[Senate Hearing 117-387]
[From the U.S. Government Publishing Office]


                                                     S. Hrg. 117-387
                                                       
                           MENTAL HEALTH AND
                        SUBSTANCE USE DISORDERS:
                    RESPONDING TO THE GROWING CRISIS

=======================================================================

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             SECOND SESSION

                                   ON

             EXAMINING MENTAL HEALTH AND SUBSTANCE USE DISORDERS: 
                 FOCUSING ON RESPONDING TO THE GROWING CRISIS

                               __________

                            FEBRUARY 1, 2022

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions
                                
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                    U.S. GOVERNMENT PUBLISHING OFFICE                    
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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                    PATTY MURRAY, Washington, Chair
BERNIE SANDERS (I), Vermont          RICHARD BURR, North Carolina, 
ROBERT P. CASEY, JR., Pennsylvania       Ranking Member
TAMMY BALDWIN, Wisconsin             RAND PAUL, M.D., Kentucky
CHRISTOPHER S. MURPHY, Connecticut   SUSAN M. COLLINS, Maine
TIM KAINE, Virginia                  BILL CASSIDY, M.D., Louisiana
MAGGIE HASSAN, New Hampshire         LISA MURKOWSKI, Alaska
TINA SMITH, Minnesota                MIKE BRAUN, Indiana
JACKY ROSEN, Nevada                  ROGER MARSHALL, M.D., Kansas
BEN RAY LUJAN, New Mexico            TIM SCOTT, South Carolina
JOHN HICKENLOOPER, Colorado          MITT ROMNEY, Utah
                                     TOMMY TUBERVILLE, Alabama
                                     JERRY MORAN, Kansas

                     Evan T. Schatz, Staff Director
               David P. Cleary, Republican Staff Director
                  John Righter, Deputy Staff Director
                            
                            
                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                       TUESDAY, FEBRUARY 1, 2022

                                                                   Page

                           Committee Members

Murray, Hon. Patty, Chair, Committee on Health, Education, Labor, 
  and Pensions, Opening statement................................     1
Murkowski, Hon. Lisa, a U.S. Senator from the State of Alaska, 
  Opening Statement..............................................     4
Burr, Hon. Richard, Ranking Member, a U.S. Senator from the State 
  of North Carolina, Opening statement...........................     6

                               Witnesses

Prinstein, Mitch, Ph.D., ABPP, Chief Science Officer, American 
  Psychological Association, Chapel Hill, NC.....................     7
    Prepared statement...........................................     9
    Summary statement............................................    21

Durham, Michelle P., M.D., MPH, FAPA, DFAACAP, Vice Chair of 
  Education, Department of Psychiatry, Clinical Associate 
  Professor of Psychiatry & Pediatrics, Boston Medical Center, 
  Boston University School of Medicine, Boston, MA...............    22
    Prepared statement...........................................    24
    Summary statement............................................    27

Goldsby, Sara, MSW, MPH, Director, South Carolina Department of 
  Alcohol and Other Drug Abuse Services, Columbia, SC............    27
    Prepared statement...........................................    29
    Summary statement............................................    35

Lockman, Jennifer D., Ph.D., CEO, Centerstone Research Institute, 
  Nashville, TN..................................................    36
    Prepared statement...........................................    38
    Summary statement............................................    45

Rhyneer, Claire, Mental Health Youth Advocate, Anchorage, AK.....    46
    Prepared statement...........................................    47
    Summary statement............................................    49

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.
Smith, Hon. Tina:
    AFSCME Council 5, Statement for the Record...................    75

                         QUESTIONS AND ANSWERS

Response by Mitch Prinstein to questions of:
    Hon. Christopher Murphy......................................    76
    Hon. Tim Kaine...............................................    78
    Hon. Tina Smith..............................................    79
    Hon. Ben Ray Lujan...........................................    81
    Hon. Lisa Murkowski..........................................    82
Response by Michelle P. Durham to questions of:
    Hon. Christopher Murphy......................................    94
    Hon. Tim Kaine...............................................    96
    Hon. Tina Smith..............................................    96
    Hon. Ben Ray Lujan...........................................    98
    Hon. Susan M. Collins........................................    99
    Hon. Lisa Murkowski..........................................   100
Response by Sara Goldsby to questions of:
    Hon. Christopher Murphy......................................   102
    Hon. Tina Smith..............................................   103
    Hon. Ben Ray Lujan...........................................   104
    Hon. Lisa Murkowski..........................................   105
    Hon. Mike Braun..............................................   108
    Hon. Tim Scott...............................................   108
Response by Jennifer D. Lockman to questions of:
    Hon. Christopher Murphy......................................   111
    Hon. Tina Smith..............................................   115
    Hon. Lisa Murkowski..........................................   116
    Hon. Tim Scott...............................................   118

 
                           MENTAL HEALTH AND
                        SUBSTANCE USE DISORDERS:
                    RESPONDING TO THE GROWING CRISIS

                              ----------                              


                       Tuesday, February 1, 2022

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.

    The Committee met, pursuant to notice, at 10:04 a.m., in 
room G50, Dirksen Senate Office Building, Hon. Patty Murray, 
Chair of the Committee, presiding.

    Present: Senators Murray [presiding], Casey, Murphy, Kaine, 
Hassan, Smith, Rosen, Burr, Collins, Cassidy, Murkowski, Braun, 
Marshall, Scott, Tuberville, and Moran.

                  OPENING STATEMENT OF SENATOR MURRAY

    The Chair. Good morning. The Senate Health, Education, 
Labor and Pensions Committee will please come to order. Today 
we are holding a hearing on our Nation's growing mental health 
and substance use disorder crisis.

    I will have an opening statement followed by Senator 
Murkowski, she is standing in for Ranking Member Burr for this 
hearing, and then we will introduce our witnesses. I believe 
the Ranking Member will join us a little later as well. After 
the witnesses give their testimony, Senators will each have 5 
minutes for a round of questions.

    While we were unable to have the hearing fully opened to 
the public or media for in-person attendance, live video is 
available on our Committee website at help.senate.gov. And if 
you are in need of accommodations, including closed captioning, 
you can reach out to the Committee or the Office of 
Congressional Accessibility Services.

    We continue to see a high number of new COVID cases, so we 
are having this hearing in a larger hearing room where we can 
be socially distanced, limiting the number of people who are in 
the hearing room, accommodating both some of our Committee 
Members and our witnesses through video as we have done 
previously, and taking additional measures such as wearing 
masks.

    As always, I appreciate the work from the staff of the 
Sergeant-at-Arms, the Architect of the Capitol, and our 
Committee Clerk and staff to make this hearing as safe as 
possible. Thank you to all of you. Even before the COVID-19 
pandemic, our Nation was facing mental health and substance use 
disorder challenges on multiple fronts. Millions of people 
experienced depression, anxiety, and other mental health 
disorders.

    Drug overdoses were on the rise, and our health workforce 
was stretched far too thin. In 2018, mental health issues were 
responsible for 56 million doctor office visits and 5 million 
emergency room visits. In 2019, suicide was the second leading 
cause of death among adolescents. From 1999 to 2019, the rate 
of overdose deaths more than tripled, and then COVID-19 hit and 
made things worse.

    Our Nation lost over 100,000 people to drug overdoses in a 
single year, and overdose deaths, especially deaths involving 
fentanyl, skyrocketed in my home State during this pandemic. 
Nationwide, we are also seeing a concerning rise in 
methamphetamine and cocaine use as well. Across the country, 
people are stressed, and this pandemic has been especially 
traumatic for children.

    Our schools, teachers, and education leaders are seeing 
this every day. Our educators are on the front lines trying to 
help so many students experiencing mental health challenges, 
often without the support of trained mental health 
professionals. We have seen sharp increases in kids' visits to 
the emergency room for mental health crises, thoughts of 
suicide, and suicide attempts, especially among girls. And as 
of last December, over a 167,000 children have had their world 
shattered after losing a parent or caregiver to COVID-19, some 
have even lost both parents. And we know marginalized students 
are facing the worst of these challenges, deepening inequities 
they already face. We also know educators and caregivers are 
facing their own mental health challenges from the strain of 
this pandemic as well.

    We need to continue helping our students and educators and 
ensuring schools have the support, training, and resources they 
need. But right now, our mental health and substance use 
disorder workforce is stretched too thin to meet the needs of 
our kids, let alone our communities at large. And if we just 
keep stretching without taking action, something is going to 
break.

    For example, nearly half of psychologists reported feeling 
burnt out last year, and we aren't even close to providing 
mental health care to everyone who needs it. Almost 130 million 
Americans live in areas with less than 1 mental health care 
provider per 1,000 people. In my home State of Washington, our 
mental health care workforce is only able to meet 17 percent of 
our State's needs. Meanwhile, nationwide, less than 1 in 10 
people who need treatment for substance use disorder actually 
get it. And these hardships are not felt equally.

    The highest increase in opioid deaths recently has been 
among Black Americans. Rates of suicide are highest among 
American Indian and Alaska Native populations, and people with 
developmental disabilities who are already almost five times 
more likely to have mental health needs have had their lives 
upended. Of course, while some communities may face greater 
behavioral health challenges, this crisis affects all of us.

    Even if we aren't personally struggling with mental health 
or substance use, we all have friends and families who are 
whether we realize it or not. We all rely on first responders, 
health care providers, teachers, and other frontline 
professionals who are facing burnout and trauma. We all have a 
stake in making sure people can get the help they need.

    That is why Democrats passed the American Rescue Plan to 
provide resources for schools to hire counselors and 
psychologists, community based behavioral health providers, 
programs to treat mental health, suicide, burnout, and 
substance use, and more. But we are not done. Healing the scars 
of this pandemic won't be quick or easy. This will take years 
and we must act accordingly. It is time to build on this 
Committee's bipartisan history of expanding access to mental 
health services and responding to rising drug overdose deaths 
like we did in 2016 and 2018.

    In my State, I have seen how communities can benefit from 
some of the critical programs this Committee has worked on, 
including programs at the Substance Abuse and Mental Health 
Services Administration. For example, in Clark County, which 
saw fentanyl deaths triple in 2020. Lifeline Connections is 
using a SAMHSA grant to better prepare teachers and school 
personnel, law enforcement, first responders, and caregivers to 
respond to mental health crises and refer those in need to 
appropriate treatment.

    Meanwhile, in King County, Federal support has allowed 
Neighborhood House to provide mental health services for over 
150 adults experiencing homelessness. And the Confederated 
Tribes and Bands of the Yakama Nation are using grant funding 
from SAMHSA to fight the high rate of suicide in their 
community by updating their health records and mental health 
procedures, hiring more therapists, and expanding telehealth 
services which have been critical to reach people during this 
pandemic.

    If we are going to respond to the behavioral health issues 
this pandemic has made worse, it is clear we have to build on 
these efforts. That will take legislative action. So I look 
forward to hearing from our witnesses about how we can do that 
and working with Senator Burr and everyone on this Committee on 
a bipartisan effort to reauthorize, improve, and expand 
critical Federal programs that address mental health and 
substance use disorder challenges. I hope that every Member of 
this Committee and the Senate can work together to bring their 
priorities forward to us to include.

    My goal is to work with Ranking Member Burr to fold these 
priorities together into a larger package that makes progress 
on many of the issues that we are going to hear about today, 
like suicide screening and prevention, youth mental health, the 
opioids and overdose crisis, and breaking down barriers in 
access to mental health.

    Finally, I want to acknowledge that mental health and 
substance use disorders do not exist in a vacuum. In addition 
to this pandemic, there are a lot of issues people are worried 
about right now, from gun violence to climate change to 
systemic racism to just making ends meet. As we work to do more 
to help people struggling with depression, anxiety, and stress, 
we also need to look for ways to solve the problems that are 
making things so hard for so many people in the first place.

    I hope to continue to work with my colleagues on these root 
causes as well. I would also like to introduce two letters for 
the record, one from the American Academy of Pediatrics, the 
American Academy of Child and Adolescent Psychiatry, and the 
Children's Hospital Association with recommendations for 
addressing the National Emergency in Child and Adolescent 
Mental Health, and the other four members of the American 
Federation of State, County and Municipal Employees, 
highlighting the importance of supporting the behavioral health 
workforce. So ordered.

    [The following information was not submitted for the 
Record:]

    The Chair. With that, I will turn it over to Senator 
Murkowski for her opening remarks.

                 OPENING STATEMENT OF SENATOR MURKOWSKI

    Senator Murkowski. Madam Chair, thank you for convening the 
hearing. I appreciate that. I also want to thank Senator Burr 
for asking me to substitute in as Ranking Member today on this 
incredibly, incredibly important and certainly timely 
conversation as we talk about mental health and substance abuse 
disorders.

    Madam Chair, you have outlined well, I think this 
statistics the challenges that we are seeing. We knew, we have 
known for years now that mental health and substance abuse 
disorders have really been at crisis levels in many parts of 
the country, certainly in my State of Alaska, and we have seen 
those challenges and those issues only further compounded by 
this pandemic. Access across the country, access to mental 
health and substance use care remains severely limited, 
exacerbating suicide and substance abuse rates.

    You have mentioned the statistics in your State, Madam 
Chair, with regards to mental health providers and facilities. 
In Alaska, more than 80 percent of our communities do not have 
sufficient mental health providers while, again, we are seeing 
this crisis only continue to elevate, and unfortunately it 
knows no barrier on the spectrum. We are seeing more and more 
young kids.

    I mean, it used to be when we were talking about suicide 
statistics, we would look at that 25, 45 year age bracket and 
now the alarm that we are seeing is in 10, 11, 12 year olds who 
are suffering, and we have an obligation to hear and to 
respond. Alaska ranks second in the country for suicide deaths. 
We have seen a sharp increase in drug overdose deaths, just as 
we have seen across the country this year. Alaska has one of 
the highest rates of binge drinking. Suicide rates among 
members of our armed services have doubled. We have seen some 
very, very disturbing trends of late.

    As we have seen across the Nation, our Native people face 
shockingly disproportionate rates of mental and behavioral 
health and substance use disorders and suicide. And these are 
statistics that keep you up at night, not just because they are 
numbers, but these are real people. These are our constituents. 
These are people in our neighborhoods, in our communities. They 
are people who are in pain.

    As we will hear from the young woman, Claire Rhyneer, who 
will be introduced in just a moment, a youth advocate from 
Anchorage, Alaska, she urges us, she reminds us that these 
people that are not statistics, but these real people are 
looking to us, they are watching, the leaders, waiting for us 
to do something. And I think the message of hope needs to be 
that we are paying attention, that we are listening, and that 
we are working together to try to address some of the root 
causes of what we have seen.

    I think just within this Committee, we have seen some 
strong collaboration on efforts. I have been working with 
Senator Hassan on the Mainstreaming Addiction Treatment Act, 
which allows health care providers to prescribe buprenorphine, 
which can truly, truly save, save lives with the medication 
assisted treatment.

    In addition to lifesaving substance use treatment, we know 
that we have to invest in wraparound recovery services. I have 
visited programs in Alaska that focus not just on preventing 
the overdose deaths, but also really building a community for 
Alaskans in recovery, because that has to be the follow on. We 
have worked--we have worked on efforts to reduce fetal alcohol 
syndrome disorders, to address the mental health needs.

    Senator Smith and I are leading both the Mental Health 
Professional Workforce Shortage Loan Repayment Act to bolster 
our supply of providers, but also to Telemental Health 
Improvement Act to ensure that insurance covers these critical 
services. Senator King and Senator Kelly and I are working on 
the effective suicide screening and assessment in the Emergency 
Department Act to provide resources for emergency room 
personnel to identify, assess, and treat individuals at risk of 
suicide.

    I think unfortunately, we know that is where far too many 
who are seeking help end up sitting in an emergency room where 
you don't necessarily have those that are trained to identify 
and assess. Later this week, I am going to be introducing the 
Guarding Our Mental Health Act to prevent Coast Guard members 
who seek help for their mental health from being automatically 
processed for discharge.

    Again, we know we have got to make headway on the stigma 
issues associated with mental health. And then with Senator 
Rosen, we are going to be introducing the Youth Mental Health 
and Suicide Prevention Act to ensure that SAMHSA can provide 
additional mental health programing to elementary, middle, and 
high school students. So, Madam Chair, I think we know around 
the Senate here there is plenty that can divide us.

    I would like to think that mental health, substance abuse, 
these are areas where we really can find true bipartisan 
consensus and hopefully we can build a package that addresses 
these issues head on. And I commend the work that you have made 
along with Ranking Member Burr to do just that.

    Again, I am looking forward to being able to introduce the 
Committee to a bright young Alaskan, Claire Rhyneer. And when 
it is appropriate, I will do that. But thank you, Madam Chair, 
and I look forward to the testimony from all witnesses today.

    The Chair. Thank you. We will now introduce today's 
witnesses. Senator Burr has joined us, so I will turn it over 
to him to introduce our first witness, Dr. Prinstein.

                   OPENING STATEMENT OF SENATOR BURR

    Senator Burr. Madam Chair, thank you very much for holding 
this hearing and for the opportunity to introduce Mitch 
Prinstein to the Committee. Mitch is from Chapel Hill, North 
Carolina.

    Dr. Prinstein is the American Psychological Association 
Chief Science Officer and responsible for leading the 
Association's science agenda. Dr. Prinstine also serves as the 
John Van Seters Distinguished Professor of Psychology and 
Neuroscience at the University of North Carolina at Chapel 
Hill.

    He began his academic career as an Assistant Professor and 
later a Director of Clinical Psychology at Yale University 
Department of Psychology. Dr. Prinstein's research is focused 
on interpersonal relationships primarily among adolescents, and 
he has published more than 150 scientific articles and 9 books 
over the course of his career.

    Dr. Prinstein earned his Doctoral and Master's degree from 
the University of Miami. His bachelor's degree from Emory 
University. Dr. Prinstein, I thank you for being here today and 
for all your work on behalf of children and families across the 
Nation and in our great State of North Carolina. Welcome. Thank 
you, Madam Chair.

    The Chair. Thank you, Senator Burr. Next, we have Dr. 
Michelle Durham. Dr. Durham is the Vice Chair of Education in 
the Department of Psychiatry and a Clinical Associate Professor 
of Psychiatry and Pediatrics at Boston University School of 
Medicine and Boston Medical Center. She is a Board certified 
physician with a background in pediatrics psychiatry, adult 
psychiatry, and addiction medicine.

    Dr. Durham's public health and clinical roles have always 
been in marginalized community, and she has been a dedicated 
advocate for equitable mental health treatment. She is also the 
Director of Clinical Training for Boston Medical Center's 
Transforming and Expanding Access to Mental Health in Urban 
Pediatrics, or the TEAM Up initiative. Dr. Durham, so glad that 
you could join us today.

    I look forward to your testimony. Our next witness is Sarah 
Goldsby. She is the Director of South Carolina Department of 
Alcohol and Other Drug Abuse Services. She was confirmed to 
that position by the South Carolina Senate in February 2018 
after serving as Acting Director since August 2016.

    Director Goldsby has led South Carolina's response to the 
opioid crisis and serves as co-chair of the State opioid 
emergency team, meaning she has been on the frontlines of the 
crisis we are talking about today. In her role, she has helped 
expand access to naloxone across South Carolina. She also 
understands the importance of addressing social determinants of 
health and making sure people have access to care.

    Director Goldsby previously came before this Committee last 
year to discuss mental health and substance use disorder 
challenges related to the COVID-19 pandemic. Director Goldsby, 
welcome back. I appreciate your joining us to share your 
expertise once again. Our next witness is Jennifer Lockman, 
Ph.D., is the CEO of the Research Institute at Centerstone in 
Nashville, Tennessee.

    Dr. Lockman oversees all research and program evaluation 
activities at Centerstone. Her work focuses on developing and 
testing new interventions to further suicide prevention care. 
She has been a lead evaluator for multiple Substance Abuse and 
Mental Health Services Administration grants, focused on 
suicide prevention in youth and adults, as well as in zero 
suicide health programs.

    Dr. Lockman, thank you for joining us today. I look forward 
to hearing from you. And finally, I will turn it over to 
Senator Murkowski once again to introduce our last witness.

    Senator Murkowski. Thank you, Madam Chair. I am delighted 
to be able to introduce to the Committee Claire Rhyneer from 
Anchorage, Alaska. Claire is an articulate youth advocate. I 
think she has been able to effectively give voice to so many 
through storytelling. She has, in this capacity, encouraged 
others to speak out.

    I first came to recognize Claire when her story was printed 
on the front page of the Anchorage Daily News some months back 
outlining what she had done as one individual who looked at 
what was happening around her as a young girl and the lack of 
availability of services, the questions that she had, and 
really nowhere to turn but literally the internet.

    She had indicated in that article, she says, mental health 
was just never talked about. It was not talked about in the 
home. It was not talked about at school. Even in health classes 
where you would expect to hear it, the discussion was about 
making sure that you ate the right foods, you got the right 
sleep, but we don't focus on mental health, and so her advocacy 
has been one that is truly, truly impressive.

    She is a recent graduate of West High School. She is 
spending her gap year working with the National Alliance on 
Mental Illness there in Anchorage. She is going to be attending 
Middlebury College in Vermont this fall.

    Claire, thank you not only for being here today and sharing 
your story, but your advocacy and your voice on behalf of so 
many. Thank you, Madam Chair.

    The Chair. Thank you, Senator Murkowski. Ms. Rhyneer, thank 
you for joining us today to share your story. It is really 
important that we hear voices like yours about what students 
are facing, so we appreciate it.

    With that, we will begin our witness testimony. Dr. 
Prinstein, you may begin with your opening statement.

   STATEMENT OF MITCH PRINSTEIN, PH.D., ABPP, CHIEF SCIENCE 
  OFFICER, AMERICAN PSYCHOLOGICAL ASSOCIATION, CHAPEL HILL, NC

    Mr. Prinstein. Sorry, can you hear?

    The Chair. Yes, we can.

    Mr. Prinstein. Chairwoman Murray, Ranking Member Burr, 
Senator Murkowski, and Members of the Committee, thank you for 
the opportunity to testify. I am Dr. Mitch Prinstein, Chief 
Science Officer of the American Psychological Association.

    APA is the largest scientific and professional organization 
representing psychology in the U.S., with over 130,000 
psychological researchers, educators, practitioners, and 
students. There's been much discussion of a mental health 
crisis in the U.S.

    Today I want to talk briefly about what that crisis looks 
like. This is an issue that began well before the pandemic, 
with millions of Americans experiencing emotional and 
behavioral symptoms that we could have prevented. The U.S. has 
fared more poorly than most, with the rate of suicide attempts 
in the United States higher than in any other wealthy Nation on 
the planet.

    There is simply not enough mental health care providers, 
and there is not enough investment in science to use what we 
know to prevent mental illness. Today, only one of seven 
Americans with mental health or substance use disorders is 
receiving treatment scientifically proven to work. Of course, 
the COVID-19 pandemic has made this much worse. In 2021 alone, 
children's hospitals saw a 42 percent increase in self-injury 
and suicide cases. School principals report that their staff 
are overwhelmed with children experiencing apathy, 
hopelessness, anxiety, and thoughts of death.

    To say that this is a mental health crisis is not enough. 
This is an accumulation of decades of neglect, stigma, and 
unequal treatment of mental health compared to physical health. 
Now we are at a turning point like we have not seen since World 
War II, when our country elected to make a serious investment 
in mental health by building the VA system, investing in mental 
health workforce, and forming the National Institute of Mental 
Health. That was over 70 years ago.

    The time has come again. Today, we know that bifurcating 
physical and mental health is based on antiquated notions. It 
is time to create a mental health system that reflects the 21st 
century, and we have no time to waste. Here is what you can do 
immediately to address this national emergency. First, we 
desperately need a diverse and robust mental health workforce. 
Today, we have 5,000 psychology trainees who could serve a far 
greater number of people if Medicare were reimbursed for their 
work during residency, just as currently occurs for medical 
residents. This just makes good sense.

    Doctoral interns in psychology have an average of over 700 
hours of independent direct patient care experience, more than 
most medical residents, and we can mobilize thousands of mental 
health care workers quickly. Second, we have the psychological 
science to deploy preventive interventions through school and 
community based partnerships.

    The Mental Health Services for Students Act and 
reimbursement for psychologists to guide these partnerships can 
have multiplier effects, so each member of our current 
workforce is building resilience with an entire classrooms and 
schools. Third, we need to expand the integration of primary 
and behavioral health care because it works, but not with a one 
size fits all approach. We will need to support all evidence 
based models and allow primary care providers the flexibility 
to determine which model best suits their patients' needs.

    Fourth, the 2022 Mental Health Parity and Addiction Equity 
Act Enforcement Report just submitted to Congress indicates 
that our Federal agencies are struggling. Congress must grant 
the Department of Labor the authority to assess civil monetary 
penalties for violations of the law or enforcement will be 
almost impossible. Now, this will only get us part of the way. 
We will need long term strategies as well to fix this problem 
that has been growing for decades. Our country invests $15 
billion annually to ensure that we have enough physical health 
care providers with the appropriate specialties and spread 
throughout the country, yet we invest less than 1 percent of 
that amount to build a mental health care workforce.

    Congress must authorize, reauthorize and significantly 
expand the Graduate Psychology Education and Minority 
Fellowship Programs and enact the Mental Health Professionals 
Workforce Shortage Loan Repayment Act. It is also critical that 
we significantly expand our scientific investment in 
psychological science so we can better understand 
psychopathology, develop novel treatments, and build resilience 
before the next stressor occurs.

    A $1 billion increase to NIMH and NICHD and NIMHD for youth 
mental health would still be a very small proportion of the 
allocation currently offered to study conditions that afflicts 
far fewer youth than those currently suffering from 
psychological disorders. Thank you again for the opportunity to 
speak with you today.

    We stand ready to help you with any and all issues dealing 
with human behavior. We have the expertise to address your 
Committee's work, and I look forward to answering your 
questions.

    [The prepared statement of Mr. Prinstein follows:]
                 prepared statement of mitch prinstein
    Chairwoman Murray, Ranking Member Burr, and Members of the Health, 
Education, Labor, and Pensions Committee, thank you for the opportunity 
to testify today on the on-going mental health and substance use 
disorder challenges facing Americans. I am Dr. Mitch Prinstein, Chief 
Science Officer at the American Psychological Association (APA). APA is 
the Nation's largest scientific and professional organization 
representing the discipline and profession of psychology, with more 
than 133,000 members and affiliates who are clinicians, researchers, 
educators, consultants, and students. Through the application of 
psychological science and practice, our association's mission is to 
have a positive impact on critical societal issues.

