secondary to overdose.
And part of that has been the escalating stressors that
people have been experiencing throughout the pandemic, so it is
something that interacts. But it is also the issues that we
have had in terms of being able to provide continuous access
and services to substance use treatment throughout the
pandemic. So that is another piece that we haven't spoken as
much about, in terms of how certain services were closed or
inaccessible for periods of time throughout the pandemic.
As a public hospital, we were very involved in making sure
that we sustained that. Some of that was through telehealth,
believe it or not, and audio contact with patients. We have
had--we had patients that only could use audio for us to be
able to access. I mean, we did a lot of street outreach and
work, but some people we could only reach through audio, and we
had people who actually offered technology so that people could
have phones and could remain in contact with their treaters.
And that prevented some overdoses in many cases.
And there are many, many other things that we are trying to
implement, because there has definitely been escalation in
that, and it really does relate to serious mental illness and
the combination with co-occurring substance use disorders in
the----
Ms. Kuster. Thank you. I am sorry, I have to move on.
Dr. Fortuna. Yes.
Ms. Kuster. But we are going to be working on that with the
audio and telehealth. So we appreciate that. I want to turn
quickly in the final seconds here to Mr. Paley.
The Trevor Project published resources demonstrating higher
substance use among LGBTQI youth and young adults. What factors
do you think contribute to that, if you could, just in the
final seconds?
Mr. Paley. I appreciate you calling attention to that. We
need more data, frankly, to better understand what is
happening. The government needs to collect better data on
sexual orientation and gender identity.
But we know that many of the same factors that create
mental health issues--victimization, discrimination, and lack
of acceptance--are many of the reasons that LGBTQ young people
face a number of the mental health and substance abuse
challenges. So that statistic about more acceptance and support
and access to care, those are all things that can help lead to
better outcomes for LGBTQ young people.
Ms. Kuster. Thank you. And I see a lot of nodding by Mr.
Thomas, so we will followup on that. Thank you.
And with that, I yield back.
Ms. DeGette. I thank the gentlelady. Chair now recognizes
Mr. Burgess for 5 minutes.
Mr. Burgess. And I thank the Chair. I really do just want
to underscore Ranking Member Griffith's comments about parity.
This committee has worked on this, as Chairman Pallone
knows, really, going back over a decade. And it was our
committee who worked on Patrick Kennedy's bill, and it was
attached to the Troubled Asset Relief Program back in 2008. Of
course, the Affordable Care Act and including mental illness
under the category of essential benefits, that had to be
covered, and I think that was 2012 when that rulemaking finally
came down. And yet here we are, 2022, still awaiting the final
rulemaking. So this is important, and I do think it would be
critical that this committee stay focused on that because,
clearly, leaving it to the agency themselves, it has
languished, and it is clearly important.
Also, what Ranking Member McMorris Rodgers alluded to with
the masks on children. Forever it is going to be ingrained as
an
[inaudible] moment, that elementary school class, when the
teacher told them that they no longer had to wear masks, the
unbridled joy of those children. I mean, that is, to me, that--
if you needed a punctuation mark for the end of the pandemic,
that was it. And certainly, we need to acknowledge the relief
that those children felt by having been told that their masks
were no longer necessary.
Dr. McCance-Katz, I want to thank you for being here. You
have been in our committee before. You have always provided
very useful testimony.
Your reference to the article in The Lancet about the
effects of isolation and subsequent mental illness, I--you
know, I am just really taken by the fact that you said that
some of this could have been avoided.
And I do remember the early days of the pandemic, back in
late January, early February 2020, when public health people
who you would recognize would come before us and talk. And in
fact, the comment was made that this is a SARS virus, similar
to what SARS was before. And in 2022 we beat SARS with
quarantine and contact tracing. But I don't know that anyone
gave proper attention to the effects of quarantine,
particularly if it was going to be prolonged.
Was this ever part of the discussion in the Administration
in the early part of the pandemic?
Dr. McCance-Katz. It was part of the discussion. I was
talking about this from the very beginning. And I think that
this was such a terrible virus, there were--there was such fear
of deaths, and the terrible illness that it--that this virus
caused, that people just couldn't consider what I was trying to
say at that time.
And mental health was not part of the White House task
force. I was invited to speak a couple of times at the task
force, and I spoke each time about these issues. But again, the
ravages of the virus on Americans was such that mental health
just, I think, couldn't be considered at that time.
Mr. Burgess. Yes, I get it. And it was. You are right. The
virus was unlike anything people had seen before.
Let me just ask you. This nexus of homelessness, mental
illness, substance use disorder, this committee worked on--when
we worked on the mental health title in the Cures for the 21st
Century, there was a lot of discussion on the--what is called
the IMD exclusion, and perhaps pausing that, or doing away with
that regulation.
Is that--and that discussion was curtailed because of the
expense of what that would be in a Congressional Budget Office
score. But realistically, when you look at the expense of what
cities and counties and towns are having to spend, keeping up
with the problems with the homeless population, is there--is it
time to reevaluate that IMD exclusion?
Dr. McCance-Katz. I think it is. My current position is
running the State hospital in Rhode Island, and I am really
seeing very severe mental illness. It is mental illness that
really needs time on an inpatient setting in order for people
to get the care that they need to recover.
The IMD exclusion is something that, if lifted, would allow
us to provide people the care and treatment that they need,
that will help them to avoid future hospitalizations,
particularly in combination with some of the other programs
that Congress has helped us to put in place.
Mr. Burgess. Very good. Well, I appreciate that answer. I
will----
Ms. DeGette. Thank you so much, Mr. Burgess.
Mr. Burgess. Thank you.
Ms. DeGette. Mr. McKinley?
Or, I am sorry, Ms. Schakowsky, you are recognized for 5
minutes.
Ms. Schakowsky. Thank you, Madam Chair, for holding this
important, very important, hearing. You know, on Tuesday I went
to a really devastating funeral of a 19-year-old girl who
committed suicide.
You know, I want to discuss one of the paths that seems to
lead to suicide in too many instances--actually not in this
case--have been things that happen on the internet. In December
I had a hearing in my Subcommittee of Consumer Protection and
Commerce, and we had--we heard from the whistleblower, Frances
Haugen, who talked about some of the dangers there for young
people, even though Facebook had made promises, had, you know,
its own statements that it doesn't lead to these kinds of
harms.
I think the time has come that the internet needs to be
regulated in a way that keeps our kids, in particular, safe.
And there are--I have introduced legislation, and Kathy Castor
has introduced legislation, and we need to move on it.
But we also heard testimony about a girl named Leona--let's
see--Anastasia Vlasova, who got hooked on Instagram, on these
images, perfect images of girls' bodies and girls' lives.
Anyway, it ended up that she had a very, very serious eating
disorder.
And so, you know, despite the, you know, the bans and the
promises and the apologies, this still goes on. And so I wanted
to ask Dr. Nesi, can you speak to the risk and the harms of
certain uses of social media, and how exactly those harms
contributed--contribute to mental illness and even suicide?
Dr. Nesi. Yes, thank you for that question. You know, I
think that, when it comes to things like suicide, these are
really complex phenomenon. And so we know that there is a
number of different factors that play a role. It is rarely one
single cause.
And I think, when we think about the effects of social
media, I think that right now the evidence would suggest that
there is both benefits and risks. So, you know, when we think
about the benefits for things like suicidal thoughts, it would
be things like social support, getting access to resources,
connecting with peers, which we know is essential.
But, of course, there are risks, as you say. So risks would
be exposure to harmful content that might be related to
suicide, cyber victimization, displacement of other activities
that are important, things like sleep and exercise. And
certainly, exposure to things like hate speech and
discrimination, all of these things we know can play a role in
the risks of social media.
Ms. Schakowsky. But would you say that it is time for the
Congress to take a look at what kinds of things are allowed on
the internet that certainly can have an adverse effect on--
especially on young people who get, you know--because often
they--the platforms target and actually entice people to go
into websites that are dangerous for them.
Dr. Nesi. Yes. So, you know, I--as my expertise is in the
research on this subject, and not--and so I won't comment
specifically on policy here, but I do think that there--we know
from the research that, when teens are exposed to content like
this, that it can be harmful. When they are exposed to content
that is potentially even promoting suicide or self-injury, that
that is clearly harmful to them.
Ms. Schakowsky. So I also wanted to ask a question--do I
have time left--about the LGBTQ community. And I just wondered
if there are any online hazards that are there to our expert on
that.
Dr. Nesi. Yes. So when it comes to the LGBTQ community and
use of social media, obviously, all teens are different, and
the way they are using social media is different. And that is
true of LGBTQ teens, as well.
We know that the benefits for those youth exists online,
including opportunities to connect with peers that they might
not have the opportunity to do in person. But we do see risks,
as well. And I think one of the key risks we see there is
exposure to discrimination and hate speech, to homophobic
content, things like that.