    The COVID-19 pandemic has placed an enormous strain on individuals, 
families, and communities. Beyond the very real physical ramifications 
of the virus, the effects of social isolation, disrupted routines, loss 
of jobs and income, and grief associated with the death of a loved one 
have caused significant distress and trauma, which typically have 
downstream effects on mental health. During the pandemic, about four in 
10 adults have reported symptoms of anxiety or depressive disorder, an 
increase from the one in 10 adults who reported these symptoms from 
January to June 2019. \1\ Data also shows a surge in emergency 
department visits attributable to a mental health crisis, suicide 
attempts, and in drug overdoses during the COVID pandemic. \2\ 
Additionally, there have been significant increases in unhealthy 
behaviors, such as eating disorders, sleep disruptions, alcohol 
consumption, and illicit drug use. \3\, \4\, \5\, \6\ven these factors, 
it is likely that the pandemic's mental and physical health impact will 
be present for generations to come.
---------------------------------------------------------------------------
    \1\  Panchal, N., et al. The Implications of COVID-19 for Mental 
Health and Substance Use. Kaiser Family Foundation. (2021). Retrieved 
from: https://www.kff.org/coronavirus-covid-19/issue-brief/the-
implications-of-covid-19-for-mental-health-and-substance-use/
    \2\  Holland, K. M., Jones, C., Vivolo-Kantor, A. M., et al. 
(2021). Trends in U.S. Emergency Department Visits for Mental Health, 
Overdose, and Violence Outcomes Before and During the COVID-19 
Pandemic. JAMA Psychiatry, 78(4), 372-379. doi:10.1001/
jamapsychiatry.2020.4402
    \3\  University of Minnesota Medical School. (2021, April 12). 
COVID-19 pandemic has been linked with six unhealthy eating behaviors: 
Study shows a slight increase in eating disorders, one of the deadliest 
psychiatric health concerns ScienceDaily Retrieved from 
www.sciencedaily.com/releases/2021/04/210412114740--htm
    \4\  Bean, S. R., Khawaja, I. S., Ventimiglia, J. B., & Khan, S. S. 
(2021, December 1). COVID-somnia: Sleep Disruptions Associated with the 
COVID-19 Pandemic. Psychiatric Annals 51(12), 566-571. https://doi.org/
10.3928/00485713-20211109-01
    \5\  Julien, J., Ayer, T., Tapper, E. B., Barbosa, C., Dowd, W. N., 
& Chhatwal, J. (2021, December 8). Effect of increased alcohol 
consumption during COVID-19 pandemic on alcohol-associated liver 
disease: A modeling study. Hepatology. https://doi.org/10.1002/
hep.32272
    \6\  National Institute on Drug Abuse. (2021, December 20). COVID-
19 & Substance Use. National Institutes of Health. https://
nida.nih.gov/drug-topics/comorbidity/covid-19-substance-use
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    To be clear, the need for greater investment in behavioral health 
care predated COVID-19. According to results from SAMHSA's 2019 
National Survey on Drug Use and Health, 26 percent of U.S. adults with 
any mental illness had unmet mental health needs during the previous 
year, and over 47 percent of those with serious mental illness report 
having unmet needs. \7\ However, the pandemic has significantly 
increased the need for services. A recent APA survey of psychologists 
shows increased demand across all treatment areas, including anxiety, 
depression, and trauma-and stress-related disorders. \8\ Rates of 
substance use also grew during COVID-19. According to the Centers for 
Disease Control (CDC), between June 2020 and June 2021, approximately 
100,000 people in the U.S. died from an overdose, which is a 
substantial increase from the previous year. \9\
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    \7\  Substance Abuse and Mental Health Services Administration. 
(2020). Key substance use and mental health indicators in the United 
States: Results from the 2019 National Survey on Drug Use and Health 
(HHS Publication No. PEP20-07-01-001, NSDUH Series H-55). Center for 
Behavioral Health Statistics and Quality, Substance Abuse and Mental 
Health Services Administration. Retrieved from https://www.samhsa.gov/
data/sites/default/files/reports/rpt29393/2019NSDUHFFRPDFWHTML/
2019NSDUHFFR090120.htm
    \8\  American Psychological Association (2021). Worsening mental 
health crisis pressures psychologist workforce. 2021 COVID-19 
Practitioner Survey. Retrieved from: https://www.apa.org/pubs/reports/
practitioner/covid-19-2021.
    \9\  National Center for Health Statistics. (2022). Provisional 
Monthly National and State-Level Drug Overdose Death Counts. Centers 
for Disease Control and Prevention. Retrieved from: https://
www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.
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    One of the more alarming trends exacerbated by the pandemic is the 
impact on youth mental health, including among children who did not 
previously exhibit symptoms of a behavioral health disorder. \10\ The 
mental health of children is frequently tied to the overall health, 
safety, and stability of their surroundings. Ongoing national surveys 
of households with young children have found high levels of childhood 
hunger, emotional distress among parents, and frequent disruptions in 
child-care services. \11\
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    \10\  Osgood, K., Sheldon-Dean, H., & Kimball, H. (2021). 2021 
Children's Mental Health Report: The Impact of the COVID-19 Pandemic on 
Children's Mental Health. Child Mind Institute. Retrieved from: http://
wvspa.org/resources/CMHR-2021-FINAL.pdf5555
    \11\  Center for Translational Neuroscience. (2021). RAPID-EC Fact 
Sheet: Still in Uncertain Times; Still Facing Hunger. University of 
Oregon. Retrieved from: https://www.uorapidresponse.com/our-research/
still-in-uncertain-times-still-facing-hunger; Center for Translational 
Neuroscience. (2021). RAPID-EC Fact Sheet: Emotional Distress On the 
Rise for Parents . Again. University of Oregon. Retrieved from: https:/
/www.uorapidresponse.com/emotional-distress-on-rise-again'utm--
medium=email&utm--source=email--link&utm--content=baby--monitor--
11042021&utm--campaign=Q1--2022--Policy+Center--Resources
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    Recent data show that nearly 10 percent of U.S. children lived with 
someone who was mentally ill or severely depressed. \12\ Furthermore, 
since the start of the pandemic, over 167,000 children have lost a 
parent or caregiver to the virus. \13\ This kind of profound loss can 
have significant impacts on the mental health of children, leading to 
anxiety, depression, trauma, and stress-related conditions.
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    \12\  Ullmann, H., Weeks, J. D., Madans, J. H. (2021). Disparities 
in stressful life events among children aged 5-17 years. National 
Center for Health Statistics. https://dx.doi.org/10.15620/cdc:109052
    \13\  Treglia, D., Cutuli, J. J., Arasteh, K., J. Bridgeland, J.M., 
Edson, G., Phillips, S., & Balakrishna, A. (2021). Hidden Pain: 
Children Who Lost a Parent or Caregiver to COVID-19 and What the Nation 
Can Do to Help Them. COVID Collaborative.
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    Increases in demand for pediatric inpatient mental health services 
are also a particularly concerning indicator. Between April and October 
2020, the proportion of children between the ages of 5 and 11 and 
adolescents ages 12 to 17 visiting an emergency room due to a mental 
health crisis increased by 24 percent and 31 percent, respectively. 
\14\ In recent months, children's hospitals have reported their highest 
number of children ``boarding'' in hospital emergency departments 
awaiting treatment. \15\ During the first three-quarters of 2021, 
children's hospitals reported a 14 percent increase in mental health 
related emergencies and a 42 percent increase in cases of self-injury 
and suicide, compared to the same time period in 2019. \16\ Faced with 
such data, in December 2021, the U.S. Surgeon General issued an 
advisory calling for a unified national response to the mental health 
challenges young people are facing. \17\ Considering the rarity of such 
advisories, this further underscores the need for action to help stem 
the long-term impacts of the pandemic on the mental health and well-
being of children and adolescents.
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    \14\  Leeb, R. T., Bitsko, R. H., Radhakrishnan, L., Martinez, P., 
Njai, R., Holland, K. M. (2020) Mental Health-Related Emergency 
Department Visits Among Children Aged <18 Years During the COVID-19 
Pandemic--United States, January 1-October 17, 2020. Morbidity and 
Mortality Weekly Report, 69(45), 1675-1680. http://dx--doi.org/10--
15585/mmwr--mm6945a3
    \15\  Children's Hospital Association. (n.d.). Emergency Room 
Boarding of Kids in Mental Health Crisis. Retrieved from: https://
www.childrenshospitals.org/--media/Files/CHA/Main/Issues--and--
Advocacy/Key--Issues/Mental percent20Health/2021/Boarding--fact--
sheet--121421.pdf
    \16\  Children's Hospital Association. (2021). COVID-19 and 
Children's Mental Health. Retrieved from: https://
www.childrenshospitals.org/-/media/Files/CHA/Main/Issues--and--
Advocacy/Key--Issues/Mental-Health/2021/covid--and--childrens--mental--
health--factsheet--091721.pdf'la--en&hash--
F201013848F9B9C97FAE16A89B01A38547C7C5C7
    \17\  Office of the U.S. Surgeon General. (2021). Protecting Youth 
Mental Health: The U.S. Surgeon General's Advisory. Retrieved from: 
https://www.hhs.gov/sites/default/files/surgeon--general--youth--
mental--health--advisory.pdf
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    Furthermore, the burdens of the pandemic have not been 
proportionately borne by race and ethnicity. People of color are at a 
higher risk of infection, hospitalization, and death from the virus as 
compared to their White counterparts. \18\ The pandemic has also shone 
a light on the historic disparities in access to behavioral health care 
among populations of color, which has further harmed their mental well-
being since the start of this crisis. \19\ This includes children and 
adolescents. Rates of suicide, which have traditionally been high 
predominantly among White and Native American kids, have risen sharply 
among Black and African American youth. \20\ Black and Hispanic 
children lost a parent or a caregiver at more than two times the rate 
of White children, while American Indian, Alaska Native, and Native 
Hawaiian and Pacific Islander children lost caregivers at nearly four 
times that rate. \21\ Additionally, young people within other 
marginalized populations, including those who identify as LGBTQ+ and 
children with developmental and physical disabilities, have been 
disproportionately impacted. \22\
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    \18\  Centers for Disease Control and Prevention. (2021). Risk for 
COVID-19 Infection, Hospitalization, and Death By Race/Ethnicity. 
Retrieved from: https://www.cdc.gov/coronavirus/2019--ncov/covid--data/
investigations--discovery/hospitalization--death---by--race---
ethnicity.html
    \19\  McKnight-Eily, L. R., Okoro, C. A., Strine, T. W., et al. 
(2021). Racial and Ethnic Disparities in the Prevalence of Stress and 
Worry, Mental Health Conditions, and Increased Substance Use Among 
Adults During the COVID-19 Pandemic--United States, April and May 2020. 
Morbidity and Mortality Weekly Report, 70(5), 162-166. http://
dx--.doi--org/10-15585/mmwr--mm7005a3
    \20\  Sheftall, A. H., Vakil, F., Ruch, D. A., Boyd, R. C., 
Lindsey, M. A., & Bridge, J. A. (2021). Black Youth Suicide: 
Investigation of Current Trends and Precipitating Circumstances. 
Journal of the American Academy of Child & Adolescent Psychiatry. 
https://doi.org/10.1016/j.jaac.2021.08.021
    \21\  Treglia, D., Cutuli, J. J., Arasteh, K., J. Bridgeland, J.M., 
Edson, G., Phillips, S., & Balakrishna, A. (2021). Hidden Pain: 
Children Who Lost a Parent or Caregiver to COVID-19 and What the Nation 
Can Do to Help Them. COVID Collaborative.
    \22\  Morning Consult & the Trevor Project. (2021) Issues Impacting 
LGBTQ Youth Retrieved from:https://www.thetrevorproject.org/wp--
content/uploads/2021/12/TrevorProject--Public--Final-1.pdf
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    Even on their own, these data are striking, but taken in aggregate, 
they could not provide a clearer picture: action is urgently needed. 
The COVID-19 pandemic continues to be incredibly challenging on an 
individual and societal level, but it has provided us an opportunity to 
reevaluate how we deliver mental health services. APA applauds Congress 
for the COVID-relief funding that has been enacted since March 2020. 
Congress' swift action was critical to addressing the crisis we were 
facing and continue to face. However, investments in mental health care 
cannot just be reactive and made solely on an emergency basis. 
Consistent, steady, sustainable support is necessary to meet the 
challenges and growing demand that will continue to arise in the 
future. We must start the hard work of rebuilding our public health and 
preparedness and response system now. We cannot afford to wait until 
the next crisis occurs.

    Further, APA supports the recent introduction of the PREVENT 
Pandemics Act discussion draft, which addresses critical gaps in the 
way our public health infrastructure responds to pandemics and other 
public emergencies, particularly as it relates to the roles and 
responsibilities of the Substance Abuse & Mental Health Services 
Administration (SAMHSA). However, this is also not enough. APA is 
hopeful and optimistic that this Committee will also consider 
comprehensive legislation reflective of the fact that mental health is 
integral to overall health. As such, APA offers the following 
recommendations focused on (1) Strengthening the Mental Health Care 
Workforce; (2) Improving Access to Mental Health Care for Children and 
Youth; (3) Promoting Integration of Primary Care and Behavioral Health; 
(4) Continuation of Evidence-Based Mental Health Programs; (5) Ensuring 
Parity for Behavioral and Physical Health Care; and (6) Investing in 
Youth Mental Health Research.
             Strengthening the Mental Health Care Workforce
    A strong mental health workforce is critical to combating the long-
term impact of the pandemic and remedying longstanding access gaps. 
Nationwide, even before COVID-19, the U.S. was facing a serious 
shortage of mental and behavioral health providers, including 
psychologists, with every state having documented mental health 
professionals shortage areas. \23\ By 2030, these shortages are 
projected to worsen significantly, \24\, \25\ with rural communities 
facing major challenges in recruiting licensed mental and behavioral 
health care professionals. \26\ Despite the need for these services, 
there are multiple barriers to educating and training psychologists, 
including the cost of attending graduate school, which most students 
are increasingly financing by taking on debt. Doctoral psychologists 
graduate with an average student debt load of between $95,000 and 
$160,000 from their graduate degrees alone, and close to half of 
doctoral-level psychologists rely on loans or their own funds to pay 
for graduate school, which takes on average 5-6 years to complete. \27\ 
Data show that psychology graduate students have difficulties affording 
health care, are concerned about being able to afford completing their 
training requirements, and have difficulties focusing on their studies 
as a result of trying to make ends meet. \28\ At the same time, student 
loan-related actions taken by the Federal Government over the last 
decade have disproportionately impacted graduate students. This 
includes the imposition of higher interest rates and multiple loan 
origination fees, as well as the elimination of subsidized Federal 
loans. \29\ These factors further increase the cost of Federal 
borrowing, particularly when financing graduate education.
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    \23\  Bureau of Health Workforce (2019) Designated Health 
Professional Shortage Area Statistics Health Resources and Services 
Administration; U.S. Department of Health and Human Services Retrieved 
from https://data.hrsa.gov/hdw/Tools/MapToolQuick--aspx--mapName--
HPSAMH.
    \24\  Health Resources and Services Administration. (n.d.). 
Behavioral Health Workforce Projections, 2016-2030: Clinical, 
Counseling, and School Psychologists. Retrieved from: https://
bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/
psychologists-2018.pdf
    \25\  Bureau of Labor Statistics. Occupational Outlook Handbook, 
Psychologists. U.S. Department of Labor. Retrieved from https://
www.bls.gov/ooh/life-physical-and-social-science/psychologists.htm
    \26\  Rural Health Information Hub. (2021). Rural Mental Health. 
RHIhub. https://www.ruralhealthinfo.org/topics/mental-health
    \27\  Doran, J., Kraha, A., Marks, L., Ameen, E. & El-Ghoroury, N. 
(2016). Graduate Debt in Psychology: A Quantitative Analysis. Training 
and Education in Professional Psychology, 10(1), 3-13.
    \28\  Lantz, M. M. (2013). Uncovering the graduate student economic 
landscape: A difficult but necessary dialog. Society of Counseling 
Psychology Newsletter, 34, 22-23. Retrieved from http://www.div17.org/
wp--content/uploads/SCP17--2013-9.pdf
    \29\  U.S. Department of Education (n.d.) Federal Interest Rates 
and Fees Federal Student Aid Retrieved from:https://studentaid.gov/
understand-aid/types/loans/interest-rates
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    Furthermore, as a result of a variety of factors, including lack of 
generational wealth, students of color, first-generation, and lower 
socioeconomic status students tend to borrow significantly more, both 
for their undergraduate and postbaccalaureate degrees. \30\ This is 
true across all fields, but data show that low-income students and 
students of color working toward doctoral psychology degrees also 
disproportionately rely on student loans. \31\ The prospect of adding 
further debt often serves as a disincentive to pursuing advanced 
degrees. Higher student loan debt further impedes workforce diversity, 
including in mental and behavioral health care fields, where demand for 
representative, culturally competent providers is high. \32\ Finally, 
research shows that debt also impacts career choice by, for example, 
reducing the probability that qualified professionals will enter public 
service careers. \33\
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    \30\  Miller, B. (2019, December 2) The Continued Student Loan 
Crisis for Black Borrowers Center for American Progress Retrieved from: 
https://www.americanprogress.org/issues/education-postsecondary/
reports/2019/12/02/477929/continued-student-loan-crisis-black-
borrowers/
    \31\  Wilcox, M. M., Barbaro-Kukade, L., Pietrantonio, K. R., 
Franks, D. N., & Davis, B. L. (2021). It takes money to make money: 
Inequity in psychology graduate student borrowing and financial 
stressors. Training and Education in Professional Psychology, 15(1), 2-
17 https://doi.org/10.1037/tep0000294
    \32\  Sullivan, L., Meschede, T., Shapiro, T., & Escobar, F. 
(September 2019). Stalling Dreams: How Student Debt is Disrupting Life 
Chances and Widening the Racial Wealth Gap. Institute on Assets and 
Social Policy, Heller School for Social Policy and Management at 
Brandeis University Retrieved from:https://heller--brandeis--edu/iere/
pdfs/racial-wealth-equity/racial-wealth-gap/stallingdreams-how-student-
debt-is-disrupting-lifechances.pdf
    \33\  Choi, Y. (2014). Debt and college students' life transitions: 
The effect of educational debt on career choice in America. Journal of 
Student Financial Aid, 44(1), 3. Retrieved from https://ir--library--
louisville.edu/cgi/viewcontent--cgi--article--1050&context--jsfa
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    To incentivize qualified providers to pursue careers delivering 
care to underserved populations, APA encourages the passage of the 
bipartisan Mental Health Professionals Workforce Shortage Loan 
Repayment Act (S. 1578), which authorizes a new student loan repayment 
program for mental health care professionals who commit to working in 
an area lacking accessible care.

    Additionally, to help decrease the reliance on student loans and 
eradicate some of the barriers obstructing the growth and 
diversification of this critical workforce, Congress must invest in 
programs that fund the education and training of future mental health 
care providers. Unlike physicians, doctoral-level psychologists are not 
eligible for Medicare-funded residency programs, which provides 
billions of dollars to support the expansion of the physician workforce 
through Graduate Medical Education or GME. In addition, although 
clinical psychology interns go through a training process similar to 
psychiatry residents, services provided by trainees under the 
supervision of a licensed psychologist are not reimbursable under 
Medicare; despite trainees having an average of 500-700 hours of direct 
patient experience It is policies like these that inhibit the expansion 
of the mental and behavioral health workforce. Before the COVID-19 
pandemic, there was a projected shortage of over 13,000 psychologists 
by 2030. \34\ With the rising mental and behavioral health needs 
associated with COVID-19, this shortage is expected to grow 
significantly. Increased funding to the programs below administered by 
the Health Resources and Services Administration (HRSA) and Substance 
Abuse and Mental Health Services Administration (SAMHSA) is essential 
to maintain a steady pipeline of trained psychologists to meet the 
anticipated mental health needs of the entire nation. APA calls for the 
expeditious reauthorization of the following programs, which are set to 
expire at the end of Fiscal Year (FY) 2022:
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    \34\  American Psychological Association. (2018). A Summary of 
Psychologist Workforce Projections: Addressing Supply and Demand from 
2015-2030 Retrieved from https://www.apa.org/workforce/publications/
supply demand/summary.pdf
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    The Graduate Psychology Education Program (GPE) is the Nation's 
primary Federal program dedicated solely to the education and training 
of doctoral-level psychologists. GPE provides grants to accredited 
psychology doctoral, internship and postdoctoral training programs to 
support the interprofessional training of psychology graduate students 
while also providing mental and behavioral health services to 
underserved populations in rural and urban communities. APA urges the 
Committee to reauthorize this important program at $50 million per 
year, a robust increase commensurate with the scale of mental health 
and substance use disorder needs and the dangerous shortage in the 
workforce.

    The Minority Fellowship Program (MFP) serves a dual purpose to both 
increase the number of minority mental health professionals and 
increase access to mental health services in underserved areas. It 
provides funding for the training, career development and mentoring of 
mental and behavioral health professionals to work with ethnic 
minorities. The program focuses on training students, postdoctoral 
fellows and residents to be culturally and linguistically competent to 
adequately address the needs of minorities in underserved areas. It 
funds trainees in psychology, nursing, social work, psychiatry, 
addiction counseling, professional counseling and marriage and family 
therapy.

    Decades of psychological research has shown that minority youth 
report less use of mental health services than non-Hispanic white 
youth. \35\ However, strong barriers for ethnic minorities to access 
mental health services continue to persist. These include a lack of 
bilingual providers and lack of culturally competent care. Therefore, 
the MFP is essential to ensure there are culturally competent 
behavioral health professionals, as they are a key component to 
improving health care outcomes for underserved communities. With the 
shortage of qualified minority psychologists to address the needs of 
minority populations, the importance of MFP is all the more important.
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    \35\  Marrast, L., Himmelstein, D. U., & Woolhandler, S. (2016). 
Racial and ethnic disparities in mental health care for children and 
young adults: A national study. International Journal of Health 
Services, 46(4), 810-824.
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    The Behavioral Health Workforce Education and Training (BHWET) 
Program supports pre-degree clinical internships and field placements 
for a broad array of behavioral health professionals, including 
doctoral-level psychology students, master's-level social workers, 
school social workers, professional and school counselors, psychiatric 
mental health nurse practitioners, marriage and family therapists, and 
occupational therapists. The program is also a key source of support 
for other mental health training programs and substance use disorder 
prevention efforts. Preserving this program is key to reaching 
underserved populations, as well as meeting the needs of patients 
wherever they are on the spectrum of mental health needs, from mobile 
crisis services for those with need for immediate intervention to early 
screening and prevention services for those who may be experiencing 
minor symptoms of a behavioral health disorder.

    The Integrated Substance Use Disorder Training Program (ISTP) 
expands the number of nurse practitioners, physician assistants, health 
service psychologists, and/or social workers trained to provide mental 
health and substance use disorder (SUD), including opioid use disorder 
(OUD) services in underserved community-based settings that integrate 
primary care, mental health, and SUD services.
     Improving Access to Mental Health Care for Children and Youth
    Significant unmet child and adolescent behavioral health needs 
existed nationwide, even prior to COVID-19. \36\,\37\ Suicide rates 
among children aged 10 and older have also climbed significantly each 
year since 2007, making it the second most common cause of death among 
adolescents before the pandemic. \38\ The stakes of untreated mental 
and behavioral health symptoms for children and adolescents are 
exceptionally high. Failing to detect and address early indicators of a 
mental or behavioral health disorder can have profound consequences on 
the overall trajectory of a child's life, including a greater 
likelihood of difficulties with learning, addiction to substances, 
lower employment prospects, and involvement with the criminal justice 
system of difficulties with learning, addiction to substances, lower 
employment prospects, and involvement with the criminal justice system. 
\39\ Sacks, V., & Murphey, D. (2018). The prevalence of adverse 
childhood experiences, nationally, by state, and by race/ethnicity. 
Child Trends. Retrieved from: https://www.childtrends.org/publications/
prevalence-adverse-childhood-experiences-nationally state-race-
ethnicity;
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    \36\  Centers for Disease Control and Prevention (2020) Youth Risk 
Behavior Surveillance Retrieved from:https://www.cdc.gov/mmwr/volumes/
69/su/pdfs/su6901-H.pdf
    \37\  Center for Behavioral Health Statistics and Quality (2018) 
2017 National Survey on Drug Use and Health: Methodological summary and 
definitions. Substance Abuse and Mental Health Services Administration.
    \38\  Centers for Disease Control and Prevention. (2020). State 
Suicide Rates Among Adolescents and Young Adults Aged 10-24: United 
States, 2000-2018. National Vital Statistics Reports. Retrieved 
from:https://www.cdc.gov/nchs/data/nvsr/nvsr69/NVSR-69-11-508.pdf
    \39\  Sacks, V., & Murphey, D. (2018) The prevalence of adverse 
childhood experiences, nationally, by state, and by race/ethnicity. 
Child Trends. Retrieved from: https://www.childtrends.org/publications/
prevalence-adverse-childhood-experiences-nationally state-race-
ethnicity;
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    Even before COVID-19, many young people were already prolific users 
of social media. Throughout the pandemic, however, for many this became 
the only means of retaining a sense of connection to their peers and 
communities. Yet psychological science suggests a darker side to young 
people's engagement with social media, with results suggesting risks 
that far exceed the findings revealed in recent months from social 
media employees themselves. Note that the brain undergoes significant 
changes at pubertal outset, and emerging research suggests that digital 
media change neural activation and brain development in long-term and 
potentially permanent ways. In addition, research demonstrates that 
youth are highly susceptible to peer influence on social media, they 
are exposed to more frequent and more severe discrimination online, 
many teens consume content that actually promotes maladaptive and 
dangerous behaviors (e.g., cutting, fasting, purging), and like adults, 
they are prey to mis/disinformation campaigns on social media 
platforms. \40\, \41\
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    \40\  Sherman, L. E., Payton, A. A., Hernandez, L. M., Greenfield, 
P. M., & Dapretto, M. (2016). The power of the ``like'' in adolescence. 
Psychological Science, 27(7), 1027-1035. http://doi.org/10.1177/
0956797616645673
    \41\  S Nesi, J., Telzer, E. H., Prinstein, M. J. (in production). 
Handbook of Adolescent Digital Media Use and Mental Health. Accepted 
for Publication, Cambridge University Press.
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    To support a multi-tiered, population health approach, which 
includes continued clinical care through a more traditional ``acute 
care'' model for those experiencing behavioral health disorders, as 
well as mitigation strategies, such as early detection and 
intervention, for those at-risk of behavioral health conditions, \42\ 
APA strongly urges the reauthorization of several pediatric mental 
health programs:
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    \42\  Evans, A. C., & Bufka, L. F. (2020). The Critical Need for a 
Population Health Approach: Addressing the Nation's Behavioral Health 
During the COVID-19 Pandemic and Beyond. Preventing Chronic Disease, 
17. http://dx.doi.org/10.5888/pcd17.200261
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    Programs for Children with a Serious Emotional Disturbance provide 
funds to government entities to deliver comprehensive community-based 
mental health services to children, youth, and young adults who have a 
serious emotional disturbance. These programs serve vulnerable, high-
risk populations, and have shown to significantly improve the mental, 
social, and emotional functioning of children and adolescents with 
severe emotional disturbances through effective evidence-based services 
and have shown to significantly improve the mental, social, and 
emotional functioning of children and adolescents with severe emotional 
disturbances through effective evidence-based services and have shown 
to significantly improve the mental, social, and emotional functioning 
of children and adolescents with severe emotional disturbances through 
effective evidence-based services. \43\
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    \43\  Substance Abuse and Mental Health Services Administration. 
(2017). The Comprehensive Community Mental Health Services for Children 
with Serious Emotional Disturbances Program: 2017 Report to Congress. 
Retrieved from: https://store.samhsa.gov/sites/default/files/d7/priv/
cmhi-2017rtc.pdf
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    Pediatric Mental Health Care Access Grants promote behavioral 
health integration into pediatric primary care by supporting pediatric 
mental health care telehealth access programs. Data show that 
psychological factors substantially influence physical health outcomes 
and efforts to address physical health needs are less likely to be 
effective without similar attention to behavioral health conditions. 
\44\, \45\ As such, to maximize the likelihood of a successful 
intervention, integrating children's physical and behavioral health 
care is critical. Reauthorizing the Pediatric Mental Health Care Access 
Grants program would further support the coordination between 
physicians and behavioral health providers.
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    \44\  Slavich, G. M., & Cole, S. W. (2013) The emerging field of 
human social genomics Clinical Psychological Science, 1(3), 331-348. 
https://doi.org/10.1177/2167702613478594
    \45\  Australian Institute of Health and Welfare. (2012). 
Comorbidity of mental disorders and physical conditions 2007. Retrieved 
from: https://www.aihw.gov.au/getmedia/05a9c315-7576-4c3f--
aa2a9ccb14964c3e/10953.pdf
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    Additionally, the Committee should consider the Pursuing Equity in 
Mental Health Act (S. 1795), which authorizes funding to support 
research on Black youth suicide, improve the pipeline of culturally 
competent providers, build outreach programs that reduce stigma, and 
develop a training program for providers to effectively manage 
disparities.

    Schools also play a critical role in providing health care to many 
children, particularly as they can be key to both early detection and 
intervention efforts. In fact, in many communities, they are an 
essential--and often the only--source of meeting the physical and 
mental health needs of students and families. While some school 
districts leverage Medicaid funds to stretch scarce resources and 
create school-based mental health programs, shortages of school-based 
behavioral health professionals continue to persist. \46\
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    \46\  National Association of School Psychologists. (2017). 
Shortages in school psychology: Challenges to meeting the growing needs 
of U.S. students and schools. Retrieved from: https://
www.nasponline.org/resources-and-publications/resources-and-podcasts/
school-psychology/shortages-in-school-psychology-resource-guide
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    Improving the behavioral health and emotional well-being of all 
students, including by instituting evidence-based comprehensive 
behavioral health systems in schools, can help mitigate the impacts of 
pandemic-related learning loss,pandemic-related learning loss,pandemic-
related learning loss,pandemic-related learning loss,pandemic-related 
learning loss, \47\ and reduce the frequency and severity of mental 
health and substance use disorders. \48\ Such a holistic approach 
provides a full complement of supports and services that establish 
multi-tier interventions and promotes positive school environments. 
They are built on collaborations between students, parents, families, 
community health partners, school districts, and school professionals, 
such as administrators, educators, and specialized instructional 
support personnel, including school psychologists.
---------------------------------------------------------------------------
    \47\  Dorn, E., Hancock, B., Sarakatsannis, J., & Viruleg, E. 
(2020, December 8). COVID-19 and learning loss-disparities grow and 
students need help. McKinsey & Company. https://www.mckinsey.com/
industries/public-and-social-sector/our-insights/covid-19-and-learning-
loss-disparities-grow-and-students-need-help
    \48\  American Psychological Association. (2020). APA's Guide to 
Schooling and Distance Learning During COVID-19. Retrieved from: 
https://www.apa.org/ed/schools/teaching-learning/recommendations-
starting-school-covid-19.pdf
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    Instead of employing resources only when a child experiences a 
crisis, our behavioral health system must focus resources earlier in 
life and address the factors that lead to such experiences. Oftentimes, 
this can be achieved in school-based settings, with the partnership and 
engagement of parents and families. Schools must receive more support 
to address these needs by increasing and retaining a highly trained 
workforce of diverse, culturally competent school-based mental health 
professionals. APA urges the Committee to pass the following 
legislation that would increase access to school-based mental health 
services:

    The Mental Health Services for Students Act (S. 1841), which would 
build partnerships between local educational agencies, tribal schools, 
and community-based organizations to provide school-based mental health 
care for students and training for the entire school community to help 
identify early warning signs of a crisis and prevent its escalation.

    The Comprehensive Mental Health in Schools Pilot Program Act (S. 
2730), which would provide resources for low-income schools to develop 
a holistic approach to student well-being by building, implementing, 
and evaluating comprehensive school-based mental health programs. 
Integrating evidence-based, culturally competent social and emotional 
learning programs and trauma-informed approaches to teaching and 
student well-being help foster positive school climates and develop 
skills such as motivation and engagement, problem-solving, emotional 
intelligence, resilience, agency, and relationship building. \49\
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    \49\  Coalition for Psychology in Schools and Education. (2015). 
Top 20 principles from psychology for preK-12 teaching and learning. 
American Psychological Association. Retrieved from https://www.apa.org/
ed/schools/teaching-learning/top-twenty-principles.pdf
---------------------------------------------------------------------------
    Such universal programs also help address student behavioral 
challenges by implementing positive, non-punitive, restorative measures 
rather than retributive and exclusionary practices. \50\
---------------------------------------------------------------------------
    \50\  Reyes, C., & Gilliam, W. (2021). Addressing challenging 
behaviors in challenging environments: Findings from Ohio's early 
childhood mental health consultation system. Development and 
Psychopathology, 33(2), 634-646. doi:10.1017/S0954579420001790
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    The Increasing Access to Mental Health in Schools Act (S. 1811) 
would expand mental health services in low-income schools by increasing 
the number of school-based mental health professionals, including 
psychologists. This bill would provide schools with the ability to 
build long-term capacity to equitably address the mental and behavioral 
well-being of their students, which can have significantly positive 
impacts on their academic development and future success.

    To further understand the implications of COVID-19 on the education 
of students, in terms of both their academic achievement and social and 
emotional development, Congress should invest in increased research and 
data collection through the Institute of Education Sciences (IES). IES 
supports research, reports data, and produces evidence-based resources 
to help improve educational outcomes for all students. Currently, IES 
is able to fund only one in ten grant applications it receives. 
Additionally, stronger collaboration and partnerships should be 
encouraged between the Department of Education, the Department of 
Health and Human Services, and the Substance Abuse and Mental Health 
Services Administration with respect to data collection efforts.

    Finally, young people of college age face unique challenges when it 
comes to their mental health. A recent survey of college students finds 
that a large majority are experiencing emotional distress or anxiety 
due to the pandemic. \51\ Future economic insecurity resulting from the 
pandemic is among the top concerns of college students, \52\ further 
contributing to stress, anxiety, and depression. \53\, \54\ Campus 
counseling centers, which even prior to COVID-19 were the only access 
point to mental health care for many college students, are seeing 
significant increases in demand for services, without a corresponding 
increase in resources, whether through funding, training, or staff. 
\55\ This care is, in part, provided by psychology interns and trainees 
completing their education, under the supervision of counseling center 
staff. One of the impacts of the pandemic on college campuses, 
particularly earlier in the crisis was either the limiting or outright 
canceling of these internships, which hamstrung the ability of 
counseling centers to stay operational and continue training future 
practitioners. APA supports the Higher Education Mental Health Act (S. 
3048) that would establish a national commission to study mental health 
concerns at institutions of higher education, and the reauthorization 
of the campus suicide prevention programs under the Garrett Lee Smith 
Memorial Act.
---------------------------------------------------------------------------
    \51\  TimelyMD (2022). College Students More Concerned About COVID-
19 Than Ever, New Survey by TimelyMD Finds. Retrieved from: https://
timely.md/college-students-more-concerned-about-covid-19-than-ever
    \52\  Chegg.org. (2021). Global Student Survey. Retrieved from: 
https://www.chegg.com/about/wp-content/uploads/2021/02/Chegg.org-
global-student-survey-2021.pdf.
    \53\  Walsemann, K. M., Gee, G.C., & Gentile, D. (2015). Sick of 
Our Loans: Student Borrowing and Mental Health of Young Adults in the 
United States. Social Science and Medicine. 124, 85-93.
    \54\  Marshall, G.L., Kahana, E., Gallo, W.T., Stansbury, K. L., & 
Thielke, S. (2020). The price of mental well-being in later life: the 
role of financial hardship and debt. Aging & Mental Health, 25(7), 
1338-1344. DOI: 10.1080/13607863.2020.1758902
    \55\  Center for Collegiate Mental Health. (2021). Part 1 of 5: 
COVID-19's Impact on College Student Mental Health. Pennsylvania State 
University. Retrieved from: https://ccmh.psu.edu/index.php'option=com--
dailyplanetblog&view=entry&year=2021&month=02&day=01&id=9:part-1-of-5-
covid-19-s-impact-on-college-student-mental-health
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      Promoting Integration of Primary Care and Behavioral Health
    Psychologists have long been at the forefront of developing 
evidence-based integrated primary care and behavioral health services. 
One of the leading models of integrated care is the Primary Care 
Behavioral Health Model (PCBH), in which primary care providers, 
behavioral health consultants (BHCs), and care managers work as a team, 
sharing the same health record systems, administrative support staff, 
and waiting areas, and collaborate in monitoring and managing patient 
progress in order to improve the management of behavioral health 
problems and conditions. In the PCBH model the behavioral health 
consultant role is often, but not always, filled by a clinical 
psychologist.

    The PCBH model is a truly population-based approach to integrated 
care, in which the goal is to improve both mental and physical health 
outcomes for the clinic's patients--of every age and condition--by 
managing behavioral health problems and bio-psychosocially influenced 
health conditions. \56\ Generally, the BHC strives to see patients on 
the same day the primary care provider (PCP) requests help, ideally 
through a ``warm hand-off,'' and works with the PCP to implement 
clinical pathways for treatment. An integrated care psychologist's day 
may include meeting with a parent of a child exhibiting behavioral 
difficulties or hyperactivity, seeing a new mother experiencing 
symptoms of depression, helping another patient manage chronic pain or 
diabetes, and working with another patient who has recently 
discontinued using his psychotropic medication. Both patients and 
providers have reported high levels of satisfaction with PCBH model 
services. \57\, \58\ From the patient's perspective, behavioral health 
services are seamlessly interwoven with medical care, mitigating the 
stigma often associated with behavioral health services.
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    \56\  Reiter, J. T., Dobmeyer, A. C., & Hunter, C. L. (2018). The 
primary care behavioral health (PCBH) model: An overview and 
operational definition. Journal of Clinical Psychology in Medical 
Settings, 25(2), 109-126.
    \57\  Petts, R. A., Lewis, R. K., Brooks, K., McGill, S., Lovelady, 
T., Galvez, M., & Davis, E. (2021). Examining patient and provider 
experiences with integrated care at a community health clinic. The 
Journal of Behavioral Health Services & Research, 1-18.
    \58\  Angantyr, K., Rimner, A., Norden, T., & Norlander, T. (2015). 
Primary care behavioral health model: Perspectives of outcome, client 
satisfaction, and gender. Social Behavior and Personality: An 
International Journal, 43(2), 287-301
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    The PCBH model is particularly well-suited to use in pediatric 
care. Interventions and supports to promote children's physical, 
behavioral, and emotional health can positively influence the long-term 
trajectory of their health and well-being into adulthood. Almost all 
children are seen in primary care, and it is estimated that one in four 
pediatric primary care office visits involve behavioral or mental 
health problems. Psychologists can be especially helpful in pediatric 
care because assessing behavioral and emotional issues in children is 
generally more difficult than in adults, and pediatric education 
traditionally focuses on children's physical health. In addition to 
improving treatment in this area, early childhood behavioral health 
services can help mitigate the effect of adverse social determinants of 
health. Ideally, integrated pediatric primary care includes a whole-
family approach to services that encompasses screening and services for 
perinatal and maternal depression, domestic violence, and adverse 
childhood experiences.

    Investing in evidence-based integrated primary and behavioral 
health care across multiple models would help us meet the current 
crisis, as more than a decade of research has shown that programs 
implementing the PCBH model, the collaborative care model (CoCM), and 
blended models of integrated care can increase access to care and 
achieve the health care triple aim of improving patient outcomes, 
increasing satisfaction with care, and reducing overall treatment 
costs. A comprehensive approach to supporting integrated care was just 
endorsed by the Primary Care Collaborative (PCC), a multi-stakeholder 
coalition of more than 60 clinician, patient, employer, and health care 
organizations committed to establishing an equitable, high value health 
care system based on effective primary care. PCC shared recommendations 
on integrating primary care and behavioral health in a letter to HHS 
Secretary Xavier Becerra and CMS Administrator Chiquita Brooks-LaSure, 
stating:

    ``At present, evidence supports multiple integrated behavioral 
health delivery models in primary care, including the collaborative 
care model and the primary care behavioral health model. To maximize 
the number of patients that can benefit from integrated care across 
diverse practice settings and communities, primary care payment options 
must be available to support a variety of evidence-based models of 
integration. Payment policy that supports multiple care integration 
models has two additional merits. It can support the development of 
real-world implementation evidence across diverse populations and spur 
further innovation in behavioral health integration at the practice 
level and in practice/payer collaboration. For these reasons, PCC 
supports a multi-component policy approach to behavioral health 
integration.'' \59\
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    \59\  Primary Care Collaborative. (January 26, 2022). The PCC sends 
Behavioral Health Integration Recommendation Letter to HHS/CMS (p. 3). 
Retrieved from: https://www.pcpcc.org/2022/01/26/pcc-sends-behavioral-
health-integration-recommendation-letter-hhscms
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    A concerted effort to promote evidence-based integrated primary and 
behavioral health is needed because unfortunately, implementation of 
integrated care remains limited. CMS data show that use of the Medicare 
behavioral health integration billing codes established by CMS in 2017 
roughly doubled between 2018 and 2019, with less than a quarter of 
providers billing using a psychiatrist-based collaborative care model 
and more than 70 percent of providers using a PCBH or similar model of 
care. However, it appears that well under 1 percent of Medicare 
beneficiaries receive care through integrated care model programs 
between 2018 and 2019, with less than a quarter of providers billing 
using a psychiatrist-based collaborative care model and more than 70 
percent of providers using a PCBH or similar model of care. However, it 
appears that well under 1 percent of Medicare beneficiaries receive 
care through integrated care model programs. \60\ Adoption of PCBH and 
other integrated care models is often challenging for primary care 
providers, as they face barriers related to physical office space, the 
need for improved information technology systems, management 
procedures, clinical staffing and policies, health records and data 
tracking practices, and provider education and training.
---------------------------------------------------------------------------
    \60\  Centers for Medicare and Medicaid Services. (2021). Medicare 
Physician & Other Providers--By Provider and Service Dataset. Retrieved 
from: https://data.cms.gov/provider-summary-by-type-of-service/
Medicare-physician-other-practitioners/Medicare-physician-other-
practitioners-by-provider-and-service
---------------------------------------------------------------------------
    APA supports the provision of Federal financial and technical 
assistance to aid in the expansion of integrated care, whether provided 
through partnerships (including state agencies) or through direct aid 
to primary care providers. Initiatives and incentives to promote 
integrated care should support implementation of not just PCBH 
programs, but all evidence-based models of integrated care. Because of 
differences in providers' patient populations and access to behavioral 
health providers, there is no ``one-size-fits-all'' approach to 
effective integrated primary care. APA urges Congress to continue to 
give primary care practices the flexibility to choose the model of 
integrated care that works best for their community and that which will 
most strongly expand access to integrated primary and behavioral health 
care, and improve population health.
         Continuation of Evidence-Based Mental Health Programs
    APA appreciates continued Federal support for the Community Mental 
Health Services Block Grant, which provides a bedrock of support for 
community-based mental health screening, evaluation, and treatment 
programs across all states and communities. The effectiveness of any 
mental health system depends on its recognition of mental health as 
existing on a spectrum, and its ability to meet the needs of patients 
wherever they are on that spectrum and wherever they are in the 
community. Without access to crisis services, patients often find 
themselves languishing in emergency rooms or seeking treatment in other 
inappropriate settings. We strongly support the CAHOOTS Act (S. 764), 
which incentivizes state Medicaid programs to cover services provided 
by round-the-clock mobile crisis teams, and Rep. Bustos' Crisis Care 
Enhancement Act (H.R. 4305), which reserves a higher set-aside amount 
under the block grant for crisis services. The increased funding for 
these services provided under these bills will, in addition to 
improving patient outcomes, increase the efficiency of states' mental 
health care systems and help enable national initiatives around mental 
health--such as the 988 National Suicide Prevention Lifeline--to reach 
their full potential.
        Ensuring Parity for Behavioral and Physical Health Care
    Enactment of the Mental Health Parity and Addiction Equity Act 
(MHPAEA) in 2008 promised to end insurance discrimination against 
individuals with mental health and substance use disorders. 
Unfortunately, frequent noncompliance with the law and inadequate 
enforcement has kept us from achieving this promise.

    Just last week the U.S. Departments of Labor, Health and Human 
Services, and Treasury issued their latest joint report to Congress on 
enforcement of MHPAEA, as required under the law. Importantly, the 2022 
MHPAEA enforcement report is the first since Congress established a new 
enforcement tool under the Consolidated Appropriations Act of 2021 
(CAA): the requirement that health plans and issuers perform 
comparative analyses of their non-quantitative treatment limitations 
(NQTLs) to demonstrate their compliance with MHPAEA and provide those 
analyses to the agencies upon request for purposes of determining 
compliance. Health plans, administrators, and issuers are continuing to 
apply discriminatory NQTLs (such as preauthorization requirements, 
admission criteria for provider networks, and reimbursement rates) to 
mental health and substance use disorder benefits and providers in 
order to constrain their beneficiaries' use of services.

    Most of the responsibility for enforcement has fallen to the 
Employee Benefits Security Administration (EBSA) within the Department 
of Labor (DOL), which has jurisdiction over MHPAEA compliance for 
approximately 2 million health plans covering more than 136 million 
Americans. Out of this universe, EBSA has issued 156 letters to plans 
and issuers requesting comparative analyses for their NQTLs. As the 
report describes, none of the comparative analyses EBSA reviewed 
contained sufficient information upon initial receipt. EBSA 
subsequently obtained sufficient information for a review of NQTLs in 
30 plans, and in all cases made an initial determination of non-
compliance with MHPAEA.

    We applaud the agencies' focus on NQTLs and its new enforcement 
authority, and for prioritizing review of both in-network and out-of-
network reimbursement rates for mental health and substance use 
providers. A 2019 Milliman Research Report compared health plans' in-
network reimbursement rates for behavioral health office visits as a 
percentage of Medicare-allowed amounts with reimbursement rates for 
medical/surgical office visits, and found that primary care 
reimbursement rates were nearly 24 percent higher than behavioral 
health visit rates. Not surprisingly, the same study found that 
consumers were almost five and a half times as likely to go out-of-
network for behavioral health services as for medical/surgical primary 
care. APA frequently hears from psychologists who have chosen to stop 
participating in insurance plans because of low reimbursement rates and 
onerous administrative hassles, and this level of frustration is being 
exacerbated by the heavy demand for services during the pandemic.

    The 2022 MHPAEA Report describes DOL's valiant effort to enforce 
the law, which we commend, but it is clear stronger tools are needed. 
We strongly support the agency's request for the authority to assess 
civil monetary penalties for parity violations--for group health plan, 
issuers, and administrators--as would be established under legislative 
language included in the House-passed Build Back Better Act. Congress 
should enact legislation this year to provide this authority.

    In addition, we support the Parity Implementation Assistance Act 
(S. 1962) to assist states in using the new enforcement authority 
granted under the Consolidated Appropriations Act to obtain comparative 
analyses and information from insurers on their implementation of 
MHPAEA. States have the authority, but often not the resources, to play 
a role in enforcing MHPAEA.

    Finally, we urge the Committee to approve legislation to close the 
loophole that allows self-funded non-Federal Government-sponsored 
health plans to opt out of complying with MHPAEA. Sadly, even after all 
we've experienced with the mental health effects of the pandemic and 
the acceleration of drug overdose deaths over the past 2 years, these 
plans covering our public servants are far more likely to claim an 
exemption from mental health parity requirements than for any other 
type of coverage requirement. It has been 14 years since Congress 
passed MHPAEA to end discrimination by diagnosis against those in need 
of mental health and substance use treatment, and now is certainly the 
time to do the same for government employees. Congress should also 
eliminate the ability of self-funded non-Federal Government health 
plans to opt out of other beneficiary protections, such as benefits 
described under the Newborns' and Mothers' Health Protection Act of 
1996 and the Women's Health and Cancer Rights Act of 1998.
                            No Surprises Act
    APA urges the Committee to investigate the disproportionate impact 
of the Interim Final Rules issued last year under the No Surprises Act 
on mental and behavioral health providers. APA and ten of the top 
mental and behavioral health organizations sent a letter to U.S. 
Department of Health and Human Services Secretary Xavier Becerra on 
January 25, 2022, requesting a stay on enforcement of requirements 
affecting routine mental and behavioral health service. \61\ 
Collectively, we expressed concerns with the impact the IFRs will have 
on access to mental and behavioral services in communities that have 
long lacked access to these services. Our practitioners have a long-
standing practice of being transparent about fees with their patients 
as is required under professional ethics codes. We have broad concerns 
that when CMS develops the rules for Good Faith Estimates (GFEs) for 
insured patients, insurers will use the information contained in the 
required Good Faith Estimates (GFEs) as a mechanism or justification to 
limit treatment beyond the scope of the GFEs. We also urge that those 
rules do not carry over the flawed Part I dispute resolution provisions 
identified in the American Medical Association (AMA) and American 
Hospital Association (AHA) lawsuit. We, and other mental and behavioral 
organizations, welcome the opportunity to work with the Committee to 
ensure unnecessary administrative burdens do not take away from the 
ability of mental and behavioral health providers to provide their 
patients access to quality treatment. Investing in Youth Mental Health 
Research
---------------------------------------------------------------------------
    \61\  American Psychological Association letter to U.S. Department 
of Health and Human Services Secretary Xavier Becerra. (January 25, 
2022). Retrieved from: https://votervoice.s3.amazonaws.com/groups/
apaadvocacy/attachments/Sign-on percent20letter percent20No 
percent20Surprises percent20Act.pdf
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    This is surely the year for Congress to address the growing crisis 
this Committee has identified by adding significant funds to NIH for an 
initiative to strengthen youth mental health. APA is calling for a 
billion-dollar investment in this initiative: this research would pay 
dividends for decades. Mental health issues, particularly for young 
people, affect their entire trajectory of life, \62\ bringing struggles 
with education, employment, and close relationships. Mental disorders 
drain our economy through lost productivity and preventable utilization 
of the healthcare system and add costs within the juvenile justice 
system, to say nothing of the enormous suffering, the loss, and the 
personal toll exacted by mental disorders. Through research funded by 
NIMH, NICHD and NIMHD, we have learned a great deal about how to 
identify those at risk and engage them in preventive programs. But 
there is much more to learn and to apply in order to develop 
interventions, target them appropriately, and treat young people when 
prevention fails. We need research on primary prevention programs that 
are ready to be brought to scale, universal socio-emotional skills 
learning, safe social media interaction, and community-based approaches 
to support kids' healthy development.
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    \62\  Veldman, K., Reinjeveld, S. A., Ortiz, J. A., Verhulst, F. 
C., & Bultman, U. (2015). Mental health trajectories from childhood to 
young adulthood affect the educational and employment status of young 
adults: results from the TRAILS study. J. Epidemiological Community 
Health, 69(6). 588-593
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    Every year, approximately 1.5 million Americans attempt to end 
their own lives due to suffering from mental health symptoms. Millions 
more have significant impairments in their functioning at work and in 
their relationships as parents and romantic partners. This is largely 
preventable based on psychological science that could be used to 
integrate mental health screening, preventions, resilience practices, 
and evidence-based interventions that we know can significantly reduce 
mental health symptoms today, and ensure that children are developing 
with far fewer risks of mental health difficulties in the decades to 
ensure that children are developing with far fewer risks of mental 
health difficulties in the decades to ensure that children are 
developing with far fewer risks of mental health difficulties in the 
decades to come. \63\
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    \63\  Fortgang, R. G., & Nock, M. K. (2021). Ringing the Alarm on 
Suicide Prevention: A Call to Action. Psychiatry, 84(2), 192-195. 
https://doi.org/10.1080/00332747.2021.1907871
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    APA is heartened by the focus on mental health in Congress, and 
eager to work with this Committee and its Members to develop 
legislation and enact the bills cited above. Your actions now can make 
all the difference in how many people are treated for their mental 
health problems and strengthened and fortified against developing 
problems. Together we can resolve the problems created by an inadequate 
mental health workforce and improve the capacity of the health care 
system to serve people who need immediate treatment. Our investment in 
mental health research now will guide improved prevention and treatment 
for decades to come. APA is a ready partner and looks forward to 
working with the Committee to put in place critical changes to our 
current system of care that will save lives and ensure access to care.
                                 ______
                                 
                 [summary statement of mitch prinstein]
    During the COVID-19 pandemic, adults' mental and behavioral health 
needs increased exponentially compared to 2019, and remain unmet for 
many. For example, over 47 percent of adults with serious mental 
illness report having unmet needs. Youth mental health is also at an 
alarming point, with disproportionate impact on youth from communities 
of color and marginalized communities. Children's hospitals have 
documented a 42 percent increase in cases of self-injury and suicide, 
compared to 2019. APA urges Congress to consider the six following 
issue areas to strengthen existing programs and/ or consider 
legislation to address these devastating developments.
           Strengthening the Mental and Behavioral Workforce:

          Pass the Mental Health Professionals Workforce 
        Shortage Loan Repayment Act (S. 1578).