Ms. Schakowsky. Yes, bullying online is really a hazard.
Thank you so much. I yield back.
Ms. DeGette. I thank the gentlelady. Chair now recognizes
Mr. McKinley for 5 minutes.
Mr. McKinley. Thank you, Madam Chairman. I think on this
subject, and I have really enjoyed the conversation with the
panelists and what they have contributed. But on this one
subject I think we can all agree that, in our classrooms, our
children all across America are suffering from this combination
of mental health and substance abuse.
So I don't expect any answers from everyone on the panel,
but I would hope that they would get back to our offices, if
they would. But I want to direct some of my questions primarily
to Secretary McCance.
And let me just start with saying that teachers across--
they are trained, and they are certified to teach. But we are
asking them to also get involved in counseling, nutrition, and
identifying autism. This distracts from their trying to teach.
So my question would be, would we be beneficial to having--
encouraging mental health counselors in each of our schools
across America?
Is there--could you address that, that subject, briefly?
Dr. McCance-Katz. Yes, thank you, Representative McKinley,
and it is nice to talk to you again.
It is very important that we put resources in our schools.
We have a history of doing that. Teachers, I agree with you,
are being asked to do far too much. In our administration, we
were so concerned about the needs for mental health services
and substance use disorder services for students that SAMHSA
and CMS actually put out a guidance to states and to
communities and to school districts about how they could think
about putting mental health services in place, and pay for it,
get it paid for.
Mr. McKinley. Thank you, thank you. If I--I have got
several other quick questions to follow back up with you on
this, as well, but the other is classroom size.
Our teachers are often confronted with 25, 30 children in a
classroom. So is there any evidence to suggest that smaller
classroom sizes allows our education community to be able to
identify these problems better, and do a better job for our
children by having small--is there any written evidence or
white papers we could study about that----
Dr. McCance-Katz. So this is not----
Mr. McKinley [continuing]. Smaller classroom size?
Dr. McCance-Katz [continuing]. Not my area of expertise,
but I believe that is the case, because I believe that
classroom sizes--they have worked to reduce classroom sizes for
many years.
Mr. McKinley. OK, let's--now, the other is--once--in a
school, once we identify these children that have problems for
a variety of reasons, in rural America we don't have the
resources. This isn't New York or Seattle or St Louis. In West
Virginia, our largest town in my district is 30,000 people. So
how do we provide these services? Once we identify someone with
autism, or someone with a mental health problem, or someone
with an opioid addiction, how are we supposed to deal with that
in rural America? What would be--what would your suggestion be?
Dr. McCance-Katz. So SAMHSA has a program called Project
Aware. Project Aware provides resources to schools in many
parts of the country. That program now allows behavioral health
aides to be in the classroom, and that is an important piece of
providing some mentoring and some support to students who are
identified as having those kinds of needs. I think those kinds
of programs should be expanded.
One of the things that I heard during my time of traveling
around to schools was that there just were not enough
counselors to--and social workers to assist all of the children
who need those services. So we need to train more of these
kinds of professionals, and we need to put mechanisms in place
to pay for those people to be in schools and provide those
services onsite.
Mr. McKinley. Thank you. Thank you. Now my last question
for all of you, would--what I would like--what are some
examples of real productive
[inaudible] that have been tested in our school systems all
across America that are working to address behavioral health
problems, opioid addiction, nutrition problems, on and on?
Are there are there some models that we have seen work very
effectively that we could be promoting throughout this country?
Any one of you could get back to--I would like to--you
could follow back up with our office or, if you would like to
add something quickly here in the few seconds I have left----
Ms. DeGette. Mr. McKinley, maybe we can ask the witnesses
to provide that written to the committee, because I think we
would all like to see that.
Mr. McKinley. Thank you. Thank you very much, Madam
Chairman. I think it would be very helpful. Thank you. I yield
back.
Ms. DeGette. Thank you so much. Chair now recognizes Mr.
Tonko for 5 minutes.
Mr. Tonko. Thank you, Madam Chair. The pandemic undoubtedly
has had an impact on the mental health and well-being of many
Americans. And the growing need for mental health services has
[inaudible] access challenges already faced by many.
So, Mr. Thomas, you have been working----
[Audio malfunction.]
Mr. Tonko [continuing]. Two of them under the cloud of this
pandemic. So what have come up in your conversations?
Mr. Thomas. I did not hear the question, I apologize. You
are breaking in and out.
Mr. Tonko. Oh, I am sorry----
Ms. DeGette. Mr. Tonko, we are having some difficulty
hearing you. I think you have got some reception issues.
Mr. Tonko. OK. Should I try it again?
Ms. DeGette. You know, maybe what I will do, if it is OK
with you, I will go to Mr. Ruiz.
Mr. Tonko. Can you hear me now?
Ms. DeGette. Oh, wait, I can hear you now. Yes, try it.
Mr. Tonko. OK, so Mr. Thomas, you have been----
[Audio malfunction.]
Mr. Tonko [continuing]. Communities and awareness about
mental health for several years, two of them under the cloud of
the pandemic. What COVID-19-related mental health challenges
have come up in your conversations?
Mr. Thomas. If I heard your question correctly, it was
about mental health challenges in the face of the pandemic, is
that correct?
Mr. Tonko. Well, that you have heard in your conversations,
which--maybe, Madam Chair, I will check on the technology here,
so that--I don't want to waste your time or mine here, lose my
time. Can you come back to me after Dr. Ruiz, perhaps?
Ms. DeGette. I am happy to do it, and I will recognize Dr.
Ruiz for 5 minutes, and then you can work on--we will give you
5 minutes when you figure out your technology.
Dr. Ruiz?
Mr. Ruiz. Thank you, thank you. And Representative Tonko, I
am sure he is dialing--speed-dialing his Millennial in his
office right now to come fix his tech for the tech support. So
the best of luck to you, my friend.
Thank you, Chairwoman, for holding this hearing to address
this important, critical topic. As a doctor who was in the
emergency department during the H1N1 pandemic, and also in the
front lines in Haiti immediately following the earthquake in
2010, you know, I understand through experience firsthand the
mental toll of being a health provider in a crisis is
[sic]. And I can only imagine how much greater the burden
is for our frontline health workers who have been fighting this
battle, day in and day out, for two years now.
A recent survey of healthcare workers and first responders
that was published in the Journal of General Internal Medicine
tells a troubling story. Thirty-eight percent were suffering
from PTSD. Seventy-four percent reported depression. Seventy-
five percent were experiencing anxiety and 15 percent had
recent thoughts of suicide or self-harm. Yes, providers are
professionals, they are trained, they put their heart and soul
on, they put the patient above their own needs. And often times
that is difficult.
But providers are also human, and they come home, and they
think about the patients and the loss and the anxiety. They
think about the vitriol that they see in the fighting in the
communities for people who are against the simple measures of
wearing a mask that would prevent the spread of the virus to
others. And they think about the human toll that this has taken
not only to those individuals, but in their own souls when they
see such trauma.
And we are trained to not associate, not internalize. But
at the end of the day, some--there is loss of sleep, and there
is a general mourning for the patients that we take care of. I
know that because I experienced that in the emergency
department, day in and day out.
Dr. Fortuna, we have seen the troubling data. But through
your hospital work these past two years, I imagine you have
seen firsthand the mental health burdens facing healthcare
providers. What additional mental health challenges are
healthcare workers experiencing as a result of the pandemic?
Dr. Fortuna. Thank you very much, Representative Ruiz, for
this question. You are absolutely right. All those statistics
are playing out where I see it here, even in San Francisco. It
is our emergency, it is our front line, it is our ICU. And I
like to underline it is also our psychiatry faculty and staff,
who are also seeing a tremendous amount of loss.
Some of the things that are happening are--is there is a
tremendous amount of either all of those things--PTSD, anxiety,
depression--or, at minimum, burnout, where--you know, we did a
recent survey, and found that over 60 percent of our physicians
and nurses are presenting with some level of burnout and
fatigue.
Mr. Ruiz. I am glad you are mentioning this, because our
country already has a physician shortage crisis.
Dr. Fortuna. Right.
Mr. Ruiz. And about a third of our doctors are over the age
of 65, in retirement age. If you are an elderly doctor that is
experiencing burnout due to this pandemic, then the likelihood
that you will retire sooner than later, it increases that risk
because of that burnout. So that can dramatically worsen our
physician shortage crisis and our provider crisis.
On top of that, if you de-incentivize the providers by
cutting their payments to provide the basic services, or you
have the insurance companies who can dictate the median rate of
payment for the surprise billing dispute, you add even more
stressors to our physicians and providers who have been heroes
during the pandemic, and will accelerate their--closing their
doors, and the hospitals also closing.
So what steps should Congress take to close the gap between
the demand for services and the supply of providers in dealing
with the burnout and the mental health issues right now?