           Reauthorize programs administered by HRSA and 
        SAMHSA, including GPE, MFP, BHWET, ISTP.

     Improving Access to Mental Health Care for Children and Youth:
    Reauthorize:

          Pediatric mental health programs that support 
        children with serious emotional disturbance.

          The Pediatric Mental Health Care Access Grants 
        program.

          Campus suicide prevention programs under the Garrett 
        Lee Smith Memorial Act.

    Consider:

          The Pursuing Equity in Mental Health Act (S. 1795).

          The Higher Education Mental Health Act (S. 3048).

    Pass:

          The Mental Health Services for Students Act (S. 
        1841).

          The Comprehensive Mental Health in Schools Pilot 
        Program Act (S. 2730).

          The Increasing Access to Mental Health in Schools Act 
        (S. 1811).

      Promoting Integration of Primary Care and Behavioral Health:

          Provide Federal financial and technical assistance to 
        aid in the expansion of integrated primary and behavioral care 
        services provided through use of evidence-based models 
        including the Primary Care Behavioral Health (PCBH) model and 
        Collaborative Care (CoCM) model.

         Continuation of Evidence-Based Mental Health Programs:

          Continue support for the Community Mental Health 
        Services Block Grant.

          Consider the CAHOOTS Act (S. 764)

          Consider the Crisis Care Enhancement Act (H.R. 4305).

        Ensuring Parity for Behavioral and Physical Health Care:

          Enact legislative language included in the House-
        passed Build Back Better Act to strengthen DOL's enforcement of 
        the Mental Health Parity and Addiction Equity Act (MHPAEA).

          Enact legislation to close the loophole that allows 
        self-funded non-Federal Government-sponsored health plans to 
        opt out of complying with MHPAEA.

          Enact the Parity Implementation Assistance Act (S. 
        1962)

                           No Surprises Act:

          Investigate the disproportionate impact of the 
        Interim Final Rules issued last year under the No Surprises Act 
        on mental and behavioral health providers.

                  Investing in Mental Health Research:

          Support a billion-dollar investment in IMH, NICHD and 
        NIMHD funding.
                                 ______
                                 
    The Chair. Thank you.

    Dr, Durham.

STATEMENT OF MICHELLE P. DURHAM, M.D., MPH, FAPA, DFAACAP, VICE 
    CHAIR OF EDUCATION, DEPARTMENT OF PSYCHIATRY, CLINICAL 
ASSOCIATE PROFESSOR OF PSYCHIATRY & PEDIATRICS, BOSTON MEDICAL 
     CENTER, BOSTON UNIVERSITY SCHOOL OF MEDICINE, BOSTON, 
                         MASSACHUSETTS

    Dr. Durham. Thank you, Chair Mary, Ranking Member Burr, and 
Senator Murkowski, and distinguished Members of the Senate HELP 
Committee for holding this hearing and providing me with the 
opportunity to speak with you today. My name is Dr. Michelle 
Durham. I am a Pediatric and Adult Psychiatrist at Boston 
Medical Center and Board Certified in Addiction Medicine. In my 
over 10 years at BMC and Academic Medical Center in New 
England's largest safety net hospital, I have never seen our 
mental health care services stretched so far beyond their 
capacity as they are now.

    Since late December 2021, we have had 30 plus patients in 
our psychiatric emergency Department, more than four times its 
capacity, presenting with a much higher level of acuity, some 
waiting for evaluation, and others boarding a waiting for 
placement inpatient psychiatric unit. The patients we serve at 
BMC are predominantly low income, with approximately half of 
our patients covered by Medicaid or the Children's Health 
Insurance Program, the highest percentage of any acute care 
hospital in Massachusetts.

    70 percent of our patients identify as Black or Latino, 
approximately one in three speak a language other than English 
as their primary language, and over have live at or below the 
Federal poverty level. BMC has a particular expertise and 
connecting marginalized communities to health and social 
services, and yet we still find it happens all too often that 
our patients with co-occurring mental health and substance use 
disorders get stuck in a revolving door, falling in and out of 
mental health and substance use treatment systems, in many 
cases ending up on the streets either episodically or 
chronically homeless, only to present repeatedly to our 
emergency Department.

    One of the issues at play is that the necessary supports 
for these patients are not in place, including affordable low 
barrier housing and coordinated care integrated with a 
supportive community. The question is really how do we get 
people with co-occurring mental health and substance use 
everything they need to survive and be healthy?

    BMC is in the very early stages of implementing a housing 
first approach in partnership with the city of Boston to get 
people living on the streets, just steps from our hospital 
campus, oftentimes living with co-occurring mental health and 
substance use issues housed first, and then provide wraparound 
medical services and social supports. Our hope is that this can 
work to break the vicious cycle for these folks, many of which 
are BMC patients and eventually can serve as a model for other 
municipalities replicate.

    Our system is also in the process of constructing an 82 bed 
psychiatric facility in nearby Brockton, Massachusetts, to 
address the shortage of inpatient psychiatric beds and increase 
our ability to treat the mental health and substance use needs 
of our patients from across the region. The facility is 
expected to provide 56 inpatient psychiatric beds with the 
capacity to treat patients with co-occurring disorders and 20 
26 clinical stabilization service beds.

    We estimate that the project will involve a total of $27 
million in sunken startup cost, a barrier that the Federal 
Government could help lower to incentivize capital investments 
to expand inpatient psychiatric capacity. As a Black, Spanish-
speaking psychiatrist waiver to prescribe buprenorphine for 
opioid use disorder, I am all too aware of the patients our 
treatment systems are failing to reach.

    Preliminary reports from the CDC indicate that the U.S. has 
eclipsed 100,000 annual drug overdose deaths for the first time 
ever. While nationally, overdose death rates have increased in 
every major demographic group in recent years, black men have 
experienced the largest increases. Even in Massachusetts, where 
we have seen population wide drug overdose death rates leveled 
off in recent years, the death rates for black men stand out in 
stark contrast, having increased astounding 75 percent between 
2019 and 2020. Communities of color are suffering 
disproportionately from COVID-19, and they are dying at 
disproportionate rates from substance use disorders, bearing 
the brunt of two compounding public health crises.

    At the same time, black men have comparably low rates of 
mental health and substance use treatment. At BMC, we have 
launched the Health Equity Accelerator to eliminate the race 
based health equity gap by utilizing data driven and community 
based research to inform and change the way we approach care 
for black people and people of color. While we don't yet have 
all the answers we seek, we do know that a one size fits all 
approach doesn't work and that access is strained across the 
mental health and substance use continuum.

    That is why reauthorizing funding to support States and 
localities responding to mental health and the substance use 
crisis and flexible ways is crucial. Thank you to the Senate 
HELP Committee for your commitment to coming together on a 
bipartisan basis to sustain funding in these critical programs 
over time. I would like to end by providing a glimpse into the 
reality of what our patients face every day. In one of my 
recent shifts in our psychiatric emergency room, a man in his 
late 20's came in seeking help for his mental health and 
substance use.

    In our short time together, he described his onset of 
opiate use at 9 years of age. His parents were both using 
substances. There was minimal supervision in the home. As we 
see, often the patient had experienced years of substance use, 
time in the correctional system, death of many family members, 
and unsuccessful relationships with limited supports.

    He has been in and out of treatment over the years as well, 
but our system as currently designed ultimately exacerbates 
issues and prevents recovery. In order to make progress, we 
must work to transform our mental health and substance use care 
system into one that recognizes relapse as a reality, 
coordinates care, destigmatizing and decriminalize substance 
use, and ultimately one that sees the humanity and people with 
mental health and substance use issues as--that enable--that 
can enable them to recover and live healthy, fulfilling lives. 
Thank you for your time and I look forward to the discussion.

    [The prepared statement of Dr. Durham follows:]
                prepared statement of michelle p. durham
    Thank you Chair Murray, Ranking Member Burr, and distinguished 
Members of the Senate Committee on Health, Education, Labor, and 
Pensions (HELP) for holding this hearing and providing me with the 
opportunity to speak today about mental health and substance use 
disorders, and the role the Federal Government can play in responding 
to a growing crisis impacting millions of Americans across all ages.

    My name is Dr. Michelle Durham, I am a pediatric and adult 
psychiatrist at Boston Medical Center (BMC), board certified in adult 
psychiatry, child psychiatry, and addiction medicine. I am Vice Chair 
of Education in the Department of Psychiatry at BMC, where I also 
trained for my residency. I hold a joint appointment at the Boston 
University School of Medicine as a Clinical Associate Professor of 
Psychiatry and Pediatrics.

    Boston Medical Center is an academic medical center and the largest 
safety-net hospital in New England. The patients we serve at BMC are 
predominantly low-income, with approximately half of our patients 
covered by Medicaid or the Children's Health Insurance Program (CHIP) 
the highest percentage of any acute care hospital in Massachusetts. 70 
percent of our patients identify as Black or Latinx, approximately one 
in three (32 percent) speak a language other than English as their 
primary language, and over half live at or below the Federal poverty 
level. The patients we see at BMC frequently have co-occurring mental 
health (MH) and substance use disorders (SUD) and oftentimes face 
numerous health-related social needs linked to poverty, including 
homelessness and malnutrition. The COVID-19 pandemic, structural 
racism, and economic crisis has further exacerbated the mental illness, 
substance use, and trauma experienced by our patients.

    In my over 10 years at BMC, I have never seen our mental health 
care services stretched so far beyond their capacity as they are now. 
(It's even worse than when I testified on this subject before the 
Senate Finance Committee in June 2021.) Since late December, we have 
had 30-plus patients in our psychiatric emergency department more than 
three to four times its capacity--presenting with a much higher level 
of acuity, some waiting for evaluation and others boarding awaiting 
placement in an inpatient psychiatric unit.

          In addition to emergency services, BMC provides a 
        continuum of outpatient and inpatient mental health and 
        addiction services, including:

          The Grayken Center for Addiction at BMC, with 11 
        clinical programs for substance use disorders, is one of the 
        nation's leading centers for addiction treatment, research, 
        prevention, and education;

          Outpatient Mental Health Clinic, which includes the 
        Addiction Psychiatry Treatment Program (APTP) and the Wellness 
        and Recovery After Psychosis (WRAP) Program;

          Outpatient integrated mental health care within our 
        pediatric and adult primary care clinics and at local community 
        health center partners;

          Mental health urgent care clinic;

          Our Boston Emergency Services Team (BEST) provides 
        community-based evaluations, a mental health crisis 
        stabilization unit, and a jail diversion program;

          BMC Health System is in the process of constructing 
        an 82-bed psychiatric facility in nearby Brockton, MA--
        including 56 inpatient psychiatric beds with the capacity to 
        treat patients with co-occurring substance use disorder and 26 
        Clinical Stabilization Services (CSS) beds.

    BMC has a particular expertise in connecting marginalized 
communities to health and social services and yet we still find it 
happens all too often that our patients with co-occurring mental health 
and substance use disorders get stuck in a ``revolving door,'' falling 
in and out of the MH/SUD treatment system, in many cases ending up on 
the streets, either episodically or chronically homeless, only to 
present repeatedly to our Emergency Department.

    One of the issues at play is that the necessary supports for these 
patients are not in place:

          Access to affordable, low-barrier housing: For 
        example, where you don't have to maintain sobriety to get a 
        roof over your head. Not enough of these places exist. Though, 
        BMC is in the very early stages of implementing this ``housing 
        first'' approach, in partnership with the city of Boston, to 
        get people living on the streets just steps from our hospital 
        campus, oftentimes living with co-occurring MH/SUD, housed 
        first, and then provide wrap-around medical services and social 
        supports.

          A good aftercare plan: We think of care transitions 
        as places where patients can fall through the cracks, e.g. 
        leaving detox or an inpatient psychiatric facility to return to 
        the community, but not linking up with outpatient treatment and 
        support. The fact is, more needs to be done on either end to 
        reach patients, understanding that addiction is a relapsing-
        remitting disease, and recovery is possible.

          A supportive community: When treating co-occurring 
        MH/SUD, the goal is not necessarily to eliminate drug use 
        completely, but how to use substances less so that a person can 
        function in society--i.e. have a job and maintain healthy 
        relationships with family and friends. At the same time, 
        overemphasis on medication at the expense of other forms of 
        treatment and support is likely not the answer. The question is 
        really, how do we get people with co-occurring MH/SUD 
        everything they need to survive and be healthy? For so many of 
        our patients, particularly from multicultural/ethnic groups, 
        connection to a supportive community is absolutely essential to 
        recovery. From a care perspective, this can mean integrating 
        community pillars like churches into care plans.

    Substance use disorder is in the Diagnostic and Statistical Manual 
of Mental Disorders (DSM), the mental health field's principal 
authority for psychiatric diagnoses. It is estimated that about half of 
people with SUD will develop a MH disorder in their lifetime, and the 
same is true of people with MH disorders--about 50 percent will develop 
a SUD in their lifetime. \1\ For the patients we treat at BMC, we 
estimate that the percentage with co-occurring MH/SUD is likely even 
higher (55-60 percent). The idea that mental health and substance use 
disorders exist in separate siloes is reflected in how our treatment 
system is designed--but the distinction is artificial, and is not a 
reflection of how patients experience MH and SUD, or how as a physician 
I seek to treat MH and SUD.
---------------------------------------------------------------------------
    \1\  National Institute on Drug Abuse (NIDA) Common Comorbidities 
with Substance Use Disorders Research Report--Part 1: The Connection 
Between Substance Use Disorders and Mental Illness, April 13, 
2021.https://nida.nih.gov/publications/research--reports/common--
comorbidities--substance--use--disorders/part-1--connection--between--
substance--use--disorders-mental-illness
---------------------------------------------------------------------------
    As a Black, Spanish speaking psychiatrist, waivered to prescribe 
buprenorphine for opioid use disorder, I'm all too aware of the 
patients our treatment systems are failing to reach. Preliminary 
reports from the U.S. Centers for Disease Control and Prevention (CDC) 
indicate that the last year for which we have data was the deadliest on 
record, eclipsing 100,000 drug overdose deaths for the first time 
ever--a grim milestone. \2\ While nationally overdose death rates have 
increased in every major demographic group in recent years, Black men 
have experienced the largest increases. \3\ Even in Massachusetts, 
where we've seen population-wide drug overdose death rates level off in 
recent years, the death rates for Black men stand out in stark 
contrast, having increased an astounding 75 percent between 2019 and 
2020 (from 32.6 to 57.1 per 100,000). \4\ Communities of color are 
suffering disproportionately from COVID-19, and they are dying at 
disproportionate rates from SUD, bearing the brunt of two compounding 
public health crises. The COVID-19 pandemic has exacerbated all the 
inequities those of us practicing in mental health and SUD care have 
known for decades--workforce shortages, lack of coordinated care, lack 
of parity, and low reimbursement.
---------------------------------------------------------------------------
    \2\  U.S. Centers for Disease Control and Prevention, National 
Center for Health Statistics. Drug Overdose Deaths in the U.S. Top 
100,000 Annually. November 17, 2021. https://www.cdc.gov/nchs/
pressroom/nchs--press--releases/2021/20211117.htm
    \3\  Gramlich J. Recent surge in U.S. drug overdose deaths has hit 
Black men the hardest. Pew Research Center. January 19, 2022. https://
www.pewresearch.org/fact-tank/2022/01/19/recent-surge-in-u-s-drug-
overdose-deaths-has-hit-black-men-the-hardest/
    \4\  Massachusetts Department of Public Health. Opioid-Related 
Overdose Deaths, All Intents, MA Residents--Demographic Data 
Highlights. November 2021. https://www.mass.gov/doc/opioid-related-
overdose-deaths-demographics-november-2021/download
---------------------------------------------------------------------------
    At the same time, Black men have comparably low rates of MH/SUD 
treatment. Racism and discrimination in all facets of life for these 
communities have not only made accessing care difficult, but once in 
treatment, unfair and inequitable systems and practices cause folks to 
quickly disengage from the treatment they so rightly deserve and need 
in order to recover.

    At BMC, we have launched the Health Equity Accelerator to eliminate 
the race-based health equity gap by utilizing data-driven and 
community-based research to inform and change the way we approach care 
for Black people and people of color. \5\ We are going directly to 
people in the community for answers and centering their experience 
seeking MH/SUD treatment to inform our interventions and programming 
moving forward.
---------------------------------------------------------------------------
    \5\  Dayal McCluskey P. Boston Medical Center launches new plan to 
address racial disparities in health care. Boston Globe. November 16, 
2021. https://www.bostonglobe.com/2021/11/16/metro/boston-medical-
center-launches-new-plan-addressing-racial-disparities-health-care/
---------------------------------------------------------------------------
    While we don't yet have the answers we seek, we do know that a one-
size-fits-all approach doesn't work and that access is strained across 
the MH/SUD continuum. That is why reauthorizing funding to support 
states and localities responding to MH and SUD crises in flexible ways 
is crucial including through State Opioid Response Grants, Substance 
Abuse Prevention and Treatment Block Grants, and Community Mental 
Health Services Block Grants. Thank you to the Senate HELP Committee 
for your commitment to coming together on a bipartisan basis to sustain 
funding in these critical programs over time.

    I would like to end with providing a glimpse into the reality of 
what our patients face every day. In one of my recent shifts in our 
psychiatric emergency room, a man in his late 20's came in seeking help 
for his mental health and substance use disorder. In our short time 
together, he described his onset of opioid use at 9 years of age--his 
parents were both using substances and there was minimal supervision in 
the home. As we see often, the patient had experienced years of 
substance use, time in the carceral system, death of many family 
members, and unsuccessful relationships with limited to no supports. He 
has been in and out of treatment over the years as well, but a system 
that does not allow relapse, a system that does not coordinate care, a 
system that stigmatizes substance use, a system that criminalizes 
substance use ultimately exacerbates issues and prevents people from 
being able to recover and live healthy, fulfilling lives.

    Because whether we're talking about mental health or substance use 
disorders, or co-occurring MH/SUD, I think the question we're seeking 
to answer is how do we as a society continue to see the humanity in 
people with mental illness and/or who are using substances, and shape 
our policies and programs intended to treat and support people with MH/
SUD accordingly.

    Thank you for your time. I look forward to the discussion.
                                 ______
                                 
               [summary statement of michelle p. durham]
    In my over 10 years at Boston Medical Center (BMC), an academic 
medical center and the region's largest safety-net hospital, I have 
never seen our mental health care services stretched so far beyond 
their capacity as they are now. Since late December 2021, we have had 
30-plus patients in our Psychiatric Emergency Department--more than 
three to four times its capacity--presenting with a much higher level 
of acuity, some waiting for evaluation and others boarding awaiting 
placement in an inpatient psychiatric unit.
    BMC has a particular expertise in connecting marginalized 
communities to health and social services and yet we still find it 
happens all too often that our patients with co-occurring mental health 
(MH) and substance use disorders (SUD) get stuck in a ``revolving 
door,'' falling in and out of the MH/SUD treatment system, in many 
cases ending up on the streets, either episodically or chronically 
homeless, only to present repeatedly to our Emergency Department.
    One of the issues at play is that the necessary supports for these 
patients are not in place, including affordable, low-barrier housing 
and coordinated care integrated with a supportive community. The 
question is really, how do we get people with co-occurring MH/SUD 
everything they need to survive and be healthy?
    As a Black, Spanish speaking psychiatrist, waivered to prescribe 
buprenorphine for opioid use disorder, I'm all too aware of the 
patients our treatment systems are failing to reach. Preliminary 
reports from the CDC indicate that the U.S. has eclipsed 100,000 annual 
drug overdose deaths for the first time ever. While nationally overdose 
death rates have increased in every major demographic group in recent 
years, Black men have experienced the largest increases. Even in 
Massachusetts, where we've seen population-wide drug overdose death 
rates level off in recent years, the death rates for Black men stand 
out in stark contrast, having increased an astounding 75 percent 
between 2019 and 2020. Communities of color are suffering 
disproportionately from COVID-19, and they are dying at 
disproportionate rates from SUD, bearing the brunt of two compounding 
public health crises. At the same time, Black men have comparably low 
rates of MH/SUD treatment.
    At BMC, we have launched the Health Equity Accelerator to eliminate 
the race-based health equity gap by utilizing data-driven and 
community-based research to inform and change the way we approach care 
for Black people and people of color. While we don't yet have the 
answers we seek, we do know that a one-size-fits-all approach doesn't 
work and that access is strained across the MH/SUD continuum. That is 
why reauthorizing funding to support states and localities responding 
to MH and SUD crises in flexible ways is crucial. Thank you to the 
Senate HELP Committee for your commitment to coming together on a 
bipartisan basis to sustain funding in these critical programs over 
time.
    In order to make progress, we must work to transform our MH/SUD 
care system into one that recognizes relapse as a reality, coordinates 
care, destigmatizes and decriminalizes substance use, and ultimately, 
one that sees the humanity in people with MH/SUD and enables them to 
recover and live healthy, fulfilling lives.
                                 ______
                                 
    The Chair. Thank you very much.
    Director Goldsby.

 STATEMENT OF SARA GOLDSBY, MSW, MPH, DIRECTOR, SOUTH CAROLINA 
DEPARTMENT OF ALCOHOL AND OTHER DRUG ABUSE SERVICES, COLUMBIA, 
                               SC

    Ms. Goldsby. Good morning, Chair Murray, Ranking Member 
Burr, Senator Murkowski, and Members of the Committee. My name 
is Sara Goldsby and I serve as Director of South Carolina's 
Department of Alcohol and Other Drug Abuse Services. I also 
serve as President of the National Association of State Alcohol 
and Drug Abuse Directors, or NASADAD, and it is a privilege to 
join you today.

    I would like to begin by thanking you for your work to pass 
the Comprehensive Addiction and Recovery Act, or CARA, and the 
21st Century Cures Act and the Support Act. In addition, thank 
you for providing historic Federal investments and programs 
housed within the Substance Abuse and Mental Health Services 
Administration, including the Substance Abuse Prevention and 
Treatment or SAPT Block Grant.

    As you mentioned earlier, our country continues to 
experience the devastating impact of substance use disorders, 
and the number of overdose deaths is simply staggering. In my 
home State of South Carolina, overdose deaths have increased by 
60 percent over the last 5 years, and more of those deaths 
occurred in the last 2 years, with the increased use during 
COVID-19, and the incredibly potent illicit fentanyl supply we 
have been inundated with.

    Overall, almost one-third of individuals admitted to 
treatment in our country's publicly funded addiction system, 
excuse me, cited heroin or prescription opioids as their 
primary substance abuse. Yet we also know substance use 
disorders impact different States, counties, and communities in 
different ways. In South Carolina, for example, we are seeing a 
rise in admissions to treatment for alcohol use disorder, where 
42 percent of people admitted to treatment reported alcohol as 
their primary problem.

    There is no doubt that the COVID-19 pandemic contributed to 
increases in problems related to substance use disorders, yet 
we have all worked to adjust. States and providers have 
developed innovative approaches to prevention, treatment, and 
recovery programing. Federal agencies and Congress have worked 
to provide important flexibilities through program guidance and 
communication.

    In addition, Congress and the Administration worked to 
provide critical funding for prevention, treatment, and 
recovery, along with lifesaving overdose reversal medication. 
As I observe the work moving forward in the field, I continue 
to be amazed and inspired by the incredible commitment, 
courage, and resolve that I see on a daily basis. I am 
particularly grateful for our frontline providers.

    Even though they are exhausted, they are stretched thin, 
they continue to serve, they continue to help, and they 
continue to save lives, and they continue to help find a road 
for recovery for everyone they serve. And I offer a number of 
recommendations as we continue our work together. First, we ask 
that Federal policy ensures a strong SAMHSA as the lead Federal 
agency on substance use disorders service delivery.

    We believe SAMHSA should be the default agency for all 
Federal substance use disorder programing, and we applaud Dr. 
Miriam Delphin-Rittmon, Assistant Secretary for Mental Health 
and Substance Use as a leader of SAMHSA. Second, please work to 
ensure that Federal policy initiatives and Federal funding for 
substance use disorders flows through State alcohol and drug 
agencies, given our work to ensure quality and evidence based 
services, and to ensure effective planning, implementation, 
oversight, and accountability.

    Third, we hope for continued support of the SAPT Block 
grant. The flexibility afforded in the Block grant allows 
States to target resources where they are needed more based on 
data and the conditions on the ground. Our country faces a 
giant workforce problem. We are struggling to find people to do 
the job. And while we appreciate HRSA, we need an all hands on 
deck approach.

    We can--we hope this Committee will give SAMHSA and its 
programs full statutory authority to immediately help with our 
workforce challenges. We appreciate this Committee's work to 
help reduce suicide and improve our Nation's response to people 
experiencing crisis. Since this time, SAMHSA has been actively 
working with stakeholders to prepare for the July 2022 launch 
of 988. And as we move forward, we ask that Congress and others 
specifically elevate and specifically reference substance use 
disorders as a core focus of work related to crisis response.

    We believe this approach is needed given the many distinct 
and unique considerations that accompany service delivery for 
people with substance use disorders and substance driven 
crisis. Finally, we hope Congress continues to work with 
stakeholders and the Administration to maintain certain 
flexibilities that were granted in connection with the public 
health emergency.

    I am happy to review other recommendations with the 
Committee as time permits. In the meantime, thank you for the 
opportunity to testify today, and I look forward to questions 
you may have.

    [The prepared statement of Ms. Goldsby follows:]
                   prepared statement of sara goldsby
    Chair Murray, Ranking Member Burr, and Members of the Committee, my 
name is Sara Goldsby, and I am the Director of the South Carolina 
Department of Alcohol and Other Drug Abuse Services (DAODAS). I also 
serve as the President of the National Association of State Alcohol and 
Drug Abuse Directors (NASADAD). NASADAD represents State agency 
directors across the country that manage their respective State alcohol 
and drug prevention, treatment, and recovery systems.

    It is an honor to testify before you today regarding the ways in 
which the Federal Government, states, communities, and families have 
been working together to address substance use disorders. I appreciate 
the opportunity to share perspectives.

    We continue to see the devastating impact of substance use 
disorders across the country. The number of overdose deaths is 
staggering. In 2020, 93,331 individuals died from drug overdoses in the 
United States, the highest number ever recorded in a 12-month period 
and a 30 percent increase from 2019. Approximately 75 percent of 
overdose deaths involved synthetic opioids and illegally manufactured 
fentanyl (Centers for Disease Control and Prevention (CDC), 2021). In 
my home State of South Carolina, overdose deaths have increased by 60 
percent over the past 5 years.

    Overall, almost one-third (30.3 percent) of individuals admitted to 
treatment in our country's publicly funded addiction system cited 
heroin or prescription opioids as their primary substance of use (TEDS/
SAMHSA, 2019). We also know substance use disorders impact different 
States, counties, and communities in many different ways. In South 
Carolina, for example, we are seeing a rise in admissions to treatment 
for alcohol use disorder. In particular, approximately 42 percent of 
treatment admissions reported a primary substance of alcohol or alcohol 
with a secondary drug (TEDS/SAMHSA, 2019).

    There is no doubt that the COVID-19 pandemic contributed to 
increases in problems related to substance use disorders. For example, 
the National Institute on Drug Abuse (NIDA) cited research that found 
increases in the number of positive urine drug tests ordered by health 
care providers and legal systems (NIDA, 2022). The reports analyzing 
the drug screen results indicated an increase in fentanyl, cocaine, 
heroin, and methamphetamine compared to previous years (NIDA, 2022).

    While the pandemic presented challenges to service delivery, we all 
worked together to adjust. States and providers developed innovative 
approaches to prevention, treatment, and recovery programming. Federal 
agencies and Congress worked to provide States and providers important 
flexibilities through program guidance and communication. In addition, 
Congress and the Administration worked to provide critical funding for 
prevention, treatment, and recovery along with life-saving overdose 
reversal medication. I had the privilege of testifying before this 
Committee in April 21 to share some of this work.

    There is no doubt that the pandemic continues to present 
challenges. We have a great deal of work ahead of us.

    Please know that the support from this Committee, the House, the 
Senate, and the Administration has been vital. Thank you.

    As I observe the work moving forward in the field, I continue to be 
amazed and inspired by the incredible commitment, courage, and resolve 
I see on a daily basis. I am particularly grateful for our front-line 
providers. Even though they are exhausted and stretched thin, they 
continue to serve; they continue to help; they continue to save lives; 
and they continue to improve lives. We should all find a moment to 
thank and recognize our providers any chance we get.

    I will review a number of recommendations for the Committee's 
consideration at the end of my remarks. All of these observations are 
critical. At the same time, it is my hope that extra energy is directed 
at addressing the many challenges related to our nation's substance use 
disorder workforce.

    Critical Role of the State Alcohol and Drug Agency: I would like to 
step back and describe the role of each State's alcohol and drug 
agency. These agencies oversee and implement the publicly funded 
prevention, treatment, and recovery service system.

    Planning: All State alcohol and drug agencies develop a 
comprehensive plan for service delivery and capture data describing the 
services provided. Our agency does this in a number of ways. Each year, 
we require a strategic plan to address alcohol and other drug issues 
from each county alcohol and drug authority. These plans are required 
to follow the strategic prevention (or planning) framework and must 
consider the most updated data available for a needs assessment.

    As we understand each county's unique needs, capacity, and 
strategies to address substance use issues, we then create a State plan 
for service delivery supported by Federal and State funds available 
through our office. Additionally, we support the State Epidemiological 
Outcomes Workgroup (SEOW), composed of statisticians, epidemiologists, 
and data holders across State agencies. The SEOW's annual reports on 
prevalence and burden of substance use in our State inform priorities 
for planning and are shared with stakeholders statewide. Finally, we 
co-lead the State's Opioid Emergency Response Team that develops and 
manages the emergency plan to address the opioid epidemic across 
sectors in the State.

    Working to support providers to ensure quality and delivery of 
evidence-based practices: An important focus of State alcohol and drug 
agency directors across the country is the promotion of effective, 
high-quality services. In South Carolina, we expect our providers to 
implement evidence-based screening tools and to use American Society of 
Addiction Medicine (ASAM) placement criteria to ensure patients are 
placed in the appropriate level of care. All of our contracted 
treatment providers are required to maintain either accreditation by 
the Commission on Accreditation of Rehabilitation Facilities (CARF) or 
the Joint Commission on Accreditation of Healthcare Organizations 
(JCAHO).

    We also conduct real-time compliance checks year-round with ongoing 
reviews of the clinical charts of all our contracted treatment 
providers. This is to ensure compliance with best practices and 
Medicaid standards. We require our providers to use evidence-based 
services across the continuum--including prevention services and 
support community programs that use the strategic prevention framework 
process.

    We ensure our contractors' use of evidence-based data from trusted 
sources and informed practices that we approve. We support our 
providers year-round with training and technical assistance as 
requested and as we deem appropriate.

    Coordinating with other State agencies on programs and services 
across prevention, treatment and recovery: State alcohol and drug 
agencies work collaboratively across State governments to ensure that 
addiction issues are addressed with a coordinated, cross-agency 
approach. For example, the State alcohol and drug agencies work with 
State departments of mental health, criminal justice, child welfare, 
education, and more. Because alcohol and drug issues cross every sector 
and impact citizens statewide, we partner closely with the other public 
health and social service agencies in South Carolina. We engage in 
daily communication with the S.C. Department of Health and 
Environmental Control (SCDHEC) for situational updates, data sharing, 
and on a number of joint projects, including HIV education and early 
intervention services, as well as overdose prevention programming for 
law enforcement officers and firefighters.

    We also employ liaison staff that bridge our agency with others. 
Our Certified Peer Support Specialists are employed by DAODAS but are 
stationed at the S.C. Department of Corrections (SCDC) as they conduct 
peer trainings for inmates and coordinate inmates' access to treatment 
and services upon their re-entry to the community. The liaison who 
works between our agency and the S.C. Department of Social Services 
(SCDSS) helps develop policy and programming for children and families 
in the social services system who are affected by alcohol and other 
drugs. This bridge has helped align best practices and good policy 
across two large public systems.

    Our liaison at the S.C. Department of Mental Health (SCDMH) is 
responsible for coordinating training for co-occurring mental and 
substance use disorders across the State's community mental health 
centers and our county alcohol and drug authorities. This work is 
helping our State achieve a ``no wrong door'' approach to serving 
citizens experiencing both mental health and substance use issues. 
Furthermore, we have a formal partnership for projects to address 
veterans with our State Department of Veterans' Affairs (SCDVA). 
Additionally, we have a contract with the S.C. Department of Probation, 
Parole, and Pardon Services (SCDPPPS) to train their officers on 
substance use disorders and evidence-based screening. Finally, I am in 
contact most days with the Major over Narcotics at the S.C. Law 
Enforcement Division as we share information on trends, trafficking, 
and State policy.

    Communicating with, and acquiring input from, providers and local 
communities and stakeholders: State alcohol and drug agencies play a 
critical role in supporting the substance use disorder provider 
community. Our staff are in regular and routine contact with staff at 
provider organizations. Leadership at DAODAS meets monthly with all of 
the directors of the county alcohol and drug authorities during their 
monthly association meeting. The managers of DAODAS' Divisions of 
Treatment & Recovery Services and Prevention & Intervention Services 
meet quarterly with the local Treatment Directors and Prevention 
Coordinators, respectively, for training and global communication, but 
they also connect one-on-one for assistance and support as needed.

    Our State Opioid Treatment Authority (SOTA) meets quarterly with 
the directors of the State's opioid treatment programs (OTPs) to 
discuss services and policy related to methadone services. 
Additionally, these directors and their program coordinators are 
routinely in touch with the SOTA for one-on-one assistance as needed.

    Our Finance & Operations team meets quarterly with the treatment 
providers' finance managers, and they make time twice a year for one-
on-one calls to answer questions regarding bookkeeping, reimbursement, 
and other financial operations issues.

    Our Recovery Services coordinator is in close contact with the 
leaders of the recovery community organizations (RCOs) around the 
State, offering support and technical assistance as they establish 
programs and grow. Before the COVID-19 pandemic, our staff often 
traveled to provider sites for visits and in-person program reviews.

    In South Carolina, we consider our agency and our providers to be a 
system with mission-driven connectivity that cannot be broken.

    State alcohol and drug agencies appreciate action taken by Congress 
to address substance use disorders in general, and the opioid crisis: 
NASADAD is appreciative of this Committee, along with Congress and the 
Administration in general, for the work done to address substance use 
disorders in general, and the opioid crisis in particular. In addition, 
we appreciate passage of the Comprehensive Addiction and Recovery Act 
(CARA), 21st Century Cures Act, and the SUPPORT Act.

    We highlight a few of the many programs below:

    Substance Abuse Prevention and Treatment (SAPT) Block Grant (21st 
Century Cures, Section 8002): The SAPT Block Grant is NASADAD's No. 1 
programmatic priority. This program is the cornerstone of States' 
substance use disorder prevention, treatment, and recovery systems. The 
SAPT Block Grant serves approximately 2 million people annually.

    Federal statute requires State alcohol and drug agencies to 
allocate at least 20 percent of SAPT Block Grant funds toward primary 
substance use prevention. This ``prevention set-aside'' is a core 
component of each State's prevention system. In particular, SAPT Block 
Grant funds make up more than 60 percent of primary prevention funds 
managed by State alcohol and drug agencies. In 14 States, the 
prevention set-aside represents 75 percent or more of the State 
agency's substance use prevention budget. In six States, the prevention 
set-aside represents 100 percent of the State's primary prevention 
funding.

    We sincerely appreciate recent action by Congress to allocate 
historic investments in the SAPT Block Grant. These investments were 
made in the fiscal year 2021 omnibus appropriations bill (P.L. 116-260) 
and subsequently in the American Rescue Plan (P.L. 117-2). Prior to 
these significant investments, the SAPT Block Grant remained 
essentially level-funded for a number of years. In particular, from 
2011 to 2021, SAPT Block Grant funding did not keep up with health care 
inflation, resulting in a 24 percent decrease in purchasing power.

    Account for the State Response to the Opioid Crisis (21st Century 
Cures, Section 1003): We sincerely appreciate the creation of an 
account for the State opioid response to the opioid crisis (Section 
1003). This $1 billion fund for fiscal year 2017 and fiscal year 2018 
helped State alcohol and drug agencies to significantly enhance 
treatment, prevention, and recovery services along with overdose 
reversal activities. This funding, initially known as the State 
Targeted Response to the Opioid Crisis Grants (STR), now known as the 
State Opioid Response Grants (SOR), provided a substantial level of 
support for innovative and lifesaving programs in States across the 
country. The Substance-Use Prevention that Promotes Opioid Recovery and 
Treatment (SUPPORT) for Patients and Communities Act re-affirmed the 
importance of grants to States to address the opioid crisis through 
Section 7181.

    Priority substance abuse treatment needs of regional and national 
significance within SAMHSA's Center for Substance Abuse Treatment 
(CSAT) (21st Century Cures, Section 7004): CSAT works closely with 
State alcohol and drug agencies to help expand access to treatment for 
and recovery from substance use disorders. CSAT focuses on work to 
improve the quality of substance use treatment services through its 
Addiction Technology Transfer Center (ATTC). NASADAD recognizes Dr. 
Ingvild Olsen, Acting Director of CSAT, for her leadership of the 
Center. Further, we wish to recognize the Division of State and 
Community Assistance (DSCA) for their support of NASADAD's members in 
working to implement State-based awards including the Substance Abuse 
Prevention and Treatment (SAPT) Block Grant. In addition, the Division 
of Pharmacologic Therapies (DPT) is a key component of SAMHSA that 
works with State Opioid Treatment Authorities (SOTAs) and State agency 
directors to ensure effective programming related to medications for 
substance use disorders, including those moving forward within our 
nation's opioid treatment programs (OTPs).

    Priority substance abuse prevention needs of regional and national 
significance within SAMHSA's Center for Substance Abuse Prevention 
(CSAP) (21st Century Cures, Section 7005): As noted by SAMHSA, CSAP 
provides national leadership in the development of programs, policies, 
and services to prevent the onset of illegal drug use, prescription 
drug misuse, and underage alcohol use and tobacco use. CSAP also works 
to help promote evidence-based practices through structures like the 
Prevention Technology Transfer Centers (PTTC). We applaud Dr. Jeff 
Coady, Acting Director of CSAP, for his direction. In addition, we 
recognize CSAP's Division of Primary Prevention (DPP) for their work 
with States.

    A NASADAD priority program within CSAP is the Strategic Prevention 
Framework--Partnerships for Success (SPF-PFS) initiative. This program 
allows State alcohol and drug agencies to utilize cross-agency 
collaboration to address prevention priorities through a data-driven 
process. State alcohol and drug agencies partner with anti-drug 
coalitions to implement this important work at the local level. At the 
national level, NASADAD partners the Community Anti-Drug Coalitions of 
America (CADCA) to help foster these relationships and promote best 
practices in prevention.

    Evidence-based prescription opioid and heroin treatment and 
interventions demonstration grants (CARA, Section 301): The evidence-
based opioid and heroin treatment and interventions demonstration grant 
was authorized in CARA to help State alcohol and drug agencies increase 
access to Food and Drug Administration-approved medications for opioid 
use disorders in order to ensure clinically appropriate care. The 
authorization requires SAMHSA to fund only those applications that 
specifically support recovery services as a critical component of the 
program involved.

    Improving Treatment for Pregnant and Postpartum Women (CARA, 
Section 501 and SUPPORT Act, Section 7062): CARA reauthorized the 
Residential Treatment for Pregnant and Postpartum Women program to help 
support comprehensive, family centered treatment services where women 
and their children can receive the help they need together in a 
residential setting. CARA also created a pilot program to afford State 
alcohol and drug agencies flexibility in providing new and innovative 
family centered substance use disorder services in non-residential 
settings. The SUPPORT Act reauthorized both programs from 2019--2023 
and increased the funding level from an authorization of $16.9 million 
to $29.9 million.

    Community Coalition Enhancement Grants (CARA, Section 103): This 
section authorized the Office of National Drug Control Policy (ONDCP), 
that coordinates with Centers for Disease Control and Prevention (CDC), 
to make grants to community anti-drug coalitions to implement 
community-wide strategies to address their local opioid and 
methamphetamine problem. States work with community anti-drug 
coalitions daily to engage in key primary prevention efforts at the 
local level.

    Building Communities of Recovery (CARA, Section 302): The BCOR 
initiative authorized SAMHSA to award grants to recovery community 
organizations (RCOs) to develop, expand and enhance recovery services. 
RCOs across the country are doing an excellent job of helping persons 
in recovery regain positive and productive relationships with their 
families, employers, and communities. NASADAD is a strong partner of 
Faces and Voices of Recovery (FAVOR) and its Association of Recovery 
Community Organizations (ARCO) as efforts are made to expand access to 
recovery support services in the publicly funded system.

    Medicare Coverage of Certain Services Furnished by Opioid Treatment 
Programs (Section 2005, SUPPORT Act): This section amended the Social 
Security Act to expand Medicare coverage to include treatment services 
provided by SAMHSA-certified opioid treatment programs (OTPs). The 
covered services include medication assisted treatment (MAT), 
counseling, drug testing, and individual and group therapy.

    Plans of Safe Care (SUPPORT Act, Section 406): This provision 
amended the Child Abuse Prevention and Treatment Act (CAPTA) to make 
grants to help State child welfare agencies, State alcohol and drug 
agencies and others facilitate collaboration in developing, updating 
and implementing plans of safe care. Plans of safe care are tools that 
inventory and direct services and supports to ensure the safety and 
well-being of an infant impacted by substance use disorders, 
withdrawal, or fetal alcohol spectrum disorders, including services for 
the infant and their family/caregiver. The grant funds may also be used 
to support developing agency-to-agency memoranda of understanding 
(MOU), training, developing and updating technology to improve data 
collection, and more.
                   Recommendations for Consideration

    Promote and ensure a strong SAMHSA that serves as the lead Federal 
agency across the Federal Government on substance use disorder service 
delivery: We support maintaining investments in SAMHSA as the lead 
agency within HHS focused on substance use disorders. The nation 
benefits from a strong SAMHSA given the agency's longstanding 
leadership in the field. A strong SAMHSA includes a vibrant role for 
each of its centers--the Center for Substance Abuse Treatment (CSAT), 
Center for Substance Abuse Prevention (CSAP), Center for Mental Health 
Services (CMHS), and Center for Behavioral Health Statistics and 
Quality (CBHSQ).

    NASADAD expresses our support for Dr. Miriam E. Delphin-Rittmon, 
Assistant Secretary for Mental Health and Substance Use and leader of 
SAMHSA, as she guides the agency and works across HHS to promote a 
unified Federal approach to substance use disorders. We strongly 
believe SAMHSA should be the default home of substance use disorder 
discretionary grants and programming related to prevention, treatment, 
and recovery. This requires financial resources but also the human 
resources needed to provide this leadership.

    Ensure that Federal policy and resources related to substance use 
disorders are routed through the State alcohol and drug agency: State 
alcohol and drug agencies play a critical role in overseeing and 
implementing a coordinated prevention, treatment, and recovery service-
delivery system. These agencies develop annual statewide plans to 
ensure an efficient and comprehensive system across the continuum. 
Further, State alcohol and drug agencies promote effective systems 
through oversight and accountability. Finally, NASADAD members promote 
and ensure quality through standards of care, technical assistance to 
providers, and other tools. As a result, NASADAD prefers Federal 
funding, programs, and policies designed to address substance use 
prevention, treatment, and recovery flow through the State alcohol and 
drug agency. This approach allows Federal initiatives to enhance and 
improve State systems and promotes an effective and efficient approach 
to service delivery. Federal policies and programs that do not flow 
through or at least coordinate with the State agency run the risk of 
creating parallel or even duplicative publicly funded systems and 
approaches.

    Continued investment in the Substance Abuse Prevention and 
Treatment (SAPT) Block Grant while maintaining maximum flexibility: 
NASADAD's top programmatic discretionary grant program priority is the 
Substance Abuse Prevention and Treatment (SAPT) Block Grant. We 
sincerely appreciate the work of this Committee on this important 
program. In addition, we appreciate recent historic financial 
investments made by Congress in the SAPT Block Grant. In the context of 
reauthorization, NASADAD prefers to maintain as much flexibility as 
possible in the use of SAPT Block Grant funds consistent with the 
nature of, and benefits related to, the block grant mechanism. The 
flexibility afforded in the SAPT Block Grant allows States the 
opportunity to target resources based on the conditions on the ground 
as opposed to pre-ordained spending requirements.

    Promote sustained and predictable funds through three-to 5-year 
discretionary grants: In addition to adequate resources, State alcohol 
and drug agencies note that sustained and predictable resources are 
absolutely critical. They allow States to partner with sub-State 
entities, providers, and others to plan activities in a systematic 
manner. One-and 2-year programs, with only a short-term commitment, can 
create an environment of uncertainty related to the future of a 
critical initiative that provides lifesaving services. It can be 
difficult, if not impossible, to successfully plan and operate programs 
with an eye on continuity of services if providers are not confident 
that resources will be available to serve their patients. NASADAD 
strongly supports the National Governors Association's (NGA) call to 
extend the duration of Federal grants beyond the typical one-or 2-year 
funding cycle to either a three-or 5-year cycle.

    Ensure new Federal initiatives and funding complement and enhance 
the current system: NASADAD appreciates the many Federal legislative 
efforts to address substance use disorders that were found in the 
Comprehensive Addiction and Recovery Act (CARA), 21st Century Cures 
Act, and the SUPPORT Act. In the process, the Association has been 
partnering with Congress, the Administration, and non-governmental 
organizations to implement many of these initiatives. This includes 
work related to program management and implementation, data collection/
reporting, and engagement in the many day-to-day activities that ensure 
programs are managed effectively and efficiently. As a result, we 
recommend policies that complement or enhance the work that has already 
been done in order to leverage our collective response in an efficient 
and effective manner.

    Continue to work to address the opioid crisis but also elevate 
efforts to address all substance use disorders, including those linked 
to alcohol and other substances: The opioid crisis is one of the worst 
public health tragedies in our nation's history. The sheer volume of 
death linked to this epidemic is difficult to grasp. We also know this 
country faces distinct challenges related to all substances whether it 
is prescription drug misuse, heroin, alcohol, marijuana, 
methamphetamine, cocaine or others. According to SAMHSA's National 
Survey on Drug Use and Health (NSDUH), alcohol remains a distinct 
problem in the country, with 28.3 million Americans battling an alcohol 
use disorder. As we look at those receiving publicly funded treatment, 
31 percent of all admissions to treatment had a primary alcohol use 
disorder; 30 percent had a primary heroin or other opiate problem; and 
11 percent had primary marijuana use disorder. State directors in 
certain States are also observing increases in problems related to 
methamphetamine and cocaine. As a result, NASADAD promotes policies and 
grant programs that are flexible yet also address the specific needs 
associated with the current opioid crisis. The flexibility included in 
the SAPT Block Grant also affords States the opportunity to target 
resources to address all substances.

    Provide SAMHSA the authority and resources to help address the 
nation's substance use disorder workforce crisis: State alcohol and 
drug agency directors across the country are observing distinct 
workforce challenges. Quite simply, my colleagues note difficulties 
finding enough people to support prevention, treatment, and recovery 
programming. We understand the issue is complex. We also know there are 
many steps that need to be taken to buildup our workforce to meet the 
variety of needs related to substance use disorders. These steps 
include initiatives around recruitment, access to all levels of 
education, training, retention, salaries, and continuing education. 
There are strategies that can help loan repayment; scholarships; and 
early outreach in schools promoting a career that helps address 
substance use prevention, treatment and recovery. We recommend action 
to give SAMHSA the full statutory authority to help address our 
challenges related to the substance use disorder workforce. This 
includes action clarifying that SAPT Block Grant funds may be used to 
help States address workforce needs. Further, we support a specific 
proposal in CARA 3.0--Section 211--that would authorize a grant in 
SAMHSA's CSAP to State alcohol and drug agencies in order to bolster 
our nation's substance use prevention workforce needs as we are not 
aware of any Federal programs that currently address this.

    Ensure that initiatives designed to implement 988 and crisis 
services improvement to specifically include programs and strategies to 
address substance use disorders: In 2020, the National Suicide Hotline 
Designation Act of 2020 was signed into law. The Act incorporated 988 
as the new National Suicide Prevention Line (NSPL) and Veterans Crisis 
Line (VCL). We wish to express our appreciation for working to draft 
and approve this important piece of legislation to help reduce the 
number of suicides and improve our response to people experiencing a 
crisis. Since this time, SAMHSA has been actively working with 
stakeholders to prepare for the July 2022 launch of 988. This work 
includes the release of funds designed to help strengthen and expand 
existing Lifeline operations and telephone infrastructure along with 
funds to buildup staffing across States' local crisis call centers.

    SAMHSA is partnering with States, providers, people with lived 
experience, and others to hold convenings in an effort to prepare for 
988. These efforts include the complex task of strengthening our 
nation's service-delivery system for crisis services. We understand the 
launch of 988 is the beginning of a long journey that promises to help 
improve our approach to helping people experiencing a crisis. As we 
move forward, we ask that Congress and others elevate and specifically 
reference substance use disorders as a core focus of work related to 
crisis response. We believe this approach is needed given the many 
distinct and unique considerations that accompany service delivery for 
people with substance use disorders.

    Maintain Recent Flexibilities to Ensure Access to Substance Use 
Disorder Services: The regulatory changes seeking to ensure continued 
substance use disorder service delivery during the COVID-19 pandemic 
should be maintained at least 1 year after the Federal Government 
determines the United States is no longer operating under a public 
health emergency. At this point, these policies should be further 
evaluated. These actions include the flexibilities regarding take-home 
doses of methadone for certain patients; the ability to initiate 
buprenorphine treatment for opioid use disorders without a face-to-face 
appointment; reasonable flexibilities related to HIPAA rules in order 
to allow service providers to utilize a variety of communication tools 
for service delivery; and others.

    State alcohol and drug agencies play a critical role in the 
prevention, treatment, and recovery of substance use disorders and I 
look forward to working with the Committee on ways the Federal 
Government, States, communities, and families can work together to 
address this very important issue.

    Thank you again for the opportunity to testify today and share my 
perspective. I look forward to any questions you may have.
                                 ______
                                 
                  [summary statement of sara goldsby]
    Continued challenges with overdose deaths: Our country continues to 
see the devastating impact of substance use disorders across the 
country. The number of overdose deaths is staggering. In 2020, 93,331 
individuals died from drug overdoses in the United States, the highest 
number ever recorded in a 12-month period and a 30 percent increase 
from 2019. Approximately 75 percent of overdose deaths involved 
synthetic opioids and illegally manufactured fentanyl (Centers for 
Disease Control and Prevention (CDC), 2021). In my home State of South 
Carolina, overdose deaths have increased by 60 percent over the past 5 
years.

    Challenges with many substances: Overall, almost one-third (30.3 
percent) of individuals admitted to treatment in our country's publicly 
funded addiction system cited heroin or prescription opioids as their 
primary substance of use (TEDS/SAMHSA, 2019). We also know substance 
use disorders impact different States, counties, and communities in 
many different ways. In South Carolina, for example, we are seeing a 
rise in admissions to treatment for alcohol use disorder. In 
particular, approximately 42 percent of treatment admissions reported a 
primary substance of alcohol or alcohol with a secondary drug (TEDS/
SAMHSA, 2019).

    Working through the pandemic: There is no doubt that the COVID-19 
pandemic contributed to increases in problems related to substance use 
disorders. While the pandemic presented challenges to service delivery, 
we all worked together to adjust. States and providers developed 
innovative approaches to prevention, treatment, and recovery 
programming. Federal agencies and Congress worked to provide States and 
providers important flexibilities through program guidance and 
communication. In addition, Congress and the Administration worked to 
provide critical funding for prevention, treatment, and recovery along 
with life-saving overdose reversal medication. I had the privilege of 
testifying before this Committee in April 21 to share some of 
this work.

    Extra support and attention to help workforce challenges: I offer a 
number of recommendations below as we continue this work. All of these 
observations are critical. At the same time, it is my hope that extra 
energy is directed at addressing the many challenges related to our 
nation's substance use disorder workforce.

    Recommendations:

          Ensure that Federal policy and resources related to 
        substance use disorders are routed through the State alcohol 
        and drug agency

          Promote and ensure a strong SAMHSA that serves as the 
        lead Federal agency across the Federal Government on substance 
        use disorder service delivery

          Provide SAMHSA the authority and resources to help 
        address the nation's substance use disorder workforce crisis

          Ensure that initiatives designed to implement 988 and 
        crisis services improvement to specifically include programs 
        and strategies to address substance use disorders

          Promote sustained and predictable funds through 
        three-to 5-year discretionary grants

          Continue to work to address the opioid crisis but 
        also elevate efforts to address all substance use disorders, 
        including those linked to alcohol and other substances
          Maintain Recent Flexibilities to Ensure Access to 
        Substance Use Disorder Services
                                 ______
                                 
    The Chair. Thank you.
    Dr. Lockman.