Dr. Fortuna. I think there are several things. I mean,
there is two components to that.
One is we definitely need to increase pathways for
workforce, right? Which I will talk about, because you are
absolutely right, people are retiring earlier, and people are
just leaving the field. And we have a tremendous shortage of
being able to have mental health providers. So, you know, there
is a few things that can be done around workforce.
But let me just talk about sort of the piece around the
burnout and mental health. One of the things that we instituted
pretty rapidly was a program called COPE, which was a program
that allowed all of our staff, physicians and otherwise, to be
able to access a line where they could screen for their mental
health needs, and immediately connected with behavioral health
services without any wait, and without any additional cost to
them. If their insurance covered it, if the insurance didn't
cover it, it didn't matter. We made sure that they got
immediate access to mental health services.
So if there was a way for Congress to be able to institute
and support resources for immediate mental health and support
services for people in the health field, that would be
fantastic, because we have to find multiple ways of doing that.
Mr. Ruiz. Dr. Fortuna, often times a patient who is--lives
in a disadvantaged community lacks social capital and social
networks, and that leads to a higher risk of anxiety and
depression, based on living in an under-served area. And there
have been some studies that show that the use of community
health workers--and in the Hispanic community they are often
called promotoras----
Dr. Fortuna. Yes.
Mr. Ruiz [continuing]. To providers in order to augment
that social capital, and to help providers reach into the
community to provide the counseling or the connection that they
need with a professional.
In your experience, is that something that Congress should
look into fostering with perhaps instituting reimbursements for
that type of community service, aligned with the clinics and
the providers?
Dr. Fortuna. Yes, absolutely. And that--some of the work
that we are doing in using these community health workers,
promotoras--in some instances navigators--that work
collaboratively with our healthcare team to be able to provide
additional supports to the health team, but also being able to
provide additional support that is culturally relevant, right,
and engaged in the community for the patients that we serve.
And we found that that improves engagement of the patient,
retention and care, and helps the workforce be able to serve
those populations when we work collaboratively. Absolutely.
Mr. Ruiz. Thank you. I ran out of time, but I would like to
followup with you in picking your brain on specific policies
that can help promote that model, which has been shown to be
effective.
Thank you, and I yield back.
Ms. DeGette. I thank the gentleman. Chair now recognized as
Mr. Long for 5 minutes.
Mr. Long. Thank you, Madam Chair.
And I was afraid my clothes were going to go out of style
during that 5 minutes, Mr. Ruiz. That was a long 5 minutes. I
don't know what happened to our clock there, but I am ready to
go now. So I would like to take a point of personal privilege
for Chris Thomas.
Mr. Thomas, that opening of yours was one of the most
heart-wrenching openings I have ever heard on this committee.
And I know that my wife is on the suicide prevention board
there, in Washington, DC. And God bless you and your family.
And anything we can do through this committee, anything that--
advocates like you speaking out really, really helps. And I
just want you to know that I, from the bottom of my heart,
truly, truly appreciate your opening remarks today.
I also want to thank Greg Walden, Diana DeGette, and Dr.
Burgess. I hate to leave anyone out, but I know in the last
Congress, Diana, Greg, and Dr. Burgess and others did yeoman's
work on telehealth and getting that in place, getting it done
before we really needed it, before the pandemic. And that was a
great, great move on the committee's part.
And so Dr. Fortuna, with that being said, I would like to
address my first question to you, and thank you for being here
today.
Throughout the public health emergency, we have heard from
patient groups and providers on how beneficial telehealth has
been for access. These telehealth flexibilities were extended
to behavioral health services, but there were some limitations.
Looking back on the changes that the aforementioned people made
along with the committee, what worked and what did not work?
Dr. Fortuna. Thank you very much for that question.
Telehealth has been critical for us to maintain behavioral
health access.
Before the changes that were made under the emergency for
telehealth at the San Francisco General Hospital, for example,
we could not see any patients through telehealth. It was not
covered for our publicly insured patients, or Medi-Cal, in
California.
And when we instituted telehealth, which--we had a lot of
support from the APA, and from others who had evidence-based
ways of doing telepsychiatry--psychiatry has been doing this
for a very long time--we instituted from, you know, 0 to 100 in
a week or two, and we actually were able to maintain, you know,
access with our patients. About 90 percent of our patients were
able to be able to be retained in mental health services.
There were a few things that helped that. One was sort of
the relaxation to be able to actually use different modalities
for being able to do video or audio. Audio, which we mentioned
a few times during this hearing, was critical for some of our
patients who did not have access to the video components of
telehealth. And it did make a difference. And I know many, many
instances where people were talking to me about that it really
prevented, potentially, a suicide or an overdose. And people
actually reached out when they critically needed help. And I
could access my patients, whether they were, you know, housed
or homeless or had WiFi or no WiFi.
So we really want to maintain that, and also the fact that
some people could not come in to the clinic. At different
points, the fact that we could see them in telehealth without
requiring an in-person evaluation, for example, actually
increased our access, reduced our no-show rates tremendously,
and gave us great flexibility to be able to serve our
population.
So, you know, we would definitely want to see that, all of
those sort of benefits of telehealth, to continue into the
future, both----
Mr. Long. Let me try to get in----
Dr. Fortuna [continuing]. If we are talking about hybrid
and----
Mr. Long [continuing]. One other question here for you, Dr.
Fortuna.
Dr. Fortuna. All right.
Mr. Long. There is a nationwide, as we know, mental health
crisis, and it is being felt acutely all throughout my
district, which is mainly a rural area, through the rural
areas, with shortages of mental health professionals. The
majority of mental health professionals shortages--the shortage
areas are rural, as I said.
I know that the mental health workforce can participate in
the Medicare graduate medical education program. But what are
the other avenues we should be looking at to train and grow the
workforce in the rural and under-served areas?
And you have 36 seconds.
Dr. Fortuna. All right. Well, I mean, I think, definitely,
if we could have more funding for medical graduate education
in--especially in the mental health fields, in psychiatry and
allied fields--mental health, psychology--fellowships and loan
repayment programs for people to work in these under-served
areas, both rural and otherwise, where there is a lack of
providers, and especially support for people who have sort of
linguistic and cultural--broadly, right--sort of expertise to
be able to come into communities. So funding that would be very
helpful.
Mr. Long. OK. I don't have any time left, but if I did, I
would yield it back. Thank you, Madam Chair.
Ms. DeGette. Thank you so much, Mr. Long. I guess Mr. Tonko
is still having some technical issues, so I will go to Mr.
Peters.
Mr. Peters, you are recognized for 5 minutes.
Mr. Peters. Thank you so much for this really important and
fascinating hearing. I do know that data from 2020 shows that,
while suicide deaths declined overall compared to 2019, death
by suicide for children and young people increased,
particularly among youth of color. I want to ask Dr. Fortuna.
Based on your research and clinical practice, do you have--
are there particular key factors that are driving these trends,
particularly among youth of color?
Dr. Fortuna. Yes. I think that it is--again, it is multi-
factorial, and research is really looking into--getting to the
bottom of this, but there is a few things.
One is I think that youth of color, especially ones living
in disenfranchised communities, are experiencing escalating
stress. It has been a long time. It was before the pandemic,
right? And those relate to issues around poverty,
discrimination, racism, inadequate supports in schools, and a
lack of, I would say, timely and appropriate and quality mental
health services early, when youth are first presenting with
these symptoms of stress or distress.
It--without the access of services, you know, what happens
to begin as mental--a more sort of anxious--and the lower
symptoms--escalates into severe depression and illness and
suicidality. So a lack of access to services and extreme
stressors.
And in terms of pandemic-related, one of the things that I
want to underline is that over 200,000 children have been
orphaned through the pandemic, or have had a significant person
near them pass away or die due to COVID, and that has been
disproportionately impacting communities of color. So that is
something that we are grappling with, on top of everything
else.
Mr. Peters. Can I ask Mr. Paley if The Trevor Project has
identified any--or adopted any new strategies in response to
these trends as they affect LGBTQ young people?
Mr. Paley. We see--many of the same issues that Dr. Fortuna
talked about related to people of color and youth of color
apply to LGBTQ young people. And I think it is really important
that we also recognize many LGBT----
Mr. Peters. I don't want to cut you off. I need to know
whether you have strategies that you--another--I only have some
so much time. Have you adopted new strategies with respect to
these new trends?
Mr. Paley. Yes, we have been working to provide more
support for young people, so that they can ensure that they can
reach out and get support. That is through more resourcing on
The Trevor Project services, as well as advocating for 988 to
be fully funded for all Americans, as well as specialized
services for LGBTQ young people, tribal communities, and other
marginalized and at-risk groups.
Mr. Peters. Thank you very much. I do want to highlight
that Mr. Bilirakis and I introduced the Suicide and Threat
Assessment Nationally Dedicated to Universal Protection--
Prevention, or STAND UP Act, which would encourage schools to
implement evidence-based suicide prevention training for
students.