   STATEMENT OF JENNIFER D. LOCKMAN, PH.D., CEO, CENTERSTONE 
               RESEARCH INSTITUTE, NASHVILLE, TN

    Ms. Lockman. Thank you.

    The Chair. You want to make sure your mic is on?

    Ms. Lockman. Can you hear me now?

    The Chair. No. We have a staff person--or Senator Burr?

    Ms. Lockman. Is that okay?

    The Chair. There you go. Yes----

    Ms. Lockman. Okay, thank you for the help. I would like to 
thank Chair Murray and Ranking Member Burr and this Committee 
for your dedication to seeking solutions to the growing mental 
health and substance use crisis our country is facing today.

    I would also like to thank Senator Braun for his leadership 
for the State of Indiana, which is one of the States we are 
proud to serve in. I am honored to be here as the voice of my 
colleagues at Centerstone, and most importantly on behalf of 
the people we serve. Centerstone is the Nation's largest 
nonprofit mental health company. Centerstone provides community 
based behavioral health care, substance abuse treatment, and 
intellectual and developmental disability services.

    At Centerstone Research Institute, a Centerstone company, 
we conduct research to prevent and cure mental illness and 
addiction. We also work to translate data into meaningful 
clinical tools and practices, thereby reducing the research to 
practice gap. We applaud this hearing today because 
unfortunately deaths due to suicide, overdose, and drug and 
alcohol related disease are all too prevalent. As of 2020, 
suicide was the 12th leading cause of death in the United 
States for adults and the third leading cause of death for 
youth.

    Between 40 percent and 50 percent of Americans have been 
exposed to suicide during their lifetime. This means that at 
least half of us sitting in this room today are likely to have 
been personally affected by the loss of someone that we loved 
to suicide. For this reason, Congress, in partnership with the 
Substance Abuse and Mental Health Services Administration, 
created the Garrett Lee Smith National Strategy for Suicide 
Prevention, Zero Suicide, and COVID-19 Emergency Response 
suicide prevention grants.

    Centerstone Health Care System is honored to share our 
experience and the outcomes from some of our SAMHSA grants we 
have received. For our Zero Suicide SAMHSA grant, we are now 
working to spread evidence based practices known to decrease 
suicide throughout our entire health system and using data to 
make them even better. For example, we have updated our suicide 
prevention pathway to ensure everyone in our health care system 
gets evidence based suicide screening, risk management, and 
treatment.

    We have moved toward a new screening system that first asks 
more about upstream risk factors for suicide, such as thwarted 
belongingness, perceived burdensomeness, and acquired 
capability for suicide, and then also asked about suicide 
directly through the PHQ-9 and C-SSRS. We anticipate the 
screening process helps us identify and treat drivers of 
suicide risk earlier and with better outcomes. We have also 
piloted a suicide prevention specialty care clinic, the first 
known and community mental health centers in the United States.

    We expect all of our Centerstone clinicians to be able to 
identify and treat suicide risk. However, it is difficult and 
costly to keep all of our clinicians up to date on suicide 
specific treatments as fast as the science changes. In 
medicine, we have seen that people often get better outcomes at 
cost when at high risk by seeing medical specialists like 
cardiologists and oncologists.

    Thus, through our grant, we are creating a referral system 
so that persons at the highest risk for suicide can also be 
seen by a specialist, someone who is trained in multiple 
suicide specific treatments, the very best that science has to 
offer. Our grants have also provided a crisis follow-up program 
for youth and adults during care transitions from inpatient 
facilities, a high risk period for suicide attempts and re-
attempts.

    Our data suggest this Federal program helps individuals 
reestablish connectedness, decrease their sense of 
burdensomeness, reduce suicidal ideation, and successfully 
linked to outpatient care 70 to 90 percent of the time. These 
services would be unbillable and impossible without the Federal 
SAMHSA grants.

    Knowing this program works to save lives is especially 
timely given the July 2022 launch of 988 as a three digit 
dialing code for the National Suicide Prevention Lifeline. As 
we look toward launching 988, we must also continue to evaluate 
strategies to ensure services are funded and available 
nationally. This is why we also support the Behavioral Health 
Crisis Services Expansion Act as a crucial component to 
financing a crisis care continuum.

    Another grant program that has been a lifeline is a 
Certified Community Behavioral Health Clinic, Medicaid 
demonstration, and CCBHC SAMHSA grant program. CCBHCs allow 
consistent care for those with mental health or substance use 
conditions and a place to go in times of crisis. This model is 
helping to address some of the dire workforce challenges our 
field has faced even prior to the pandemic.

    We recommend continued investment in the CCBHC program. 
Centerstone is also pleased to be one of the only few 
comprehensive opioid recovery center grant recipients in the 
Nation. We recommend continued investment in this promising 
program. Of all the things you might take away from my 
testimony today, please be sure to hear this, Federal funding 
works. Federal funding saves lives. Federal funding helps 
prevent suicide and substance related deaths, uses program 
evaluation to help make evidence based programs even better, 
and helps individuals recover and contribute in their 
communities.

    In the words of one of our clients, ``there is no way to 
define a future if you are not there for it, and everyone is 
really focused on making sure that you stay there for it. Stay 
alive, stay safe. It has been really helpful for me to develop 
my own path. It has made a lot of difference.''

    It has been one of the great joys of my life to watch 
people go from a place of deep despair to go on to rediscover 
their talents, their strengths, and go on to build a life that 
they really want to live. Thank you, and I look forward to your 
questions.

    [The prepared statement of Ms. Lockman follows:]
                 prepared statement of jennifer lockman
    I would like to thank Chair Murray and Ranking Member Burr and this 
Committee for your dedication to seeking solutions to the growing 
mental health and substance use crisis our country is facing today. I'd 
also like to thank Senator Braun for his leadership for the State of 
Indiana, which is one of the states we are proud to serve in. I'm 
honored to be here as the voice of my colleagues at Centerstone and 
most importantly on behalf of the people we serve.

    Centerstone is the nation's largest nonprofit mental health 
company. Centerstone provides community-based behavioral health care, 
substance-abuse treatment, and intellectual and developmental 
disabilities services in Florida, Illinois, Indiana, and Tennessee. At 
Centerstone's Research Institute (CRI), a Centerstone company, we 
conduct research to prevent and cure mental illness and addiction. We 
also work to translate data into meaningful clinical tools and 
practices, thereby reducing the research-to-practice gap.

    We applaud this hearing today because unfortunately, deaths due to 
suicide, overdose, and drug and alcohol related disease are all too 
prevalent. As of 2020, suicide was the 12th leading cause of death in 
the United States for adults, and the 3d leading cause of death for 
youth. For every suicide death, there are approximately 1.1 million 
suicide attempts, or about one every 27.5 seconds (Drapeau & McIntosh, 
2021). Between 40 percent to 50 percent of Americans have been exposed 
to suicide during their lifetime (Cerel et al., 2014; Feigelman et al., 
2017). This means that at least half of us sitting in this room today 
are likely to have been personally affected by the loss of someone we 
loved to suicide. Although suicide deaths decreased approximately 3.4 
percent between 2019 and 2020, perhaps due to a ``pulling together 
effect'' we have seen before during national crises, the deeply painful 
impact of suicide deaths on American individuals, families, and 
communities remains high (Drapeau & McIntosh, 2021; Joiner et al., 
2006).

    For this reason, Congress in partnership with the Substance Abuse 
and Mental Health Services Administration (SAMHSA) created the Garrett 
Lee Smith, National Strategies for Suicide Prevention, Zero Suicide, 
and Covid-19 Emergency Response suicide prevention grants. 
Centerstone's healthcare system is honored to share our experience and 
the outcomes from some of the SAMHSA grants that we have received.

    Through our Zero Suicide SAMHSA grant, we are now working to spread 
evidence-based practices known to decrease suicide throughout our 
entire health system, and using data to make them even better. For 
example, we have updated our Suicide Prevention Pathway to ensure 
everyone in our healthcare system gets evidence-based suicide 
screening, risk management, and treatment. We have moved toward a new 
screening system that first asks about more ``upstream'' risk factors 
for suicide (such as thwarted belongingness, perceived burdensomeness, 
and acquired capability for suicide; Joiner et al., 2005), and then 
asks about suicide directly (PHQ-9; C-SSRS). We anticipate this 
screening process helps us identify and treat drivers of suicide risk 
earlier, with better outcomes (Louzon et al., 2016: Richards et al., 
2019).

    We have also piloted a suicide prevention specialty care clinic, 
the first known in Community Mental Health Centers in the United 
States. We expect all of our Centerstone clinicians to be able to 
identify and treat suicide risk; however, it is difficult and costly to 
keep all of our clinicians up to date on suicide-specific treatments as 
fast as the science changes. In medicine, we have seen that people 
often get better outcomes at cost, when at high risk, by seeing medical 
specialists (e.g., cardiologists, oncologists). Thus, through our 
grant, we are creating a referral system so that persons at the highest 
risk for suicide can be seen by providers who are trained in multiple 
suicide-specific treatments--the best that science has to offer.

    Our grants have also provided a Crisis follow-up program to youth 
and adults during care transitions from inpatient facilities, a high-
risk period for suicide attempts and re-attempts (Chung et al., 2017). 
Our data suggest this program helps individuals re-establish 
connectedness, decrease their sense of burdensomeness, reduce suicidal 
ideation, and successfully link to outpatient care (70-90 percent of 
the time). These services would be unbillable, and impossible, without 
the Federal SAMHSA grants. Knowing this program works to save lives is 
especially timely given the July 2022 launch of ``988'' as the three-
digit dialing code for the National Suicide Prevention Lifeline (NSPL). 
As we look toward launching 988 we must also continue to evaluate 
strategies to ensure these data-supported services are funded and 
available nationally. This is why we also support the Behavioral Health 
Services Crisis Expansion Act (S. 1902) as a crucial component to 
financing a crisis care continuum.

    Another grant program that has been a lifeline is the Certified 
Community Behavioral Health Clinic (CCBHCs) Medicaid demonstration and 
CCBHC SAMHSA grant program. CCBHCs allow consistent care for those with 
mental health or substance use conditions and a place to go in times of 
crisis. This model is helping to address some of the dire workforce 
challenges our field has faced even prior to the pandemic. We recommend 
continued investment in the CCBHC program. Centerstone is also pleased 
to be one of only a few Comprehensive Opioid Recovery Center grant 
recipients in the Nation. We administer this grant in Indiana, where we 
were able to train over 467 professionals in evidence-based practices 
and open a recovery house for women. We recommend continued investment 
in this promising program.

    Out of all the things you might take away from my testimony today 
please be sure to hear this: Federal funding works. Federal funding 
helps prevent suicide and substance-related deaths, uses program 
evaluation to help make programs better, and helps individuals recover 
and contribute in their communities. Thus, it's critically important 
that future Federal grants to require evidence-based programs and data-
driven program improvements. It has been one of the great joys of my 
life to watch our SAMHSA grant programs help individuals who previously 
did not want to live, re-build a life based on their values, talents, 
and strengths, often overcoming psychosocial barriers and past trauma 
to do so. In the words of one of our clients: ``There's no way to 
define a future if you are not there for it. And everyone is really 
focused on making sure that you stay there for it, stay alive, stay 
safe. It's been really helpful for me to develop my own path, and feel 
supported, but feel directed in ways that need to be. It's made a lot 
of difference.''

    Thank you, and I look forward to your questions.

    I would like to thank Chair Murray and Ranking Member Burr and this 
Committee for your dedication to seeking solutions to the growing 
mental health and substance use crisis our country is facing today. I'd 
also like to thank Senator Braun for his leadership for the State of 
Indiana, which is one of the states we are proud to serve in. I'm 
honored to be here as the voice of my colleagues at Centerstone and 
most importantly on behalf of the people we serve.

    At Centerstone's Research Institute (CRI), we conduct research to 
prevent and cure mental illness and addiction. We also work to 
translate research into meaningful clinical practices and implement 
research-based strategies in real-world settings, thereby reducing the 
research-to-practice gap. CRI's workforce is interdisciplinary and 
comprised of Physicians, Psychologists, Dissemination and 
Implementation Scientists, Counselor Educators, Program Evaluators, 
Social Workers, Public Health Advisors, Biostatisticians, Clinical 
Transformation Specialists, Design Thinking Experts, and others. 
Centerstone's Research Institute is a company of Centerstone, the 
nation's largest nonprofit mental health company who provides 
community-based behavioral health care, substance-abuse treatment and 
intellectual and developmental disabilities services in Florida, 
Illinois, Indiana, and Tennessee.

    We applaud this hearing today because unfortunately, our rates of 
deaths of despair are rising. Deaths of despair are deaths by suicide, 
overdose, and disease due to excessive drug or alcohol use. Over the 
last 10 years, deaths of despair have increased nearly twofold to over 
185,000 deaths in 2020 (CDC, 2022). Deaths of despair have increased so 
drastically that they have substantially impacted our life expectancy 
in the United States in 2015, marking the first decrease in life 
expectancy in decades; all of this occurring BEFORE the pandemic.

    Today, mental health and addiction services are needed now more 
than ever as the COVID-19 pandemic has increased the prevalence and 
incidence of behavioral health disorders in adults and children/
adolescents. Nationwide, 2020 was the deadliest year on record for 
fatal overdoses. \1\ Within the pediatric population--children's 
emergency room visits related to mental health spiked dramatically--up 
24 percent for kids 5 to 11 years old and 31 percent for teenagers 12 
to 17 years old. \2\ Even before the pandemic, 75 percent of U.S. 
counties experienced severe shortages of mental health providers. \3\ 
As demand for behavioral health services continues to rise, and 
workforce challenges increase, providers around the Nation are 
struggling to meet the demand.
---------------------------------------------------------------------------
    \1\  https://www.politico.com/news/2021/07/14/covid-pandemic-drug-
overdoses-499613
    \2\  https://www.cdc.gov/mmwr/volumes/69/wr/mm6945a3.htm
    \3\  Macher, D., Seidman, J., Gooding, M., & Diamond, C. (2020, May 
11). COVID-19 is Stressing a Fractured Mental Healthcare System in the 
US. https://avalere.com/insights/covid-19-is-stressing-a-fractured-
mental-healthcare-system-in-the-us.
---------------------------------------------------------------------------
    As one of the nation's leading not-for-profit providers of 
behavioral health--we are acutely aware that mental health and 
substance use disorder challenges are a growing concern within our 
communities. We see it with our teachers, healthcare workers, our 
firefighters and police, our returning military service personnel, and 
our own families. To this end, in addition to our oral testimony, we 
offer several policy recommendations to address the nation's growing 
behavioral health needs that we believe are realistic, bipartisan, and 
aligned with the best science of care.

          I. Advancing the best science of care relative to suicide 
        prevention and intervention; particularly as the Nation 
        prepares to launch 9-8-8 in July of '22

    In 2020, nearly 46,000 people died by suicide a slight decrease 
from the year before. However, this doesn't tell us the whole story. 
Deaths of despair have been rising dramatically in the US over the past 
decade. Deaths of despair is defined as all deaths by suicide, 
overdose, and disease due to excessive drug or alcohol use; it is a 
term often used because of their shared underlying factors and the 
difficulty to parse apart one death from the other (that is, suicides 
are often misclassified as overdoses). Over the last 10 years, deaths 
of despair have increased nearly twofold to over 185,000 deaths in 2020 
(CDC, 2022). Deaths of despair have increased so drastically that they 
have substantially impacted our life expectancy in the United States in 
2015, marking the first decrease in life expectancy in decades; all of 
this occurring BEFORE the pandemic (see table 1 and table 2).




    In response to these alarming trends, Congress in partnership with 
the Substance Abuse and Mental Health Services Administration (SAMHSA) 
created the Zero Suicide Initiative and other grant programs aimed at 
suicide prevention. Indeed, research suggests that up to 90 percent of 
individuals at risk for suicide interact with healthcare systems within 
the year before there death, such that healthcare systems are an ideal 
place for suicide prevention and treatment (Ahmedani et al., 2019). 
Centerstone's healthcare system is honored to share our experience and 
the outcomes from some of the SAMHSA grants that we have received. I 
hope to illustrate that through national funding efforts, evidence-
based practices, and data-driven program innovation, suicide deaths can 
be prevented.

    Through our Zero Suicide SAMHSA grant, we are now using existing 
evidence-based practices known to decrease suicide throughout our 
health system, and using data to make them even better. For example, 
through our grant, we have updated our Zero Suicide Pathway to ensure 
everyone in our healthcare system gets evidence-based suicide 
screening, risk management, and treatment. Specific to suicide 
screening, we have realized through Centerstone data surveillance that 
the Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al., 
2011) works well at identifying many people who are suicidal and need 
care--but does not identify a group of individuals who may be most 
likely to die by suicide. For this reason, we have moved toward a new 
screening system that first asks about more ``upstream'' risk factors 
for suicide (such as thwarted belongingness, perceived burdensomeness, 
and acquired capability for suicide; Joiner et al., 2005), and then 
asks about suicide directly (PHQ-9; C-SSRS). In this way, we are 
building on the existing evidence to cast a ``wider net,'' to 
potentially prevent and treat drivers of suicide risk earlier in the 
course of illness, and identify a unique cohort of individuals who may 
be at the highest risk for suicide who may not disclose if asked 
directly (Louzon et al., 2016: Richards et al., 2019).We were able to 
find this out due to data monitoring strategies enacted with Zero 
Suicide funding. As a result, we are able to apply lessons learned from 
this data by going upstream, testing new research ideas and asking 
different questions that target the DRIVERS of suicidal thinking (i.e., 
disconnection, burdensomeness) but not suicidal thinking directly.

    Through our Zero Suicide SAMHSA grant, we have also piloted a 
suicide prevention specialty care clinic, the first known in Community 
Mental Health Centers in the United States. Whereas we expect all of 
our Centerstone clinicians to be able to identify suicide risk, manage 
risk at the appropriate level of care, and know at least one frontline 
evidence-based treatment for suicide, we realize it is difficult and 
costly to train all of our providers in multiple suicide-specific 
treatments and keep them up to date as fast as the science changes. In 
medicine, we have seen that people often get better outcomes at cost, 
when at high risk, by seeing a medical specialists (e.g., 
cardiologists, oncologists). It is possible, then, that the same may be 
true for suicide risk. Through our grant, we are creating a referral 
system to where persons at the highest risk can be seen by providers in 
our specialty clinic for their care. Our providers in this clinic have 
been well-trained in over six, modern, evidence-based, suicide-specific 
treatments and are well-equipped to manage high risk conditions and co-
occurring diagnoses. Thus far we've had really great feedback and 
outcomes--both from the clinicians we've trained as well as the clients 
we're serving. As one of our clinicians stated recently: ``My 
perspective on suicide prevention has changed significantly since I 
started being part of this clinic . . . I believe being part of this 
[specialty] clinic has helped me gain confidence in treating clients, 
reduced the fear in treating suicidal ideation/behavior, and start to 
have in-depth . . . conversations with clients about how to manage 
their crisis and explore steps toward a life worth living.''

    An additional area where we've applied our Zero Suicide funding is 
what is referred to as ``implementation science.'' We know that a lot 
of treatments that are studied in the lab or university--as great as 
they are--once you put them in a real-world environment often times do 
not work in the way they were designed. This is because there are 
systems level barriers to where it may be harder to use those therapies 
or treatments in the ways that were studied. Implementation science 
helps us to truly understand how these approaches are implemented and 
how we can navigate workflow challenges and other community-level 
barriers to change our treatments so that they can be modified to truly 
work in real world practice settings.

    We have also participated in several SAMHSA grants, such as the 
Garrett Lee Smith and National Strategy for Suicide Prevention Grants 
(GLS; NSSP) that have allowed us to provide suicide crisis follow-up 
services to adults and youth. Research suggests that individuals 
discharged from emergency departments and inpatient units are at high 
risk for suicide and often experience difficulty linking to outpatient 
care services (Chung et al., 2017). Our Crisis Follow-up Program 
provides phone calls to clients and a supportive phone app within the 4 
weeks post-discharge. Our program uses an evidence-based framework 
(Joiner et al., 2005) to help adults and youth re-establish a sense of 
connectedness to others, re-discover and apply their talents and life 
values--such that they don't feel that they are a burden to others, 
monitor their suicide risk using a phone app, and successfully link to 
outpatient care. Data outcomes from our program suggest statically 
significant and clinically meaningful outcomes, including reductions in 
suicidal ideation, increases in self-efficacy to prevent suicide, and 
that between 70 percent to 90 percent successfully link to outpatient 
care (compared to the national average of 40 percent). It's critically 
important to note that, because adults and youth in this program are 
experiencing care transitions, these services provided to them would be 
unbillable, and impossible, without the Federal SAMHSA grants. Knowing 
this program works is especially timely given the July 2022 launch of 
``988'' as the three-digit dialing code for the National Suicide 
Prevention Lifeline (NSPL).

    As we look toward launching 988 we must also continue to evaluate 
strategies to ensure these data-supported services are funded and 
available nationally, this is why we also support the Behavioral Health 
Services Crisis Expansion Act (S. 1902) as a crucial component to 
financing a crisis care continuum. With appropriate funding and 
resources--we know we can prevent deaths and save lives. That's why 
this grant is so important. Additionally, we encourage Congress's 
consideration of longer term, more sustainable financing mechanisms.

    As we look toward launching 988, we must continue to evaluate 
strategies to ensure these data-supported services are funded and 
available nationally. To that end, we recommend:

          Passage of the Behavioral Health Services Crisis Expansion 
        Act (S. 1902) as a crucial component to financing the crisis 
        care continuum; and

          That the final Conference Report for the fiscal year 2022 
        Labor-HHS Appropriations bill include:

                  10 percent set-aside for mental health crisis systems 
                in the Mental Health Block Grant (MHBG) program;

                  $100 million to establish the Mental Health Crisis 
                Response Partnership Pilot Program to help communities 
                create mobile crisis response teams that divert the 
                response for mental health crises from law enforcement 
                to behavioral health teams; and

                  $375 million to provide grants to Certified Community 
                Behavioral Health Clinics (CCBHCs) to provide treatment 
                for those with mental health illness.

    Ultimately, we believe that our nation's ability to respond to 
behavioral health crises in the same way we respond to other medical 
emergencies--with prompt, effective, and culturally competent care--is 
essential to our collective well-being. With the new three-digit crisis 
number becoming universally available in July 2022, it is essential to 
act quickly to fund and implement important components of the overall 
988 system.

          II. Addressing the behavioral health workforce shortage, 
        while increasing care integration/access

    There are other community behavioral health and substance use 
disorder grants that have also made a meaningful impact on the people 
we serve. For example, a program that has been a lifeline is the 
Certified Community Behavioral Health Clinic (CCBHCs) Medicaid 
demonstration and CCBHC SAMHSA grant program. Our CCBHC program also 
allowed us, when the COVID-19 Pandemic hit, to examine if our clients 
were getting good outcomes via tele-health and phone compared to face-
to-face treatment. Our evidence indicated they were, which has 
increased our continued application of telehealth throughout our 
operations to ensure patient access and outcomes.

    On the whole, Certified Community Behavioral Health Clinics 
(CCBHCs) can play a transformative role in addressing historically dire 
workforce shortages, creating a more seamless/integrated care delivery 
system, and bolstering the nation's 988 preparedness; all while 
ensuring providers meet quality metrics. Specifically, these entities 
are designed to provide a comprehensive range of mental health and 
substance use disorder services to vulnerable individuals in a single 
location. CCBHCs are responsible for providing nine types of services, 
implementing evidence-based practices, coordinating care, and 
integrating with physical healthcare services. To date, there are two 
types of this model--the grantees, which are in the pilot phase, and 
CCBHC Medicaid demonstrationsites which have permanently expanded the 
model and adopted a new payment methodologies, more akin to the FQHCs, 
to support on-going services.

    Nationally, the CCBHC model has generated the following outcomes.

          Indiana Outcomes (*Pilot/Grantee Phase)

          The CCBHC model in Indiana has helped ensure positive 
        outcomes among Centerstone clients, including:

          73 percent of adult clients reported little/no depressed 
        feelings

          93 percent reduction of clients hospitalized for mental 
        health reasons in previous 30 days

          100 percent reduction of clients who utilized an emergency 
        room for behavioral health issues in previous 30 days

          64 percent increase in adult clients reporting their symptoms 
        were not bothering them

          Illinois Outcomes (*Pilot/Grantee Phase)

          The CCBHC model in Illinois has helped ensure positive 
        outcomes among Centerstone clients, including:

                  50 percent decrease in homelessness

                  60 percent reduction of clients who utilized an 
                emergency room for behavioral health

                  50 percent decrease in nights spent in jail

    New York

          New York officials reported that CCBHCs had a 54 percent 
        decrease in the number of individuals using inpatient 
        behavioral health services, which translated to a 27 percent 
        decrease in associated monthly costs.

    Texas

                  The CCBHC model in Texas is projected to save $10 
                billion by 2030;

                  In 2 years, there were no wait lists at any CCBHC 
                clinic; and

                  40 percent of clients treated for co-occurring SUD 
                and SMI needs, compared to 25 percent of other clinics

    Missouri

                  Overall access to mental health and addiction 
                treatment services increased 23 percent in 3 years, 
                with veteran services increasing 19 percent; and

                  Missouri found a 76 percent reduction emergency room 
                visits and hospitalizations where CCBHCs were embedded 
                in those facilities. In those same CCBHC areas, 
                Missouri law enforcement saw a 55 percent decrease in 
                interactions with people with behavioral health 
                conditions.

    Additionally, data from providers across the Nation has found that 
the CCBHC model significantly addresses workforce challenges. \4\

    \4\  https://www.thenationalcouncil.org/wp-content/uploads/2021/05/
052421--CCBHC--ImpactReport--2021--Final.pdf--daf--375ateTbd56 (p. 7)

          Specifically, the payment methodology associated with CCBHCs 
        allows providers to reimburse for services they may not have a 
        direct reimbursement for--i.e., assistance with addressing 
        social determinants of health, robust care coordination, crisis 
        services, and covering positions (i.e., peer support 
        specialists) that may not be recognized by all payer types, 
        etc. Many of these non-billable services and provider types are 
        critical in providing coordinated care that results in 
        increased patient outcomes as well as a financial model that 
---------------------------------------------------------------------------
        supports the existing workforce.

                  It's estimated that as of January 2021 CCBHCs added 
                9,000 new positions nationwide; and

          On average, this resulted in 41 new jobs per clinic.

    Given the growing need for improved access, bolstered workforce, 
and assurances that consumers received evidenced based treatments; we 
support the passage of The Excellence in Mental Health and Addiction 
Treatment Act of 2021--S. 2069 led by Senators Stabenow (D-MI) and 
Blunt (R-MO) which would allow every State the option of joining the 
innovative Certified Community Behavioral Health Clinic (CCBHC) 
Medicaid demonstration and authorize grant (pilot) investments in the 
model for current and prospective CCBHCs.

    II. Expanding access to telehealth services for behavioral health 
care

    While we applaud inclusion of the telemental health services 
provision in the December 2020 end of year COVID relief package 
(Consolidated Appropriations Act of 2021, Section 123), we believe 
putting service restrictions on telehealth access for mental health 
services through in-person requirements undercuts the very tenets 
around the flexibility and access afforded by telehealth and other 
virtual care modalities. For example, under this new rule a beneficiary 
who--during the PHE was seeing a provider several hours from their home 
via telehealth--will have to now see their provider in-person, at least 
one time per year, to maintain continuity of care after the pandemic. 
This will most certainly delay or fully eliminate access to care for 
some consumers. Furthermore, the new requirement for an in-person visit 
applies only to mental health treatment, whereas Medicare beneficiaries 
seeking treatment for substance use disorder (SUD) via telehealth are 
not subject to this requirement. Given the elevated occurrence of SUD 
with mental health comorbidities, and recent reports indicating that 
2020 was the deadliest year for overdoses, \5\ this requirement 
ultimately creates new barriers which could result in significant 
delays in access to lifesaving care. Last, this requirement will 
further encumber already overworked providers to arbitrarily delineate 
between their patients on ``who gets what type of service'' based on 
diagnosis, rather than clinical presentation and best practice. This 
approach is counter to the gold standard of providing the ``right care 
at the right time'' to improve patient and population health outcomes.
---------------------------------------------------------------------------
    \5\  https://www.politico.com/news/2021/07/14/covid-pandemic-drug-
overdoses-499613
---------------------------------------------------------------------------
    With regard to program integrity--telehealth, by design, is a 
transparent and accountable means of care delivery. Technology 
platforms that provide telehealth are currently capable of capturing a 
range of data points from telehealth and telephonic encounters that can 
offer transparency to the delivery of virtual care and protect against 
fraudulent actors. Unlike in-person care, telehealth encounters 
conducted over platforms such as Electronic Health Records (EHRs) or 
other tech-enabled landscapes that automatically capture the time call 
took place, duration, patient information, and other details that can 
be used to strengthen compliance efforts. As long as the provider is 
utilizing a technology platform that records relevant data, it does 
this for every connection--making the engagements recordable, 
auditable, and actionable.

    In order to address this telemental health access gap, we recommend 
passage of The Telemental Health Care Access Act--S. 2061 led by 
Senators. Smith (D-MN), Cassidy (R-LA), Cardin (D-MD), and Thune (R-
SD). The Telemental Health Care Access Act would provide continuity in 
behavioral health care access by removing the statutory requirement 
that Medicare beneficiaries be seen in person within 6 months of being 
treated for a mental health service via telehealth.

    In summary, Federal funding works. Through these grants, our 
clients are establishing safer, better lives they are wanting to live, 
and we couldn't provide this treatment without these grants. We need to 
continue to ensure that SAMHSA grants require the implementation of 
evidenced-based services, so we can test these models and iterate based 
on lessons learned. Additionally, we need to look toward nation-wide, 
sustainable means of funding for areas where the data has indicated 
need and benefit to consumers. Broadening insurance and telehealth 
coverage for the full continuum of behavioral health services--and, in 
particular, crisis care--as well as advancing CCBHCs can play a 
transformative role in meaningfully addressing our nation's growing 
behavioral health crisis.

    Thank you for your continued focus on this important matter, if 
there are any additional questions and/or data we might be able to 
provide--please do not hesitate to reach out by contacting either 
myself or Lauren Conaboy, VP of National Policy, Centerstone at 
[email protected].
                                 ______
                                 
                [summary statement of jennifer lockman]
    As of 2020, suicide was the 12th leading cause of death in the 
United States for adults, and the 3d leading cause of death for youth. 
For every suicide death, there are approximately 1.1 million suicide 
attempts, or about one every 27.5 seconds (Drapeau & McIntosh, 2021).

    For this reason, Congress in partnership with the Substance Abuse 
and Mental Health Services Administration (SAMHSA) created the Garrett 
Lee Smith, National Strategies for Suicide Prevention, Zero Suicide, 
and Covid-19 Emergency Response suicide prevention grants.

    Through our Zero Suicide SAMHSA grant, we have updated our Suicide 
Prevention Pathway to ensure everyone in our healthcare system gets 
evidence-based suicide screening, risk management, and treatment. We 
have moved toward a new screening system that first asks about more 
``upstream'' risk factors for suicide (such as thwarted belongingness, 
perceived burdensomeness, and acquired capability for suicide; Joiner 
et al., 2005), and then asks about suicide directly (PHQ-9; C-SSRS).

    We have also piloted a suicide prevention specialty care clinic, 
the first known in Community Mental Health Centers in the United 
States. Through our grant, we are creating a referral system so that 
persons at the highest risk for suicide can be seen by providers who 
are trained in multiple suicide-specific treatments--the best that 
science has to offer.

    Our grants have also provided a Crisis follow-up program to youth 
and adults during care transitions from inpatient facilities, a high-
risk period for suicide attempts and re-attempts (Chung et al., 2017). 
Our data suggest this program helps individuals re-establish 
connectedness, decrease their sense of burdensomeness, reduce suicidal 
ideation, and successfully link to outpatient care (70-90 percent of 
the time).

    These services would be unbillable, and impossible, without the 
Federal SAMHSA grants. Knowing this program works to save lives is 
especially timely given the July 2022 launch of ``988'' as the three-
digit dialing code for the National Suicide Prevention Lifeline (NSPL).

    Another grant program that has been a lifeline is the Certified 
Community Behavioral Health Clinic (CCBHCs) Medicaid demonstration and 
CCBHC SAMHSA grant program, which allow consistent care for those with 
mental health or substance use conditions and a place to go in times of 
crisis.

    Centerstone is pleased to be one of only a few Comprehensive Opioid 
Recovery Center grant recipients in the Nation. We administer this 
grant in Indiana, where we were able to train over 467 professionals in 
evidence-based practices and open a recovery house for women.

    All the things you might take away from my testimony today please 
be sure to hear this: Federal funding works. Federal funding helps 
prevent suicide and substance-related deaths, uses program evaluation 
to help make programs better, and helps individuals recover and 
contribute in their communities. We need to continue to ensure that 
SAMHSA grants require the implementation of evidenced-based services, 
so we can test these models and iterate based on lessons learned. 
Additionally, we need to look toward nation-wide, sustainable means of 
funding for areas where the data has indicated need and benefit to 
consumers.
                                 ______
                                 
    The Chair. Thank you very much.
    Ms. Rhyneer, we will turn to you.

  STATEMENT OF CLAIRE RHYNEER, MENTAL HEALTH YOUTH ADVOCATE, 
                         ANCHORAGE, AK

    Ms. Rhyneer. Chair Murray, Ranking Member Burr, Senator 
Murkowski, and Members of the Committee, thank you for having 
me here to testify today. My name is Claire Rhyneer, and I am 
from Eagle River, Alaska. In high school, I was a storyteller 
and facilitator for mental health advocacy through 
storytelling.

    This organization is a youth led, youth founded group of 
Anchorage students working to decrease stigma and increase 
access to mental health resources. Last year, I worked as a 
program and outreach coordinator for NAMI Anchorage, the Alaska 
affiliate for the National Alliance on Mental Illness.

    I am here today to advocate for youth who have or currently 
are experiencing mental health conditions. I am advocating for 
myself, for my peers, for Alaskan youth, but also for youth 
across the Nation to give them a voice. To be completely clear, 
the people who most need the services are least able to be here 
advocating. I am representing the tip of the iceberg.

    A few years ago, I experienced a difficult and dark period 
of depression. But more than being difficult and dark, my 
experience was governed by confusion. I was self-harming and 
all I felt was uncertainty. I asked myself, do I need help? How 
should I know? I turned to Google, taking dozens of are you 
depressed quizzes. However, Google is not a doctor and is in no 
position to diagnose a middle school girl or anyone. It left me 
more confused. Each night, I wondered what was wrong, and in 
hindsight, it is terrifying to know that I was physically 
harming myself and still unsure if I needed support. What I 
uncovered online and on social media was horrifying.

    The photos, videos, and stories were disturbing, but it was 
even more disturbing to discover that I was attracted to it and 
found myself going back to it. No one bullied me or neglected 
me. From an external perspective, my life was perfect. But 
mental health was never discussed at school, at home, or even 
in my health classes beyond the, take care of yourself, get 
sleep, eat well, and exercise spiel.

    I kept telling myself everything was okay, Why should I 
feel sad? Why should I feel lost? I am so fortunate. How could 
I possibly feel this way? Ultimately, I didn't seek help 
because I didn't know if anything was wrong. And I am more than 
an anecdote. When I tell a roomful of people that I was 
confused or that I turned to Google for help, I see a course of 
nods.

    I need more than one hand to count the number of close 
friends who have experienced suicidal ideation. And barriers to 
care do not discriminate. They infiltrate every home, 
regardless of ethnicity, class, or geography. Compared to most, 
I am privileged. Finding a community of peers let me know that 
I was not alone. I was once again able to be focused on school, 
sports, my family and friends. I learned how to maintain my 
wellness. And I am proud to be able to say, I know where you 
are coming from, and this pain can be temporary and to know 
that it is true.

    The people who did not find these supports, unlike me, are 
not here. Many of them will never be able to tell us their 
story. So we have an obligation to these youth to make a 
difference. We need to support school counselors, station 
social workers in schools, fund wellness programs at 
universities, and introduce mental health curriculum into 
health classes where they belong.

    We must reflect on the way we separate academic success 
from mental well-being. We need to make care more affordable, 
and insurers incorporated into primary care and that it is 
covered by insurance. We need culturally competent health care 
workers and diversity among providers. We need to reduce 
stigma, promote early intervention, normalize mental health 
conversations early, and educate our youth, teachers, and 
parents.

    Those of us who know suicide and mental illness are 
preventable are watching the leaders of this country and 
waiting for you to do something. And the ones who think suicide 
and suffering is inevitable, they need you. Vulnerability is 
contagious and powerful.

    I am here in the hopes that my story might inspire change, 
both for all of us to work toward healthier communities, but 
also to inspire other young people who may be listening. If you 
are suffering, I urge you to speak up. Thank you.

    [The prepared statement of Ms. Rhyneer follows:]
                  prepared statement of claire rhyneer
    Chair Murray, Ranking Member Burr, Senator Murkowski, and Members 
of the Committee: Thank you for having me here today to speak from the 
perspective of a young person who understands the importance of mental 
health awareness.

    My name is Claire Rhyneer, and I am from Eagle River, Alaska. In 
high school I was a storyteller and facilitator for MHATS (Mental 
Health Advocacy through Storytelling). MHATS is a youth-led, youth-
founded group of Anchorage students working to decrease stigma and 
increase access to mental health resources through true, personal, 
short stories of mental health struggle and triumph. Last year, 
following my work with MHATS, I worked as Program and Outreach 
Coordinator for NAMI Anchorage, the Alaskan affiliate for the National 
Alliance on Mental Illness.

    I'm here today to advocate for youth who have, or currently are 
experiencing mental health conditions. I'm advocating for myself, for 
my peers, for Alaskan youth, but also for youth across the Nation to 
give them a voice.

    To be completely clear, the people who most need the services are 
least able to be here advocating. I am representing the tip of the 
iceberg.

    A few years ago, I experienced a difficult and dark period of 
depression. But more than being ``difficult'' and ``dark'' my 
experience was governed by confusion. I was self-harming and all I felt 
was uncertainty. I asked myself: Do I need help? How should I know? I 
turned to Google, taking dozens of ``Are You Depressed?'' quizzes.

    However, Google is not a doctor and is in no position to diagnose a 
middle school girl--or anyone. It left me more confused. Each night I 
wondered not only what was wrong, but if something was wrong at all. In 
hindsight, it is terrifying to know that I was physically harming 
myself and still unsure if I needed support. No one bullied me or 
neglected me. From an external perspective, my life was perfect. I was 
getting good grades, my parents loved and cared for me, and I had 
friends I could talk to. But mental health was never discussed at 
school, at home, or even in my health classes, besides the ``take care 
of yourself, get sleep, eat well, and exercise'' spiel.

    In the absence of relevant information, I turned to online 
communities. What I uncovered on social media was horrifying. I could 
find images, drawings, stories, even videos of intense self harm. It 
was disturbing to find, but it was even more disturbing to discover 
that I was attracted to it and found myself going back to it.

    I still cannot look back at the journal entries from those years, 
but I know I wrote down ``I don't know what is happening to me'' over 
and over and over again. I kept telling myself everything was okay. Why 
should I feel sad? Why should I feel lost? I'm so fortunate, how could 
I possibly feel this way? Maybe I'm making this all up in my head, I 
thought.

    Ultimately, I didn't seek help because I didn't know if anything 
was wrong. I didn't believe myself. It's like having a broken leg and 
telling yourself that you're just imagining the pain, it will go away 
on its own, and there's no bother in telling anyone because it's 
probably not a real problem. I told myself my self harm was just for 
attention.

    I am more than an anecdote. When I tell a roomful of people that I 
was confused, or that I turned to Google for help, I see a chorus of 
nods. I can count on more than one hand the number of close friends who 
have experienced suicidal ideation. Starting in middle school, there 
were nights when I wasn't sure if I would see my friend the next day at 
school.

    In suicide prevention, we emphasize that there is no one reason 
that someone dies by suicide. There are always a multitude of factors. 
Not only do college and university therapy offices have months-long 
waitlists, but private practitioners are cost-prohibitive and aren't 
covered by insurance. High school counselors are scarce and ill-
equipped. Many youth never even reach the point of asking for help. 
They are like me. They doubt and diminish their experience. They don't 
believe anything is wrong. They're scared to reach out. They're worried 
about what their community will say. They think their family will crack 
jokes or not take them seriously. They expect their parents to blame 
themselves. They're afraid they'll be seen as ``weak,'' ``crazy,'' 
``attention-seeking,'' ``wacko,'' ``broken,'' or a ``lost cause.''

    These barriers to care do not discriminate. They cross every border 
and infiltrate every home, regardless of race, class, or geography.

    However, living in Alaska poses unique challenges. First, Alaska's 
dark winters make SAD (Seasonal Affective Disorder) more prevalent. In 
areas near the equator, only 1 percent of the population experiences 
SAD. In Alaska, that number is closer to 10 percent. Second, the 
generational trauma our Alaska Native populations suffer from 
colonization contribute to higher rates of substance use and mental 
health conditions. Third, the prevalence of guns in Alaska generate 
higher suicide rates. Alaska Native men between the ages of 15-24 have 
the highest rate of suicide among any demographic in the country. 
Fourth, providers are few and far between, especially in rural areas 
and small villages. Youth who need services must fly 2 hours away from 
their home, leaving behind their family and support systems. While 
tele-health has become more accessible, good weather, power, wifi, and 
service are not guaranteed. Fifth, the services Alaska does have are 
limited. They are overwhelmed, underfunded, and exhausted. While I 
worked at NAMI, I had to tell people they would be on a waitlist for 9-
12 months before they'd receive care from a case worker. It would be 3 
months before the patient would even be contacted to confirm they were 
accepted as a patient. It would be another 6 months after that before 
they could talk to a case worker and begin care. And last, 
transportation is especially onerous in Alaska, even in its central 
hub, Anchorage. People who signed up for NAMI recovery programs 
canceled after they realized it wasn't virtual. They couldn't afford 
transportation for the few miles between their home and our centrally 
located office building.

    The Covid-19 pandemic exacerbated and introduced new issues. During 
typical high school classes, a teacher is one of the first lines of 
defense. They can catch changes in a student's behavior, performance, 
and attitude. But during zoom classes, I stared at a screen of gray 
squares. Questions from the teacher were met with silence. Teachers 
found fewer opportunities to ask, ``Hey, are you okay?'' ``How are 
things going at home?'' ``You seem a little off, is there anything you 
want to talk about?'' Furthermore, during the first year of online 
school, student support programs disappeared. Suicide prevention 
trainings and presentations were put on hold. General clubs moved 
online and lost attendance. Sport games and races barred spectators and 
family members. Students in unsafe families couldn't find the security 
they typically found at school.

    Compared to most, I am privileged. In my Junior year, I was 
introduced to YANA (You Are Not Alone) Club, suicide prevention 
trainings, and MHATS. It was my own friends at MHATS who taught 
curriculum related to mental health and helped me tell my story. It's 
because of these resources and education that I opened up to my parents 
last year. I am now able to be focused on school, on sports, on my 
family and friends, and maintain my wellness. I am proud that I am now 
able to point my friends in the right direction when they express 
similar feelings. I am proud to be able to say ``I know where you're 
coming from,'' or ``I know how that feels.'' I am proud to be able to 
say ``this pain can be temporary'' and to know that it is true.

    But this is only true because of the education and support I 
received. We need to support school counselors, station social workers 
in schools, fund wellness programs at universities, and introduce 
mental health curriculum into health classes where they belong. We must 
reflect on the way we separate academic success from mental well-being. 
We need to make care more affordable, ensure it's incorporated into 
primary care, and that it's covered by insurance. We need culturally 
competent health care workers and diversity among providers. We need to 
reduce stigma, promote early intervention, normalize mental health 
conversations early, and educate our youth, teachers, and parents.

    We cannot be satisfied with allowing our children and youth to be 
educated by mental health through social media and searching online. We 
cannot be complicit in allowing my friends and classmates and your kids 
and neighbors to suffer in silence. We cannot knowingly let our 
students experience the confusion, doubt, and harm that I felt.

    I am here because I am a privileged voice. The people who are 
failed by this system aren't here. They can't be. They are busy going 
to school, they are caring for their families, they are working 
multiple jobs. They are searching ``Am I depressed?'' on Google and are 
self harming in their bedroom. Their friends are filling in as 
therapists, sacrificing their own well-being to listen and support.

    Those of us who know suicide and mental illness are preventable are 
watching the leaders of this country and waiting for you to do 
something. And the ones who think suicide and suffering is inevitable? 
They need you.

    Thank you for inviting me to testify. I would not have been here 
without my peers at MHATS, the people at NAMI, my parents, and the 
friends and family who have been generous enough to share their stories 
with me and the rest of the world. Vulnerability is contagious and 
powerful. I'm here in the hopes that my story might inspire change--
both for all of us to work toward a healthier community, but also to 
inspire other young people. If you are suffering, I urge you to speak 
up. Thank you.
                                 ______
                                 
                 [summary statement of claire rhyneer]
    In high school, I was a storyteller and facilitator for MHATS 
(Mental Health Advocacy through Storytelling). MHATS is a youth-led, 
youth founded group of Anchorage students working to decrease stigma 
and increase access to mental health resources through true, personal, 
short stories of mental health struggle and triumph.

    Last year, following my work with MHATS, I worked as Program and 
Outreach Coordinator for the Alaskan affiliate of the National Alliance 
on Mental Illness (NAMI) in Anchorage.

    I am here today to advocate for youth who have or currently are 
experiencing mental health conditions. I am advocating for myself, for 
my peers, for Alaskan youth, but also for youth across the Nation to 
give them a voice.

    Mental health was never discussed at school, at home, or even in my 
health classes, besides the ``take care of yourself, get sleep, eat 
well, and exercise''.

    I didn't seek help when I was experiencing mental health issues, 
because I didn't know if anything was wrong. I did not believe myself. 
I told myself my self harm was just for attention.

    The Covid-19 pandemic exacerbated and introduced new issues. During 
online school, teachers found fewer opportunities to ask, ``Hey, are 
you okay?'' ``How are things going at home?'' ``You seem a little off, 
is there anything you want to talk about?''

    At school, I was introduced to YANA (You Are Not Alone) Club, 
suicide prevention trainings, and MHATS. It is because of these 
resources and education that I opened up to my parents last year.

    I am now able to focus on school, on sports, on my family and 
friends. I learned how to maintain my wellness.

    We need to support school counselors, trained social workers in 
schools, fund wellness programs at universities, and introduce mental 
health curriculum into health classes where they belong. We must 
reflect on the way we separate academic excellence, success and mental 
well-being. We need to make care more affordable, ensure it's 
incorporated into primary care, and that it is covered by insurance.

    We need culturally competent health care workers and diversity 
among providers. We need to reduce stigma, promote early intervention, 
normalize mental health conversations early, and educate our youth, 
teachers, and parents.
                                 ______
                                 
    The Chair. Thank you very much. I want to thank all of our 
witnesses, but Ms. Rhyneer, thank you so much for your very 
compelling personal story, your courage, and you are making a 
difference. We all appreciate it. With that, we are going to 
begin a round of 5 minute questions. I again ask my colleagues 
to keep track of the clock and stay within those 5 minutes.

    I will begin with Dr. Prinstein. And as we all know, the 
last 2 years have been incredibly difficult in so many ways, 
but especially on children and youth. They have faced huge 
disruptions in their own lives. They have lost loved ones, 
including their parents. They have missed out on valuable time 
with their friends and teachers.

    It has become so dire that some of our leading experts have 
declared a ``national emergency'' when it comes to child and 
adolescent mental health. You know, as a mother, myself, a 
grandmother, and as a former preschool teacher, I am really 
worried about our kids right now. And we just heard very 
compelling story from one of them. I know parents from my home 
State of Washington all the way to here to the Capitol are 
really concerned about this.

    I think it is really important to address the effects of 
trauma, substance use, grief, and other stressors on our kids. 
And I wanted to ask you today to talk with us about the best 
practices for identifying trauma and other stressors among our 
children.

    Mr. Prinstein. Thank you. We have a number of assessment 
tools that we can use to screen kids and to understand what 
their experiences may be or even before they experience a 
crisis. We need the support to be able to launch those tools 
and also to do research to examine how we can use technology to 
really make the most use of the kinds of passive screening or 
opportunities to intervene and offer mental health tips, 
anything that we can do.

    In particular, this is really important when we think about 
underserved and underrepresented youth. It is absolutely 
critical that we are discussing mental health in schools that 
we are building into our curriculum social emotional 
competence.

    We have the tools to build kids' resilience. We just need 
the opportunity to be able to teach what we know to all of 
those teachers and counselors and administrators so we can help 
them to identify kids before they reach a moment of trauma.

    The Chair. Thank you. Dr. Durham, Dr. Goldsby, I want to 
talk about inequality within our health care system. It has 
really led to disparities in our health care access and 
outcomes and resources, and behavioral health is obviously no 
exception. When trying to get care, people of color often face 
systemic barriers and are less likely to complete treatment or 
even get appropriate services. Individuals with disabilities 
are five times more likely to have mental health needs, often 
can't find providers to get the care they need.

    Meanwhile, in our rural communities, we face significant 
provider shortages, and members of the LGBT community are more 
likely to experience mental health and substance use disorders. 
So as this Committee now considers legislation to improve 
mental health and substance use disorder outcomes, we have to 
do everything we can to address those disparities.

    Dr. Durham, I wanted to start with you. Your work is at a 
safety net hospital, and you see parents experiencing--patients 
experiencing mental health and substance use crisis. What 
barriers to care do your patients experience and how do they 
impact behavioral health outcomes and access?

    Dr. Durham. Thank you, Senator Murray, for that question. 
You described a lot of things in your opening statement that 
are inequitable in substance use and mental health treatment in 
general. I think largely what many of us, as witnesses have 
said during our testimony so far, is that there is a huge 
inequity in just the workforce issue. Having mental health 
providers that maybe don't want to work with people with 
substance use issues, having folks with--that focus on 
substance use issues that don't want to work with the mental 
health aspect of the patient.

    I think that adds a complexity when people want to go for 
care that they have to go to many different providers to get 
the treatment that they need. We need to stop siloing in health 
care in general and in the mental health care. This distinction 
that our physical health is separated from our mental health.

    We see often that people get lost because they go from one 
provider to another trying to get the treatment they need and 
deserve, and they can't find one provider to do all of those 
things. The second thing I would say is that just in general, 
getting access to care is very hard for our patients. There are 
a lot of barriers when we start thinking about what substance 
use treatment programs only want to give medication versus 
thinking about other psychotherapeutic interventions.

    How people get into treatment is very difficult sometimes. 
Unfortunately, providers will say, well, you need to go to the 
emergency room intoxicated to get a detox bed. If not, they are 
not going to accept you.

    This is the reality of how patients get treatment in the 
system because of bed availability, because of the way 
reimbursement happens, because of the way insurers operate. And 
last but not least, I do want to think about how do we think 
about substance use in general, the inequity in that.

    I think it is probably the only disorder that we consider a 
crime. You can get stopped, you can get pulled over for simply 
using or possessing this, and we don't treat it like other 
mental health or physical health issues. I do believe it is a 
brain illness. It is chronic. It is relapsing and remitting. 
And it deserves the full treatment like anybody with diabetes, 
hypertension, or any other condition.

    The Chair. Thank you. And I am out of time with Goldsby. I 
am going to come back to you, if I can, later on to ask you 
that question. And I will turn it over to Senator Murkowski.

    Senator Murkowski. Thank you, Madam Chair. Claire, thank 
you. Thank you for your testimony. Very, very compelling and 
thank you for your voice, your leadership in this very 
important area.

    I recall a visit that I made out to rural Alaska some years 
ago. It was a town hall meeting with Native leaders and young 
people from neighboring village had come to the town hall and 
asked to be recognized, and they raised the issue of suicide. 
None of the adults in the room wanted to talk about it.

    The young people, one young man said suicide is becoming 
normal within our village as far as the youth were concerned, 
which was shocking and troubling. But it was almost as if there 
was a generational disconnect. The kids wanted to speak about 
it, needed to speak about it, and the elders in the room were 
afraid. They were afraid, I believe, that if they spoke about 
it, it might be encouraged.

    You have been involved in suicide prevention trainings in 
school, peer to peer. Share with me a little bit, if you will, 
and the Committee, not only the importance of increasing access 
to these trainings and the recommendations for how we can reach 
out to kids, because again, it is younger--it seems younger and 
younger children are feeling these sense of depression and 
despair and crisis and suicidal ideation.

    It is important how we speak to one another so that it is 
heard. Can you address how we can provide for more in the 
curriculum that is actually meaningful to kids? How can we 
provide for counselors who understand how to speak the 
language? Because I fear that there is a disconnect there.