Mr. Thomas, you mentioned in your testimony that your
foundation is focused on working with adults. We interact with
students in the school community. What role do you think
teachers and coaches, in particular, can play in mental health
awareness?
And why did you choose to focus the foundation's efforts on
these community leaders?
Mr. Thomas. Yes, thank you for the question. And our focus
has been, actually, working with the teachers and coaches who
have an influence and impact young people, particularly young
people of color, and we believe the key strategies there are
teaching them the importance of what we call the D Lines: don't
ignore your gut; listen for the signs; interact; name the
concern; evidence the concern; and support--provide a
supportive environment. So that is what we are doing right now,
teaching these lessons in schools in Dallas and in Vegas, with
the goal to go national.
Mr. Peters. And do you think there is a role for something
like the STAND UP Act which would support training, best
practices, and implementation of evidence-based suicide
prevention programs in schools, get people to look out for
these things on the ground, and, you know, sort of before you
even get to the professionals? Do you think that resources like
that would help build awareness and save lives?
Mr. Thomas. I definitely believe evidence-based programing
in schools that is sort of mandated, as well as funded, would
definitely help the students--in particular students of color,
because, as said before, the lack of access to care, as well as
all the other structural issues that exist for people of color,
whether it is racism or micro-aggressions, plays a significant
impact in their mental health.
Mr. Peters. And I just want to highlight one of the things
that you said is that almost all of these folks, these young
people, give us a sign about----
Mr. Thomas. Yes, sir.
Mr. Peters [continuing]. That they are considering this.
And just the power of people in the public knowing what to look
for can make a big difference in interventions.
Mr. Thomas. Yes, sir.
Mr. Peters. So I really appreciate your loss. I want to say
I certainly--I grieve for you.
And I want to thank all the witnesses for coming out and
offering this wonderful testimony.
Thank you, Madam Chair, I yield back.
Ms. DeGette. Thank you so much, Mr. Peters. Chair now
recognizes Mr. Palmer for 5 minutes.
Mr. Palmer. Thank you. Thank you, Madam Chairman, and I
want to thank the witnesses and the ranking member for holding
this hearing. It is very important. I have had several of our
members raise these questions about the suicide rate among
young people. I think it was an all-time high for people under
24.
And back in July 2020, former CDC director, Robert
Redfield, noticed that there was a mental health crisis among
young people, and argued that the lockdowns were
disproportionately affecting that age demographic. The CDC
reported that there was a 51 percent higher rate of suicide
attempts, compared to the same timeframe in 2019. And I just
want to know if anyone on the panel has made any attempt to
study the impact of the school lockdowns and the link to the
unprecedented rise in suicides among school children.
And also, I also think the unprecedented increase in the
number of overdose deaths, drug overdose deaths--I may be off
base here a little bit, but I think, in some of those cases,
some of these drug overdose deaths were tantamount to a
suicide.
I would just like to get some comment, and maybe start with
Dr. McCance-Katz, please.
Dr. McCance-Katz. Well, I certainly follow the literature,
and I am quite concerned about these issues. It is my belief
that probably a fair number of opioid overdose deaths and drug
overdose deaths at large are suicides, and they are just
suicides that we haven't been able to identify as such.
When people are isolated and lack the supports that they
need, and our healthcare system at the time you were speaking
of was basically not available, it is not surprising that
people had more access to drugs and alcohol, and sought relief
from what they were experiencing.
Mr. Palmer. I can't see the time clock. I am in my vehicle.
So I am going to go ahead and move----
Ms. DeGette. You are at about--sir, you are about two
minutes and 40 seconds.
Mr. Palmer. OK, thank you, Madam Chairman. I want to go
ahead and move to something else, and it is better than
suicide, and I am surprised no one has mentioned that in this
hearing.
According to the U.S. Department of Veterans Affairs, their
2021 National Veterans Suicide Prevention Annual Report showed
that the overall veteran suicide rate had decreased in 2019
from 2018 to 2017. But when we hit the middle of the lockdowns,
it started back up. From April to June it was up 11.3 percent.
In the third quarter it was up 22 percent. And then, in the
fourth quarter of 2020, it was up a shocking 25 percent.
And Dr. McCance-Katz, have you looked at that? Have we
looked at the impact of the lockdowns on veteran suicides?
Dr. McCance-Katz. What--yes. What I can say is that there
have been a number of different types of programs that have
been put in place to support veterans, and these are programs
that include pairing veterans with other veterans. They include
the ability for veterans who are experiencing these kinds of
serious mental health effects to be with other veterans, and to
get the supports that they need. And during the course of the
pandemic, these programs were not available because of the
mitigation responses to COVID-19. And so, again, it is just a
very unfortunate reality that we live with, that this affected
veterans in this way.
Mr. Palmer. Thank you.
I know I have got very little time left, but Madam
Chairman, at some point I think we also need to expand this,
and talk about the mental health aspect related to
homelessness, and what we need to be doing there. And it is
also a problem for veterans. There are a number of veterans
with mental health issues who are also homeless.
And I imagine my time is almost up, so I will yield back.
Ms. DeGette. OK. Yes, your time is almost up, Mr.--I was
just informed by staff that members are supposed to have their
cameras on under the House rules in these hearings. But I
thought that----
Mr. Palmer. I have it on, don't I?
Ms. DeGette. No, it is----
Mr. Palmer. Yes, I think I----
Ms. DeGette. First of all, my name is Diana.
But second of all, you are not--it is not coming on the
screen. But that is OK. We will----
Mr. Palmer. All right.
Ms. DeGette. We will--I thought your questions went great,
and we will now go to our next questioner, who is going to be--
I don't know if Mr. Tonko's--I don't know if Mr. Tonko's
technological issues have been resolved. I don't see him, so I
am going to go to Ms. Schrier.
Ms. Schrier. Well, thank you, Madam--and thank you to our
excellent witnesses today for this discussion.
As the only pediatrician in Congress, I am particularly
concerned about the mental health----
[Audio malfunction.]
Ms. Schrier [continuing]. Nation's children. The public
health response to this pandemic initially curtailed our in-
person interactions with friends, and with family, and, boy,
for tweens and teens, whose healthy development really hinges
on these relationships with peers at that age, most have turned
to online interactions with their friends, and social media, in
that sense, has really helped maintain friends and limit
feelings of isolation.
But social media is also a rabbit hole that can lead to
exposure to harmful content, and really hurt children. And the
algorithms used by platforms like Facebook make it even more
likely that a simple online search might lead children deeper
and deeper into exposure to dangerous content. For example, a
girl who looks for information about healthy eating could
quickly be exposed to content that leads to eating disorders.
And this is even more dangerous at a time of uncertainty,
when people are just looking for a little bit of control in
their lives. Children feeling sad, as we heard, might find
themselves channeled to discussions that glorify suicide or----
[Audio malfunction.]
Ms. Schrier. And boys are often targeted by hate groups.
Yesterday I spoke with a psychologist at my son's school, who
shared these concerns and noted that she is seeing markedly
increased levels of acuity with depression, anxiety, and eating
disorders. But she is also seeing them in younger children. And
she echoed concerns about social media. And it was interesting,
because she said many children wish that their parents would
monitor their use more because sometimes they see such shocking
things online that they are embarrassed--that they don't even
know how to ask their parents about it.
So, Dr. Nesi, I know you have done so much research in this
area, and I was wondering if you could talk more about the role
that parents, therapists, pediatricians, and schools can play
in helping teens kind of manage their social media use, and
navigate this brave new world, and help them be more thoughtful
about how and when they use it.
Dr. Nesi. Yes, thanks for this question. I know that a lot
of parents are--and schools are concerned about social media
and how they can protect their kids' mental health.
I think let's maybe focus on parents for a minute. I think
for--what is going to work for each family is going to be a bit
different. But there are some key principles, I think,
supported by research that parents can keep in mind.
So I think emphasizing open communication with teens about
social media, engaging them in the process of learning what is
working for them and not working for them is critical.
Setting reasonable limits and expectations. So parents
might consider setting limits by times of day, location that
their kids can use their phones, or maybe limiting certain
content or activities in order to reduce exposure to harmful
content.
I also think protecting sleep is critical. The evidence is
pretty clear that nighttime device use can get in the way of
sleep, and so parents need to help their teens ensure that they
are getting adequate sleep.
And then finally, I think parents need to be aware of signs
that their teen is really struggling. So if they are not
themselves, you know, there is--using technology in a way that
seems excessive, or is really interfering with their well-
being, then they may need to get professional help, and seek
out therapy services for their teen.
Ms. Schrier. Thank you. And now we just have to coach
parents--how to do some of those things that require some
technical expertise themselves.
I just have a minute left. So Dr. Fortuna, the psychologist
at my son's school also noted that she is really overstretched.
She works for a hospital. They have a school levy that pays for
them. Now they only have two for the whole district, and that
we need more psychologists, but there just isn't a pipeline.
There just aren't enough people to go around in the private or
school realm.
I was wondering if you have any ideas about how to leverage
her expertise--you know, groups, or training others to do some
of that work. How can we be creative about using that limited
resource?
Dr. Fortuna. Yes, I mean, I think it--thank you for that--I
mean, I think it goes a little bit to what we were just talking
a little bit before, with--about the workforce expansion and
diversification of that, right?
So beyond trying to get more people into the workforce
through different incentives, I think we can use para-
professionals, you know, community health workers, even in the
school, peer partners, peer, you know, family partners, who can
work with families and young people.
I mean, we have actually tried a project which really
trained peers to be able to be a supportive group for special
populations like LGBTQ youth or otherwise.
And to have training. I think what we are finding in
psychology and psychiatry is we can do a lot with training
people in aspects of our expertise, so that we can work in a
very collaborative model, and not just rely on people at
higher--with higher degrees of the profession.
Ms. Schrier. Thank you. She noted that, too, that helping
kids know how to handle it when a friend comes to them is
really important. Thank you.
I yield back.
Ms. DeGette. Thank you so much.
Mr. Joyce, you are now recognized for 5 minutes.
Mr. Joyce. Thank you for yielding, Chair DeGette, and for
convening such an important hearing.
According to the results from the 2020 National Survey on
Drug Use and Health, almost eight million adults in and around
rural areas reported having any mental illness. In addition,
almost two million adults in these areas reported having
serious thoughts about suicide during that year.
While the prevalence of mental illness is similar between
rural and urban residents, the services can be very different.
Mental healthcare needs are often not met in many rural
communities across our country, because adequate services are
not available. This is particularly acute in pediatric
populations. And I would like to thank Chair Eshoo for the work
that we have been doing to address this matter together.
My questions are first for Dr. McCance-Katz.
Dr. McCance-Katz, what factors are unique to rural
communities that challenge mental healthcare delivery?
Dr. McCance-Katz. Well, one of the huge challenges is just
distance. You are quite right that the services tend to be
limited. But there is great distances for people to travel,
which is why telehealth and hybrid versions of telehealth are,
I think, in my view, are so important to continue.
Mr. Joyce. Are there additional steps besides telehealth,
which I, as a physician, find to be incredibly important? Are
there additional steps that we can take, particularly while
trying to address pediatric healthcare and the shortfall of
providers in rural communities?
Dr. McCance-Katz. Well, one of the areas that still awaits
major expansion, but which I think is very promising for rural
areas, is mobile health. And this is a resource that is being
developed in some states. It is a resource that, at SAMHSA, we
encouraged use of, in collaboration, actually, with the
Department of Agriculture.
And we think that--I think that this is a way to help
people to get services who would otherwise not have any chance
at all of getting face-to-face services. And when that can be
also supplemented by telehealth services, including use of
telephone, because rural areas really are at a deficit in terms
of their access to broadband, those--that combination will help
people to get the care and treatment they need.
We also need to expand services in our schools, so that
rural-based children and their families can get those services
easily.
Mr. Joyce. I think the all-of-the-above approach that you
directed--expanding mobile health, telehealth, telephone
health, I think that those are all important options that we
need to continue to evaluate.
And just yesterday we had a similar hearing regarding rural
broadband, but I want to talk about coordination. If we want to
be better in coordination with primary care doctors and with
mental health providers, what is the best avenue to explore and
to do that?
Dr. McCance-Katz. Is it a question for me?
Mr. Joyce. Yes.
Dr. McCance-Katz. Yes. So I think the model exists. And
again, I said it earlier, but I will say it again because I
think this is the way of the future, and that is the integrated
healthcare for those with serious mental illnesses that expands
to all age groups: elders, adults, and children and
adolescents. Integrated services in the form of certified
community behavioral health clinics that also offer 24/7 crisis
intervention services, mobile services, and bricks and mortar,
so that an individual doesn't have to go to an ED, but can go
to a service that is--has individuals there that are trained to
meet their needs.
Mr. Joyce. In rural communities that are often--as we have
mentioned throughout this hearing, there are not the resources
to provide psychiatric--pediatric psychiatric care. And so
primary care doctors actually shoulder a majority of the
psychiatric care, because they are the only resource that is
available.
Do you feel that additional training in psychiatric and
psychological care should be instituted and occur in primary
care programs?
Dr. McCance-Katz. I think that would be immensely helpful.
We know that the seriously mentally ill are the population that
are more likely to be seen by behavioral health and
psychiatrists. But the majority of mild to moderate mental
illness is going to be seen by primary care, and they don't get
a substantial amount of training to meet those needs, so it can
be overwhelming for them.
SAMHSA has programs to help with that training. HRSA also
has the ability to provide those kinds of resources. And I
think that Congress looking at that and expanding those
resources, I think, would be very, very helpful to millions of
Americans in need.
Mr. Joyce. Thank you. I share those concerns, and those
millions of Americans will need that care.
Thank you, Chair DeGette, and I yield my remaining time.
Ms. DeGette. Thank you so much.
I want to thank Mr. Tonko for his perseverance. I
understand that he is in a better place now, and I will
recognize him for 5 minutes.
Mr. Tonko. OK, thank you, Madam Chair. I hope so. Can you
hear me?
[No response.]
Mr. Tonko. OK. Mr. Thomas, again, you have been working to
engage communities in awareness about mental health for several
years, two of them under the cloud of this pandemic. What
COVID-19-related mental health challenges have come up in your
conversations?
Mr. Thomas. Oh, thank you for that question, Mr. Tonko. And
our organization has been in existence for about a year now,
starting in May 2021. But I have also been working on the
American Foundation for Suicide Prevention boards.
And the things we have noticed is a lack of connection as
relates to COVID-19. We have seen an increase in the
realization of the issues of institutional and micro-
aggressions of racism among our organizations, our communities,
and that creating a divide amongst ourselves. And then, the
lack of access of care is sort of what we have noticed, as
well, as a result of COVID-19.
But the other thing we have noticed, from a positive
standpoint, has been the opening up and normalization of
conversations amongst influencers about mental health and
suicide prevention. Whether it is, you know, Kevin Love or
Simone Biles, my own son Solomon talking about the importance
of mental wellness and suicide prevention, we have seen an
uptick in that kind of conversation for folks to understand
that it is OK to not be OK, and to start talking about the
importance of whole health.
Mr. Tonko. Well, thank you. These kind of examples led me
to introduce H.R. 1716, the COVID-19 Mental Health Research
Act, with Congressman Katko. This bipartisan legislation would
fund research to study the effects of COVID-19, the pandemic,
and what it has had on mental health of Americans, including
its impact on children and healthcare providers.
Dr. Fortuna, as a researcher, do you think it is important
to research the pandemic's impact on Americans' mental health?
And how might such research help us better understand how
to meet the Americans' mental health needs?
Dr. Fortuna. Yes, I mean, absolutely. I think it is
critical that we study the mental health impacts.
I mean, like all disasters and crises, this pandemic, it
has the--first, health issues that it has an impact on. But
then the wave, the tsunami that we call it often in our field,
of the mental health impact of such crises.
And it is multi-factorial, right? So that is why I think it
is really important to have research, because we can understand
what are the different elements that are impacting across the
lifespan, and we can also really--and definitely need to study
interventions.
The way that we can come out of this pandemic is to be
ready with understanding how do we prepare for future crises.
Because I think that is something that we can learn, as well.
And how do--we can have the agility to be able to respond
to the mental health needs of America through the different
kinds of resources, telehealth, you know, integrated services.
You know, how do we have to get those things to the evidence
base, so that we can be able to serve Americans throughout this
crisis and the next one, right?
Mr. Tonko. Thank you. Thank you. And just to briefly
confirm, Doctor, the pandemic's impact on children's mental
health, I would think, is multi-faceted and, despite claims
this morning, is not due to a single factor, like children
wearing masks. Would you agree with that?
Dr. Fortuna. I would definitely agree that it is multiple
factors.
You know, no one liked being, you know, social distancing,
but there were so many other things, like in the story that I
opened up with, in terms of, you know, loss. People were really
sort of grappling with already pre-existing mental health
needs, economic devastation in dis-enfranchised communities. It
just--it is just very multi-factorial, and we have to look at
it comprehensively.
Mr. Tonko. Right. Well, I thought it was important to put
that on to the record.
It is important that we base our decisions on sound data,
and those data are extremely important, and not just on
conjecture.
Mr. Paley, your testimony discussed some of the pandemic's
harmful impacts on LGBTQ1+
[sic] young people. Do you believe these impacts are
indicative of similar effects on young people, and particularly
youth of color, as well?
Mr. Paley. Yes. The pandemic has had--exacerbated a lot of
the inequality inequities that we saw in access to mental
healthcare before the pandemic. So it has had very profound
impacts on LGBTQ people, youth of color, tribal communities,
veterans.
And I think it is really important that we recognize that
many people occupy multiple identities. We have many people who
are LGBTQ youth of color, and veterans of color, and LGBTQ
veterans, and that it--that is why it is so important we
recognize that mental healthcare is not one size fits all, and
we need to make sure that we are providing care that is
culturally competent, and that is appropriate for every type of
person, regardless of what--depending on what their needs are.
Mr. Tonko. Well, thank you to all of our witnesses for
helping us better focus on the mental health needs of Americans
through this trying time.
And Madam Chair, thank you for your flexibility. I yield
back.
Ms. DeGette. Thank you so much. Chair now recognizes Mrs.
Trahan for 5 minutes.
Mrs. Trahan. Thank you, Madam Chair.
On December 19th, 2021, the New York Times published a
story titled, ``Where the Despairing Log On and Learn Ways to
Die.'' Since then, my office has been conducting an
investigation, alongside Representative McKinley and others, on
online suicide instruction forums. In this work I have heard
heartbreaking stories from parents.
Mr. Thomas, thank you for sharing your daughter's story
with us today. Mary-Ellen Viglis, a Virginia resident, gave me
permission to share her son's story, as well.
And Mary-Ellen describes her son, Demetrios James, as an
incredibly loving individual. But like so many young people, he
struggled with depression and anxiety in his early teen years.
Demetrios James first attempted to die by suicide when he was
just 14 years old. And after the attempt, I understand it took
a year to get off a wait list to see a psychiatrist. Public
schools in the area did not offer mental health services, so
his mom put him in a special school with regular access to peer
recovery counselors, where he thrived for a period of time.
Throughout his late teens, however, he continued to
struggle with combinations of depression and substance abuse.
At 19 he was doing better. He had a job, and he had a community
of older young people in recovery that he met with regularly.
When the pandemic hit, he lost his job, and his meetings were
canceled. The isolation became too much.
He discovered a website that encouraged suicide, and
provided information and access to methods. There he learned
about a poison popularized by the website, and where he could
buy it, which he did, with ease, on Amazon. Not long after the
package arrived, he died by suicide.
What makes this story so powerful is that it speaks
directly to the multi-faceted set of issues that all of my
colleagues have raised today: a shortage of psychiatrists, the
importance of funding for school mental health programs, the
existence of online forums that lack accountability for their
safety of their products.
One element of Demetrios James's story that is uniquely
troubling is the method he used, a poison described in a recent
court case as a substance that ``turns a living person into
jerky.'' Amazon not only sells this poison using expedited
shipping, but once a user searches for the product it may be
recommended to them, along with an ad for an instruction manual
and an acid reduction medicine that makes the poison easier to
take.
Dr. Nesi, can you speak to why ease of access, in general,
to death-by-suicide methods are so problematic, once an
individual is experiencing suicide ideation?
Dr. Nesi. Thank you for sharing that story, and for this
question.
Yes, I--so I think we know that easy access to means is a
key risk factor for suicide among youth and adults. That is why
one of the main methods that we have for reducing suicide risk
is limiting access to means. And that is something that we do
with patients, as psychologists and psychiatrists. So clearly,
it is an issue to have easy access to that kind of thing,
whether that comes in person or if it comes online.
Mrs. Trahan. And similarly, Dr. Nesi, what does the
research tell us about the impact of online content related to
death-by-suicide methods on young people who may be struggling
with mental health?
Dr. Nesi. Yes, this is a really important question, and I
think that there is--you know, so when it comes to suicide-
related content, I think that there is a lot of different types
of content out there. And some of it can be helpful. For
example, when it provides support, when it offers opportunities
for intervention when kids are in crisis, or when it provides
them information on resources like the crisis text line or
information from AFSP.
But obviously, there are cases where it can be really
problematic, and that includes as we discuss cases where
content might glamorize or even encourage suicide cases, where
methods are described in detail. We know that that can have a
harmful effect on both young people and adults.
Mrs. Trahan. Well, I want to thank you all for all the
important work. As a mother, I am particularly grateful to the
parents who have shared their stories, and who work tirelessly
to improve mental healthcare in this country.
And if any of my colleagues are as horrified as I am that
online forums that encourage suicide exist, and want to hold
them accountable for the deaths that they cause, let me know.
Thank you, I yield back.
Ms. DeGette. I thank the gentlelady. Mr. O'Halleran, you
are now recognized for 5 minutes.
Mr. O'Halleran. Thank you, Madam Chair. I appreciate that.
I--this has been a very sad day to hear all that is going
on in this particular issue. Caring for mental health and--for
Americans is essential, and the need has become even more
pronounced during the pandemic. We know that different
populations have particular needs. In particular, children are
in dire need of mental health support, particularly Native
Americans, and rural Americans, and other under-served
communities that often lack and do, in fact, lack adequate
mental health resources.
Importantly, we know that our children are susceptible to
mental health challenges posed by an increased reliance on
social media. And many of our children are only just recovering
from spending much of the last two years away from classrooms,
having to engage in remote learning with limited, in-person
interaction.
I--in a past life I was a Chicago police homicide
detective. I have seen way too much attempted suicide and
suicide. I have seen the impacts that it has had on
communities, but most importantly on families, families that
are addressing mental health and still struggling, families
that do not have the help needed, families that have lost a
loved one, and the trauma that that brings to that family year
after year after year.
We have to do better. We have to find a way to address this
in a way that is--it recognizes what it does to our society,
what--the impacts from our society, and--has done to our
children and adults and, again, families.
We spend a lot of money on social services. It hasn't
gotten us to where we need to be. We--prior to the pandemic we
did not have the workforce available. And now, earlier on, we
talked about workforce development. They are on overload. They
are overwhelmed, and they were overwhelmed prior to this. I
see, day in and day out, the fact that we cannot find the
people that want to get back into it, and did not want to get
into it, even beforehand.
So there is--disparities between communities is tremendous.
Therapies alone, just throwing money at therapies, is just not
enough. We need telecommunications, obviously, and
telemedicine. We need people out in the field. We are losing
our practitioners and providers just at terrible rates. And
this is a dire time.
So with that doctor, Dr. Fortuna, thank you for your
testimony. What are some of the disparities you are seeing
among children, and what factors do you believe lead--or what
is driving them to these specific mental health challenges?
Dr. Fortuna. Right. I mean, when we are talking about
disparities, you know, we really have to think about--the way I
think about the way out of, you know, this problem and toward
solution is how can we work across our systems of care, right?
We have talked about schools, right, and teachers being
completely overwhelmed, and having to deal with mental health,
primary care providers having to take the big bulk of
addressing mental health services, and there being very few
child psychiatry and psychology-trained workforce people,
right? There is only between 8,000 to 9,000 child psychiatrists
in the country for millions of children who need mental health.
And the way that we can do that is how do we expand those
resources through multiple factors.
You know, one is the one that we have been talking about,
is telehealth. But telehealth allows not only for one-to-one
services, but can also provide consultation and expanding
services to schools and primary care. So I think that that is
one thing. That is another way of looking at primary--at
telehealth as important, not just sort of one-to-one care, but
to actually provide consultation to schools and to primary care
providers.
Integrated primary care services, where pediatricians are
seeing patients very early, from infancy onward, and can pick
up mental health and developmental health needs. You know, the
APA is really supporting an issue of integrated care and a
collaborative care model, which allows psychiatrists to work
with primary care providers and care managers in providing
comprehensive care that is evidence-based, and has over 90
studies showing that that can be very effective in taking a
really sort of, you know, outcomes-focused approach to that,
and also population health, where you can work with panels of
young people. It can do that for adult and child services, and
integrating, you know, really good mental health services
within schools.
So those are the--you know, primary care in schools are
places where kids are. So----
Mr. O'Halleran. Doctor, I have to say thank you, and my
time is up.
And I hope we have learned, from this last 2 years and the
many decades beforehand, that this issue must be resolved in
order to make sure our families can have a quality of life
throughout America that is conducive to the way of life we
expect to have.
Thank you very much.
Ms. DeGette. Thank you so much. Thanks, Mr. O'Halleran.
We--now we will turn to our members who are waiving on.
Welcome. We are glad to have you. And we are going to start
with Mr. Latta.
Mr. Latta, you are recognized for 5 minutes.
Mr. Latta. Well, thank you very much. First I would like to
thank the Chair for allowing me to waive on today, and also for
holding this very important hearing. And also, thanks for our
witnesses today, for your testimony.
As we continue to navigate coronavirus and work to return
to normalcy, we must address one important aspect of life that
has been severely impacted since COVID lockdowns were first
implemented, and that is mental health.
And as we have heard today, with social isolation the
continuous fear of an invisible enemy and the loss of familiar,
everyday routines compounded the challenges our Nation was
facing prior to the onset of the pandemic. And we are also
seeing the tragic consequences because of it.
Substance use disorder is one of the greatest challenges to
accompany the mental health crisis. And it is no coincidence
that the United States had a record number of overdoses last
year of 101,263 over a 12-month period during the peak of the
public health emergency. We saw more people suffering
depression and anxiety turn to outlets that they thought would
help them with their struggles. We also saw suicide rise to be
the second-leading cause of death among people between the ages
of ten and 34.
Americans who are experiencing crisis need help, and I am
proud to have worked on bipartisan legislation to designate 988
as the National Hotline--Suicide Hotline. In addition, I have
introduced several pieces of legislation that provide immediate
assistance to those who are suffering, such as the CRISIS Act,
which would allow for better access to crisis call centers and
outreach, and treat--the TREAT Act, which would remove barriers
to telehealth services such as mental healthcare across State
lines.
Dr. McCance-Katz, if I could begin with you, during your
time leading SAMHSA, what roadblocks did you witness that
resulted in patients not receiving care?
Dr. McCance-Katz. Some of--there were a number of ways that
patients experienced roadblocks. There was an overall lack of
access to care.
We lack the behavioral health providers that we need. It
has been mentioned a number of times, but I think it is worth
reiterating just what kind of severe shortage we had prior to
the pandemic, and it has only worsened with the loss of
behavioral health providers and other healthcare providers from
the field.
Low payments, low reimbursements for providers also are a
disincentive for people to enter the field and, in some cases,
make it impossible for some facilities to continue offering
services.
And we have really what continues to be a disjointed
service system, where it is very difficult for providers to
share information. Congress has made some legislative changes
that will help with that. I personally think that should be
followed to make sure that that is happening.
And I think the kinds of legislation that you are talking
about are exactly the kinds of legislation that will be helpful
in moving our system forward and meeting the needs of the great
number of Americans with these issues.
Mr. Latta. Let me add--continue another question with you
on this, because, again, as I mentioned in my remarks, I
introduced the CRISIS Act, which would direct states to utilize
funds for the Mental Health Block Grant for call centers 24/7,
mobile crisis services, and better programs offering care.
Do you believe that services like this could help improve
the situation, and help save lives?
Dr. McCance-Katz. I do, particularly the provision of
crisis services. We know that crisis services provided by
behavioral health providers are really key to keeping people
out of the hospital, to providing them the kinds of outpatient
supports that would allow them to continue in the community,
and get into recovery with the appropriate support. So those
crisis services are really critical.
Mr. Latta. You know, to followup on a point that you made,
you had said about the ability to share information, you said
that we have--we are doing better at it. But what should be
done, maybe in your opinion, to make it even better?
Dr. McCance-Katz. So I--it is my own view, and I am an
addiction specialist--so I can tell you that the 42 CFR part 2
is a big barrier to sharing information and getting people to
the kind of care and treatment that they need when they have
co-occurring disorders. Congress has directed that 42 CFR part
2 be subsumed under HIPAA. I think that was the right move.
And having said that, I have not heard to this point where
that is at, so I hope that that will move along. I do think
that that will improve service delivery.
Mr. Latta. Well, thank you very much.
And again, Madam Chair, I appreciate the ability to waive
on to the subcommittee today. Thank you very much.
Ms. DeGette. You bet.
Doctor, that was the issue that Mr. Murphy and I worked on
together when he was the Chair of this subcommittee. And the
effort continues.
I am now very pleased to recognize Mr. Cardenas for 5
minutes.
Mr. Cardenas. Thank you very much, Madam Chairwoman and
also Ranking Member Griffith, for holding this very critical
and important hearing. And I know we have had other hearings in
the past, but it couldn't be more timely than it is today. So
thank you so much for your leadership.
And also, I want to thank the committee staff and also the
witnesses for providing these important statistics and
information regarding the disproportionate impacts on Native
American communities, Black communities, LGBTQ communities, and
others. It is unfortunate that a community that is negatively
impacted at a greater rate, if not equal rate, is the American
Latinos. So I would like to suggest and hope that the witnesses
and the committee staff please include the statistics on the
impacts of the Latino community in their statements and reports
from this day, and also going forward.
So also, I have--my first question is to Mr. Paley.
Mr. Paley, I want to thank you for The Trevor Project's
dedication to serving our young people, and for calling
attention to the urgent need to make sure 988 is ready when the
number is activated in July. I share your concerns, and will be
leading a bipartisan 988 and crisis services task force for the
congressional Mental Health Caucus to address these issues.
In the next few weeks I will be introducing bipartisan
legislation to support 988 implementation. One of its
provisions increases funding for 988 operations and call
centers throughout the country. As calls to the 988 hotline are
expected to be very, very high immediately, the increased
funding is needed to ensure that a timely 24/7 response is
available, so people aren't left waiting or on hold during a
mental health emergency.
Importantly, it is also--allocates resources for
specialized services for LGBTQ individuals, people of color,
people who speak a language other than English, people who are
deaf or hard of hearing, and other populations that have not
been served well with a one-size-fits-all approach.
Mr. Paley, can you comment on why a timely response and
specialized services are important, especially for marginalized
communities and under-served populations, including rural
communities, as well?
Mr. Paley. The need is critical, because different people
have different needs, as we said before. There isn't a one-
size-fits-all solution. That is why we had a veterans line. We
need solutions for veterans. We need solutions for people of
color, for LGBTQ young people, and for people of many different
identities.
I am very grateful for your leadership on these issues, and
I--we agree with you that we need to fully fund the lifeline,
and particularly the--appreciate your attention to specialized
services for at-risk groups, including LGBTQ young people.
And I think it is important that we call out that we need
more funding, and we need to make sure that the planning is
happening appropriately, so that when we launch 988--and many
people are going to be aware of it and reaching out--that we
have the services needed to help them. That includes the
overall infrastructure for all Americans, and including
infrastructure for specialized services in communities like
LGBTQ young people.
So there is a lot more that needs to be done to make sure--
--
Mr. Cardenas. Thank you.
Mr. Paley [continuing]. We are taking care of everyone.
Mr. Cardenas. Thank you very much, Dr. Fortuna, and thank
you so much for all the work you do for our young people. On
the topic of 988 and crisis response, could you briefly comment
on the importance of the crisis continuum of care, and if
further investments in crisis care would benefit youth and
their families who currently wait in an emergency room for
days, or sometimes don't even get the true access to care?
Dr. Fortuna. Yes, absolutely. I mean, I just want to
underline what has been said so far is that, you know, we
really do have to have sort of this diversity of resources for
people to be able to access--and that continuum of care. And I
would say that that is not only inpatient services, which are
at a complete deficit for child and adolescent population, but
with that we have to have the full continuum of care, including
crisis. In some states they have even instituted what we call
sort of urgent care in crisis, where you can immediately access
services.
So all of those things are critical.
Mr. Cardenas. Thank you. I have a followup question to
that, and thank you for earlier pointing out some of the
various factors that contribute to that lack of care.
The U.S. Department of Labor, Department of Health and
Human Services, and Department of Treasury issued a joint
report which found--and I quote--``Health plans and health
insurance issuers are failing to deliver parity for mental
health and substance use disorder benefits to those they
cover.'' The Affordable Care Act has required it by law that
there be parity for health services, as well as physical
health.
How does this inadequate coverage play out in the clinic or
the hospital, and how does it impact patients, especially our
children and teenagers?
Dr. Fortuna. When there is a lack of parity, obviously,
people lose access to behavioral health services, right?
I mean, I had mentioned earlier how, you know, even in
inpatient services, we can--you know, we can constantly get
rejections because, you know, they do not want to further cover
a stay, because it was not doing well enough or good enough.
And it is across the, you know, public-insured and
insured--privately insured patients that we have found that
cannot access services because it is not covered, and people
cannot afford to reach mental health services in a timely
fashion. So it is critical.
Mr. Cardenas. Thank you.
I am sorry, I went over my time, Madam Chairwoman. And
thank you so much for allowing me to waive on. I yield back.
Ms. DeGette. Thank you for your questions. Chair is now
very pleased to recognize Mr. Armstrong for 5 minutes.
Mr. Armstrong. Thank you, Madam Chair, and thank you for
letting me waive on, as well.
Over the past two years I have consistently heard from both
providers and patients in North Dakota about how they benefit
from expanded access to telehealth. This was important prior to
the pandemic in rural states, but obviously, has been escalated
over the last several years.
A report published in December 2021 by the U.S. Department
of Health and Human Services found that the share of Medicare
telehealth visits increased 63fold in 2020. The report also
found that one-third of behavioral health specialist visits
were completely by telehealth. This is a figure that I am not
surprised by, as I continue to hear from patients who are more
comfortable with virtual visits for mental health over in-
person evaluation.
These constituents face everyday barriers to mental
healthcare access, such as limited providers in rural areas,
unpredictable North Dakota winters preventing travel, and just
overall small community stigma. However, now they are no longer
putting off care. As expected, telehealth has--as expanded
telehealth has afforded this increased participation in mental
health services.
During--the COVID-19 pandemic resulted in a rapid
transition across our State. My State reacted quickly, and in
the early months of the pandemic, March and April 2020, saw the
number of health providers at behavioral health clinics using
telehealth grow from 71 to over 350 providers.
The Consolidated Appropriations Act of 2021 permanently
expanded access to telehealth for mental health services. I am
proud this legislation will allow Medicare beneficiaries to
receive telehealth services for mental health from the comfort
and privacy of their home. However, when the public health
emergency ends, the patients will need an in-person exam with a
provider within six months before the initial telehealth
encounter. This is a huge hurdle in rural America.
Dr. McCance-Katz, should we continue to utilize telehealth
for mental health treatment, once the pandemic is over?
And I am assuming the answer is yes. And if so, do you see
this in-person evaluation as a barrier to care, or is it an
important function for ensuring the patient receives the
personalized care they need?
Dr. McCance-Katz. Yes, so I believe that patients do need
to be seen by their clinician. I think that we need to provide
flexibility, so that the kinds of problems that you are talking
about don't occur.
So for example, I wouldn't say that a person needs to be
seen in person before they can have a telehealth visit. I think
that there are certain guardrails that we do have to have to
reduce the likelihood of fraud, because that is an issue we
have to consider with this kind of modality.
But having said that, it is an essential modality, and
particularly for rural areas. This is going to be, I think,
lifesaving for people with mental health issues.
Mr. Armstrong. Well, and for those that don't know, and
most of you probably wouldn't, my grandmother was the head of
the North Dakota Mental Health Association in North Dakota for
20 years during the farm crisis, and all of those issues. So I
agree with that.
And I also think it is really important to recognize that,
you know, if you have to delay an ACL surgery by three weeks or
a month, it is different. If you are actually in mental health
crisis, waiting three weeks to get in to see somebody is just
an unacceptable outcome.
But given the rapid transition from in-person treatment to
telehealth that I talked about earlier, do providers need
specific training on how to use audio and video approaches for
mental health treatment, or is it a relatively seamless
transition for most providers?
Dr. McCance-Katz. Well, thank you for that question,
because I think it is really a very important conversation that
we need to have with providers.
You do--I think you do need training to do this in a way
that protects patients' rights, that protects their privacy. It
is important to train providers on how to engage their patient
in a technology-based kind of interaction, how to judge what is
going on in the environment where the patient is, what needs to
be going on in your own environment to make sure that you are
giving the patient the attention and care that they need in a
way that is going to be, again, protective of their needs and
their rights to privacy. So I do believe that training on
telehealth is necessary.
Mr. Armstrong. And then I guess my last question is unique,
and I would really--not unique, but, I mean, every State in the
country has done a very good job of building white picket
fences around their own licensure apparatuses. Some are better
than others, some are worse than others.
But how--as we do this, what can the Federal Government to
do to work to what I call--to avoid paralysis by licensure?
Because we are asking people to do this from other states in
North Dakota, not just from larger communities.
That is 12 seconds left to answer. That is unfair, but give
it a go.
Dr. McCance-Katz. Well, I would simply say that Congress
can expand, through legislation, the ability of providers in
distant states to provide telehealth in other states.
Mr. Armstrong. Thank you very much. I yield back. Thanks
for allowing me to waive on.
Ms. DeGette. Thank you so much.
And now, thank you for your patience. Congresswoman Blunt
Rochester is recognized for 5 minutes.
Ms. Blunt Rochester. Thank you so much, Madam Chair, also
for the recognition and allowing me to waive on, and thank you
so much to our witnesses for sharing your testimony today.
The COVID-19 pandemic, along with the upcoming
implementation of 988 as a universal number for mental health
crises and suicide prevention, have forced us to rethink how we
approach mental health in our country. From the places people
seek support and treatment, how we finance mental health
services and hold insurers accountable for mental health
coverage, to focusing on the unique needs of special
populations like children, this hearing is pivotal.
Children and adolescents are not just little adults or, as
Mr. Paley said, it is not a one size fits all. And
unfortunately, investments in existing mental health programs
do not always meaningfully reach the organizations and
providers serving them. That is why I have been laser focused
on advancing legislation tailored to meeting the unique needs
of children and youth like our bipartisan TIKES Act, which is a
telehealth for children bill that is led by myself and
Representative Burgess. Also, our bipartisan Children's Mental
Health Infrastructure Act.
My first question is for you, Mr. Thomas. First I want to
just thank you so much for sharing your story, and also
removing the stigma of mental health. We deeply appreciate the
work that you are doing and that your family is doing.
Trusted community-based organizations and schools are
critical access points for children needing behavioral health
intervention. And further, children remain more stable when
they are connected to resources that provide ongoing behavioral
health support. My legislation, Helping Kids Cope Act, H.R.
4944, would provide flexible funding to support a wide range of
activities, including collaborations between community-based
organizations, healthcare providers, and schools.
But I know it is often difficult for community-based
organizations to find and coordinate with healthcare providers.
Can you speak to your experience connecting youth to providers,
and outline any suggestions on how these collaborations could
be made easier?
Mr. Thomas. Thank you for your question, and it is a very
great question, and I look forward to hearing more about your
Act.
I do think it is critical that we do connect and work with
communities that are providing services to children, in
particular children who are trying to focus on mental health.
In our experience with the Defensive Line, we have been
able to work with key organizations like American Foundation
for Suicide Prevention, Mental Health America to provide
evidence-based training and programs to the schools, the
parents, the coaches, and the teachers to understand the
warning signs.
So we have found it to be a very effective way to work
together to collaborate, whether it is with the national
organization, like I just mentioned, or even local ones like
the Defensive Line's work with Faith, Fight, Finish, Dak
Prescott's organization, to provide mental health, suicide
prevention training.
We are finding it came at the right time, because of the
focus amongst influencers, whether it is Dak, whether it is
Solomon, whether it is other people like Lady Gaga, who are
talking about mental health. So we have been able to leverage
that synergy, that energy, and momentum to get into schools, to
teach the--to provide the training. So it is possible, and we
are finding it--that it is growing and becoming easier.
Ms. Blunt Rochester. Thank you. Thank you.
And Dr. Fortuna, I want to thank you, too, for your
testimony on the impact of social media on our children. My
bill, the DETOUR Act, seeks to address the impact of social
media by regulating a phenomenon known as dark patterns, which
are design practices that manipulate people, often children, to
use social media platforms compulsively.
Dr. Fortuna, why should we be concerned about these
manipulative and compulsion-inducing practices when addressing
youth mental health crises?
Dr. Fortuna. And I don't know if you want to give that to
Dr. Nesi, because I think she was covering that.
Ms. Blunt Rochester. Yes, yes. Dr. Nesi, if you would.
Thank you so much, Dr. Fortuna.
Dr. Nesi. Absolutely. Yes, thanks for this question.
You know, I do think--I am always hesitant to use the word
``addiction'' here, as I think that, you know, addiction
typically falls under the realm of a diagnosed mental illness.
But we do know that there are features of social media sites
that make them hard to stop using, so in some ways can lead to
compulsive behaviors in some youth and adults. That is things
like endless scrolls, notifications, targeted recommendations.
And we do know that those things make it harder to log off of
these of these platforms for people of every age, but
especially teens.
Ms. Blunt Rochester. Well, I want to thank all of you for
your testimony, especially at this pivotal time in our country,
and I look forward to working with you.
Thank you so much, Madam Chair, and I yield back.
Ms. DeGette. Thank you so much. And I want to add my thanks
to all of our witnesses for really illuminating this subject. I
think we need to have a followup to this hearing.
In particular, I would like to continue our investigations
into the LGBTQ community, and the disproportionate impact, and
also, critically, how it impacts different racially diverse
communities: the Hispanic community, the African American
community, so many others, because it really--this was a crisis
before, as I said in my opening statement, but it is a crisis
that has really been made more urgent by the pandemic.
I would like--I know several members, including Dr.
Burgess, would like to ask additional questions. But because of
the time constraints, and the many additional members of the
full committee who waived on today, we won't have time to do
that now.
But I do want to remind members that, pursuant to committee
rules, every member has ten business days to submit additional
questions for the record to be answered by witnesses who have
appeared before the subcommittee. And I know all of the
witnesses here will be eager to respond to those questions,
should they receive them.
And so, with that, this important hearing is finished. I
want to thank everybody, and the committee is adjourned.
[Whereupon, at 2:25 p.m., the subcommittee was adjourned.]
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