    Ms. Rhyneer. Absolutely. Thank you. Yes, suicide is a huge 
issue in Alaska and actually one thing Alaska does the CUBS 
Behavior Survey, and they show that the percentage of students 
attempting suicide has grown significantly in the past few 
years. So in 2019, 25 percent of all students in the school 
district seriously considered suicide and 20 percent of them 
attempted--20 percent of them attempted it, and so that is one-
fifth of my classmates. But like, how many parents do you think 
knew about it? Do you think one-fifth of parents really knew 
that their student had seriously attempted suicide?

    One thing that prevents students from talking about it is 
honestly the stigma that parents have. So they never even reach 
the point of asking me out or asking for help because they 
doubt and diminish their experience. They don't believe 
anything is wrong. They are scared. They think their family 
will crack jokes or not take them seriously, or they expect 
their parents to blame themselves.

    They are afraid they will be seen as weak or crazy or 
attention seeking wacko, broken, a lost cause, any of those 
things. So reducing stigma in general, one of those things that 
we can do. Like in Alaska, what we are trying to do is pass a 
bill that would help bring mental health education into K-12 
schools. So by talking about mental health in schools, 
specifically in health classes, we begin conversations early 
and allow space for people to share.

    Health classes currently cover topics like nutrition and 
physical health, exercise, dental health, all these sorts of 
things, cancer prevention, and so mental health deserves to be 
a topic in one of those classes. It is just as important. And 
guidelines for this kind of curriculum would be developed with 
local and statewide and national agencies to make sure we are 
safe and age appropriate.

    Of course, we wouldn't be teaching the same thing to high 
schoolers as elementary school kids, but it would help see 
symptoms and recognize them, and then what to do about them and 
reach out for help. So that is one really important thing.

    Also, in terms of suicide prevention, just like clubs like 
you are not alone club, that those suicide prevention trainings 
in schools and goes around to classes and talks about it. That 
is a really important thing, too. So all of those things 
working together.

    Senator Murkowski. Thank you, Claire. Madam Chair, I am 
almost out of time, but I think every one of the witnesses in 
one way or another has talked about the need for workforce, and 
whether it is school counselors, those that can work with kids 
in programs, or whether it is all the way to the other end with 
a full psychiatric care that is available.

    My hope is, is that we build out a package of focus on 
mental health. We really key in on the workforce issues because 
I think we recognize that in all our States, we are sorely, 
sorely lacking.

    The Chair. Thank you very much. I look forward to working 
with you on that. Senator Casey.

    Senator Casey. Chair Murray, thank you for the hearing. And 
I want to thank you and Senator Murkowski and Ranking Member 
Burr, and of course our witnesses. I want to start with 
Director Goldsby with a question regarding plans of safe care.

    This is an issue I have worked on for years to support both 
infants and families affected by substance use disorder. We 
know that infants and their parents need what I think most 
would refer to as non-punitive services, as well as treatment 
and support as parents navigate both recovery and parenting a 
young child. But despite longstanding Federal law, plans of 
safe care remain very much underutilized.

    I appreciate the work of this Committee in the CAPTA 
legislation and authorization over time to address some of the 
issues that have contributed to these plans of safe care being 
underutilized.

    Too many families are slipping through the cracks, and so 
in particular, I appreciate the effort to establish a reporting 
mechanism when an infant needs a plan of safe care that is 
separate from the child welfare system.

    But Director Goldsby, I would ask you, what steps can we 
take in Congress, especially here in the Senate, to help States 
and communities adopt public health driven approaches to 
substance use in both pregnancy and as well as to reach more 
families in need of support?

    Ms. Goldsby. Senator Casey, I am glad you asked. You know, 
I think thanks to the work of this Committee and CAPTA work 
that we have underway. We are currently engaged in some in-
depth technical assistance with my agency and our South 
Carolina social services agency as we work hand in hand to 
develop a plan to address your exact concern.

    Our Plan of Safe Care Workgroup is focusing on moving 
intervention services upstream, a more public health approach 
to support all pregnant individuals who might or may or may not 
have a substance use issue. But the screening earlier, having 
that universal screening brief intervention and referral to 
treatment for everyone earlier in pregnancy and often in 
pregnancy really minimizes additional prenatal substance 
exposure.

    We have decided to call our plan of safe care a family 
wellness support plan because our aim will really be to 
initiate that prenatal plan sooner and as soon as the mother is 
identified, either with toxicology or the screening, so that we 
are offering a non-punitive, supportive set of services across 
our systems to include mental health and substance use 
treatment and all the wraparound services.

    For some who have severe substance use diagnosis, this plan 
might include a referral to one of our family care centers, 
which is our residential treatment centers for women and 
children that are supported by the Substance Abuse Prevention 
and Treatment Block Grant, so that mothers can really stay 
engaged in services and supported through the delivery of their 
child. And that way, health care providers know that they are 
engaged, know that they are in treatment.

    This is all going to lead to more likely results of family 
remaining unified at the time of delivery so that the mother 
and the children can continue on in that residential treatment 
or be discharged home to community based services.

    But a lot of education has to be done among our health care 
community for them to understand that, like we mentioned, 
substance use disorders is not a moral failing, but is a health 
care issue, a disease State, and that people with mental health 
and substance use issues really shouldn't be further 
stigmatized but assisted.

    I will just note that all of this work is supported by our 
Pregnant and Parenting Women program through SAMHSA, our expert 
work supported by SAMHSA discretionary grants and, of course, 
our Block grant.

    Senator Casey. Director, thank you for your work, and I 
appreciate your answer. I wanted to turn to Dr. Prinstein. On 
page 16 in your testimony, you note that implementation of 
integrated care, where primary care and behavioral health care 
providers work as a team, remains unfortunately limited.

    While there are a lot of models that integrate physical and 
mental health care, many physicians still don't have the 
ability to seamlessly connect patients to a mental health 
provider.

    You mentioned some of the barriers, whether it is physical 
space or IT issues or clinical staffing. What should we do in 
terms of our focus to help more primary care providers move 
toward integrated care, and how can telehealth support the 
shift?

    Mr. Prinstein. Thank you. Integrated care is, in fact, an 
excellent way to go. As we just heard before, it is very hard 
for people to find a health care provider and a mental health 
care provider. And due to stigma, sometimes even pursuing that 
in person is difficult.

    But walking into your physician's office is not attached to 
stigma. Three things to remember with integrated care. One, it 
is a lot more than just sticking to mental health care provider 
into the office of a physician.

    This is really about the time and the funding that is 
required for cross training so that way physicians and mental 
health care providers can speak different language--each 
other's language, share records, share billing processes. These 
are usually not the traditional 1 hour sessions with the mental 
health care provider, so new billing processes are needed.

    Two, substantial infrastructure costs are required to 
successfully integrate the integrated behavioral care, to 
implement that. So it is important to incentivize physicians to 
do so. And finally, a one size fits all approach is just not 
going to work with integrated behavioral care.

    We have evidence that all approaches can be very effective, 
and primary care providers needs to be the folks to decide how 
best to set it up in a way that meets their needs, their 
patients, and their community.

    Senator Casey. Thank you, Doctor. Thank you, Chair Murray.

    The Chair. Thank you.

    Senator Collins.

    Senator Collins. Thank you, Madam Chair. Dr. Prinstein, I 
want to discuss with you the impact that the prolonged COVID 
pandemic has had on our children's mental health. I was struck 
by two recent columns and the New York Times, written by David 
Leonhard, in which he makes the point very well. He writes, 
``the pandemic's disruptions have led to loss learning, social 
isolation, and widespread mental health problems for children.

    Many American children are in crisis''--and here is the 
important point--``as the results of pandemic restrictions 
rather than the virus itself.'' We know, as Senator Murray has 
mentioned, that three medical groups representing pediatrics, 
child psychiatrists, and children's hospitals have recently 
declared a national emergency in child and adolescent mental 
health.

    The New York Times columnist has concluded that remote 
schooling has failed and that there is little evidence that 
shutting schools leads to fewer COVID cases among children.

    Given that the pandemic has persisted for 2 years, which is 
a good portion of many children's lives, what should we be 
doing as policymakers to balance pandemic response policies 
with the serious concerns that many parents have expressed to 
me about their children's--the impact on their children's 
mental health, the social isolation, the remote learning, the 
restricted activities that they are seeing directly are harming 
their children's social and mental development?

    Mr. Prinstein. Thank you for raising that, Senator Collins. 
APA joined with HIA and AAP in declaring that national 
emergency, and we agree. The science is telling us that kids 
are experiencing mental health difficulties for a whole host of 
reasons. One is, of course, the major stressor that has 
occurred in their lives. They are watching relatives that are 
passing away or being so ill that they need to go to the 
hospital. They have tremendous disruption of their roles and 
routines.

    They see polarization in leaders with disagreements between 
parents and schoolteachers on what it is that they are supposed 
to do. And they are having a very difficult time also with 
social isolation, but not necessarily because of the isolation 
per se, but because of the time that kids are spending on 
social media instead, which we now know has incredibly 
dangerous effects not only on kids development but on the 
development of kids' brains during that time.

    This is a very big issue and very concerning. It also is an 
opportunity. This is a time when we have people talking about 
mental health like they have never talked about before, and 
people are recognizing the need for us to be addressing mental 
health before it reaches the acute crisis, excuse me, of people 
needing to go and get outpatient or inpatient treatment.

    This is an opportunity for us to really build into the 
fabric of how we educate, how we talk within our communities, 
the importance of mental health and resilience programs. Our 
entire mental health system right now is built for adults. It 
is built also for people who are already at the point in a 
crisis and need treatment. That is not what the science 
suggests. What we could be doing now and what this presents us 
with an opportunity to do is to pay attention to all of those 
folks who are at risk or who have not even shown any 
psychological symptoms yet and build the resilience necessary 
to ensure that they will never need outpatient or inpatient 
treatment.

    That is what we are seeing with kids right now. There is a 
wide openness to talking about these issues, and kids, just as 
Ms. Rhyneer was talking about so eloquently, want us to step up 
and teach them information about mental health so they can 
learn the skills before they reach a crisis point.

    Senator Collins. Thank you. Dr. Goldsby, my time is almost 
expired, but an estimated 636 people in Maine died from drug 
overdoses last year. That is a terrible and alarming record 
high.

    But what it obscures is the actual number of overdoses 
which was in the neighborhood of 8,000 overdoses in the State 
of Maine, where thanks to the heroic efforts of first 
responders, medical professionals, and sometimes bystanders, 
they were saved.

    How can we ensure that non-fatal overdose patients are not 
just a statistic, but receive the care that they need to 
prevent a subsequent and potentially fatal overdose?

    Ms. Goldsby. Senator Collins, we talk about overdose 
reversal in South Carolina as an intervention. And it is in 
that moment when somebody has faced a life threatening 
situation that they may be best reached by someone who offers 
them hope, hope to live, hope to a path to recovery, and I 
think those intervention services are key as we do more 
outreach, as we have our first responders saving lives, taking 
advantage of this critical crisis moment to engage people in 
services that will lead them on a path to long term recovery.

    That can look at a number of ways with a number of 
different programs, but I think it is taking advantage of that 
moment, that lifesaving moment that we really engage in 
treatment services.

    Senator Collins. Thank you.

    The Chair. Thank you.

    Senator Baldwin.

    Senator Baldwin. Thank you, Madam Chair. In 2019, I 
introduced the bipartisan National Suicide Hotline Designation 
Act, which was signed into law in 2020. Converting from the 
existing 10 digit number to 9-8-8 will make it easier for 
Americans to get the help they need, and I am proud of the 
investments included in the American Rescue Plan to support 
this transition.

    Dr. Lockman, as you know, the 988 dialing code will be 
available nationally for calls, texts, or chat beginning in 
July 2022. What else should we be doing in Congress right now 
to make sure that the lifeline is equipped to facilitate real 
access to care? And how can we make sure that the lifeline 
reaches those in greatest need, including our LGBTQ youth?

    Ms. Lockman. Thank you so much for that question and thank 
you for your support. As you know, the advent of 988 opens up a 
whole new opportunity for people to have ready access to mental 
health care providers and paraprofessionals in ways that they 
haven't before. There is a couple of things that I think of in 
terms of what we can do to make sure that we are prepared for 
this transition.

    The first one is to make sure that everyone has access on 
the crisis hotline to the very best in training. We know that 
the science advances so fast and there needs to be continued 
training and retraining to make sure we are using the very best 
practices to take care of people. For example, we rarely use 
language such as committed suicide anymore because it denotes 
that it is a crime. Instead, we say, died by suicide, and that 
is important for someone to know.

    We also talk about things such as it is important to not 
die, not just for the sake of not dying, but for the sake of 
having time to transition to recovering the life that you 
really want to live. So one thing is making sure that there is 
continued investment and support and making sure that every 
single person, whether you are the person that they call or 
that they text, is ready and equipped to provide evidence based 
practices, interventions, and the language around suicide, 
safer care.

    The other thing that I think about in terms of making sure 
that everyone is equipped to reach a care provider who cares 
about them, including our LGBTQ community, is making sure that 
we are using inclusive language and the messaging around 988 
and making sure that everyone knows that they have a safe place 
to go when they are talking about suicide.

    We have seen in our own SAMHSA grant programs, including 
serving this community, that talking about connectedness, 
talking about mental health wellness, talking about meaningful 
living, and as others have testified, moving the language more 
upstream to where everyone has a place to grow and become their 
very best self, this language is likely as important as talking 
about reducing suicide.

    Thank you for your attention to this very important 
transition. The third thing I will say is that we need to make 
sure that we are building out the entire crisis continuum. 988, 
as we know, is the starting place.

    But there also are plans to go into making sure that our 
mobile crisis services are well-equipped and well-trained, and 
also making sure that we are standing up other crisis 
infrastructure. For example, and there is over 600 CSUs, or 
Crisis Stabilization Units, operating in the United States 
right now. That provides a really important and critical part 
of the crisis continuum to make sure that there is diversion 
from emergency Departments.

    The emergency Departments are wonderful in terms of being 
able to, when people are well-trained, to address and prevent 
suicide. But CSUs have a different model. They have a living 
room model to where you are coming in and treated from a 
standpoint of recovery from the beginning, and also treated 
with peer support, with a focus on growing and wellness and 
recovering from suicide or substance abuse or other host of 
other concerns.

    I thank you for your support and making sure that we are 
building out the entire continuum to make sure that someone 
reaches someone well-trained who can respond to their immediate 
need, but also can put them on the path to long term growth, 
wellness, and well-being.

    Senator Baldwin. Thank you. Dr. Prinstein, it sounds like 
you would like to also reply. Please do.

    Mr. Prinstein. Thank you. I have spent the last 22 years 
doing research on suicidal youth, those who are at most risk, 
and thank you so much for the work you have done to establish 
988. It is incredibly important that when folks call, of 
course, they are getting treatment that is likely to work.

    We now only have science to support one approach to 
treatment, and the vast majority of folks are not trained in 
that approach. It is very, very important that we increase the 
training of providers. In addition, it is important that we 
have culturally competent providers, so folks are able to call 
and understand the embeddedness of suicidal thoughts within 
their communities.

    When I have done that research, we found that suicidal 
participants would call 10, 12 outpatient providers and not be 
able to find anyone who would take their case. We need more 
people trained in suicide.

    We need more people trained to deal with the scientifically 
evidence based approaches to suicide, in particular. Happy to 
help in any way that we can.

    The Chair. Thank you.

    Senator Cassidy.

    Senator Cassidy. Thank you all. Dr. Durham, great to see 
you.

    Dr. Durham. Great to see you as well.

    Senator Cassidy. For my colleagues, Dr. Durham is a former 
student, and despite my training, heard has done very well.

    [Laughter.]

    Senator Cassidy. And is the only one in the room who 
recognizes that I am wearing a Mardi Gras tie and trained in 
New Orleans. Everybody else thinks I can't match colors. Dr. 
Durham, you mentioned you opened a 56 bed facility. Now, I 
understand that Massachusetts has a waiver from the IMD 
exclusions.

    IMD, which says that you can only have 16 beds in your 
facility. And the issue here is both cost, but the perception 
of going back to the bad old days when we just put people in a 
big warehouse of the mentally ill and not let them out.

    But you mentioned as a positive that you are going beyond 
the 16 beds to 56 beds. Can you speak to the importance of that 
waiver or that ability to go above 16? Because I assume these 
are Medicaid patients?

    Dr. Durham. Yes, many of them will be--thank you, Senator 
Cassidy. Again, good to see you as well. Many of them are 
Medicaid, Medicare, and we do see a very small number of 
privately insured folks at BMC. But the--BMC is a large safety 
net hospital for the city of Boston and beyond Boston, and we 
have never had our own inpatient psychiatric unit.

    That has caused increased boarding in our own psychiatric 
emergency room, in our emergency room period, for decades. So a 
big investment of the hospital is like where do we send our 
patients who are on Medicaid or Medicare, because many of the 
facilities in and around Boston are also full in at capacity? 
And so it was an investment for our patients essential.

    Senator Cassidy. So just to be sure, unlike the kind of 
stereotype and the criticism that if you go beyond 16 beds you 
are just warehousing, here, you find that you are able to 
provide needed services that otherwise would not be available, 
correct?

    Dr. Durham. I am not familiar with what you are talking 
about exactly, but what I can say is that we do need a 
continuum of care for mental health.

    Senator Cassidy. Sounds good.

    Dr. Durham. So we need investment in community, in 
intermediate resources, and in inpatient level of care, so 
across the continuum.

    Senator Cassidy. And over 16 beds allows you to get an 
economy of scale as well as to provide more services. I will 
add that editorial because that is something for we 
policymakers to consider just to say that.

    Dr. Lockman, in your full testimony, you mentioned the 
telemental health bill that we are trying to push out, and can 
you kind of comment upon the ability of allowing telemental 
health to address the person power shortage of providers that 
was previously referred to?

    Ms. Lockman. Absolutely. So when the pandemic hit at 
Centerstone, we had never used telling mental health widely, 
and we couldn't actually find research to understand the degree 
to which it would be effective, particularly in our population. 
Our population has a lot of community based needs, a lot of 
psychosocial barriers, and there was a great need to be able to 
reach them quickly.

    We have done our own research in terms--and actually in 
part through the SAMHSA grant, so we are so thankful for that 
Federal funding. And we have seen that providing services via 
phone or telehealth has about the same outcomes as being seen 
face to face.

    This has allowed us incredible mobility during the time of 
the pandemic. It has allowed our providers to see more 
patients, and it has also allowed more people to come and have 
better access to care that really transverses a lot of 
psychosocial barriers.

    Senator Cassidy. I am running out of time. To cut to the 
chase, you would highly recommend that Congress pass my bill.

    [Laughter.]

    Ms. Lockman. We highly support telehealth services and 
phone based services for mental health services.

    Senator Cassidy. Sounds great. Dr. Prinstein, you highlight 
the importance of programs such as the programs for children 
with a serious emotional disturbance, which Senator Murphy and 
I were able to get passed as part of a bigger piece of 
legislation. And the Community Mental Health Block Grant 
targeting funds that children with serious emotional 
disturbances.

    Now we have heard from States that because it is perceived 
in the regs that the child has to have a diagnosis of serious 
emotional disturbance before they would qualify to benefit from 
these funds, that we should make it clear that the funds could 
be used for preventive services to prevent a child from 
developing SED, if you will. Any comment on that?

    Mr. Prinstein. Yes. First of all, thumbs up on the toll the 
Mental Health Improvement Act. Excellent. Science supports that 
that is working.

    Second, yes, there is a huge backlog right now for folks 
who are waiting to get an individualized education plan from a 
school psychologist, sometimes waiting years until they can get 
that diagnosis so they can access those funds.

    I agree that having the ability to access funds for 
preventive services would be fantastic.

    Senator Cassidy. Okay, I am almost up. Now, Mr. Rhyneer, 
thank you so much for what you do. As someone whose family has 
being affected by suicide by a young person--I am sorry to be 
emotional.

    Thank you.

    I yield back.

    The Chair. Thank you.

    Senator Murphy.

    Senator Murphy. Thank you to this tremendous panel. Thank 
you, Madam Chair, for convening this hearing. Thank you, 
Senator Cassidy, for your heroic work, standing up for people 
with mental illness and learning disabilities. And if I can 
just for a moment lift up a piece of legislation that Senator 
Cassidy and I worked on and this Committee supported, we passed 
legislation through this Committee making real the mental 
health parity legislation that Congress passed decades ago.

    The reality was we told plans to cover mental health just 
like you cover health the rest of the body, but it didn't work 
out that way. Plans ended up putting up all sorts of barriers 
and bureaucracy and red tape in front of getting reimbursement 
for mental health that they didn't for an orthopedic procedure 
or an operation on your heart or lungs.

    One of the things we did a few years ago is require the 
Department of Labor and Department of Health and Human Services 
to do an audit of a select group of insurance plans. And we 
just got the report. It is both defeating and encouraging. It 
basically came to the conclusion that not a single insurance 
plan that they reviewed was in full compliance with parity.

    But through these audits, they actually got the plans to 
change their practices and parameters such that now tens of 
thousands of mental health consumers are now actually getting 
what they paid for when they paid their insurance premiums. You 
know, an example is one insurance plan was covering nutritional 
therapy for diabetes, but was not covering it for anorexia, 
bulimia, or binge eating.

    Another example was a plan was requiring prior 
authorization for all outpatient procedures for mental health 
and substance abuse but was not requiring it for a broad range 
of orthopedic procedures.

    We are finally getting this right, and I wanted to maybe 
pose this question to you, Dr. Durham, to talk a little bit 
about your experience in dealing with insurance companies and 
families who are trying to get reimbursement, and the 
differences that you see in a big medical system in the way 
that barriers are put up when it comes to mental health and 
substance abuse that just don't exist when you are going to get 
the follow-up treatment on an operation on your knee.

    I think we are making progress here thanks to this 
Committee, but I think we still have a long way to go.

    Dr. Durham. Thank you, Senator Murphy, for your question. I 
agree completely that none of this is new to us that are on the 
front lines that are serving patients day in and day out. 
That--I have not read the report fully, but I understand that 
all in all that insurers are not allowing us to treat people 
with the best evidence and at all times, whether that is 
medication, whether that is therapy, whether that is trying to 
get them into another facility for more intense care.

    What happens in our emergency room, for an example, is that 
we do have to get what we call a prior off, prior to sending 
someone to an inpatient psychiatric facility. You would never 
do that with someone who comes in with a heart attack to the 
emergency room. They immediately go and get the help they need 
on the medical floor and no questions asked.

    We spend hours, sometimes, our social work colleagues, 
ourselves, our case managers in the emergency room just trying 
to get someone placed, and at times to the level of where 
someone like me as a physician has to do a doc to doc to 
essentially say our case, why do we want this patient to go 
into an inpatient psychiatric unit?

    There are times where we are denied, and we have to figure 
out another level of care. In the outpatient world as well. I 
am a child psychiatrist and I see kids in the clinic, and I 
have been on the phone with an insurer as well when a 
medication adjustment needs to be made for hours.

    My time in the clinical setting, where I should be seeing 
patients, is spent on the phone trying to essentially get a kid 
that was always on a medicine, but the formulary changed, and I 
wanted them to continue that medicine.

    We need a lot of help in this area. We need to have parity 
for physical and mental health and not have to be at the beck 
and call, if you will, of these prior off.

    Senator Murphy. Very well said. And this is an issue I know 
that there will be bipartisan agreement on because we are just 
asking for compliance to the existing law. We don't have to 
pass a new requirement to insurers. We just have to give the 
tools to the Departments to make sure that the insurers comply.

    I am going to submit a question for the record to the panel 
with respect to how we get more professionals who are in 
contact with kids, a little bit of extra learning on mental 
health first aid and mental health diagnosis.

    We spend billions of dollars on training for teachers, for 
pediatricians, and we could do better by giving a little bit 
additional help on identifying some of the root causes. And 
last, let me just say thank you to you, Ms. Rhyneer.

    Thank you for speaking truth to power on this issue and for 
standing up for kids. I am a parent to a teenager and a pre-
teen, and so I see the rabbit hole that kids can go down when 
they are experiencing those first signs of crisis given out 
online some pretty toxic information and influences are, and I 
think you have opened our eyes to that with your testimony 
today. Thank you, Madam Chair.

    The Chair. Thank you.

    Senator Braun.

    Senator Braun. Thank you, Madam Chair. In March 2021, 
American Rescue Plan was signed into law, $4 billion to address 
the opioid epidemic. But with that the lack of anything 
substantive in terms of trying to crack down on the source. 
Fentanyl is mostly made in China, trafficked through Mexico. 
Listen to these statistics. I want the public to hear it 
mostly.

    100,000 Americans have died in the last year due to 
overdoses. Many of them, if not most of them, from fentanyl. 
This is the part that is most shocking. In the age group 18 to 
45, we have lost more young people from overdoses than COVID, 
car accidents, and suicides.

    It is another example of where spending money was not a 
solution without real teeth, real substantive directives at the 
source of it. We visited the Southern border a little less than 
a year ago and we were going from record low illegal crossings 
to about 70,000 to 75,000. That is now leveled out at about 
170,000.

    I mean, appalling. I have got two questions, both for Ms. 
Goldsby. When it comes to not only the impact on losing lives, 
but along with workforce to boot, I think we have lost close to 
2 million prime age workers due to the fact that they are 
contending with opioid issues, how much of this issue is 
directly related to the policies we have on our Southern border 
where illegal crossings are up, fentanyl comes along with it. 
How much is that contributed to this tragic loss of life?

    Ms. Goldsby. Senator Braun, thank you for your question. 
You know, a couple of things, my expertise rests with 
prevention, treatment, and recovery service delivery, but from 
2018 to 2019 in South Carolina, we were really making headway 
and saw the number of overdoses leveling off due to all of our 
efforts and all of the Federal funding with State targeted and 
State opioid response funds.

    Since then, and in the last 2 years, our overdoses have 
skyrocketed, and we are estimating about 63 percent of our 
overdose fatalities in 2020 were a direct result of the 
extremely potent illicit fentanyl and the drug supply.

    I think in the last 2 years, we have pivoted to doing 
everything we can to keeping people alive and implementing 
evidence based harm reduction and intervention services. We 
have got naloxone everywhere that we can get it. The lifesaving 
antidote. With the flexibilities and the funding support from 
SAMHSA, we have been able to distribute fentanyl test strips to 
those individuals who may not know what substances they are 
ingesting as the illicit fentanyl has gotten into the 
methamphetamine supply and the cocaine supply.

    The evidence suggests that people are better able to 
prevent an unintended overdose death if they use these fentanyl 
test strips, they are using less of the drug. And every 
interaction to get these supplies to people on the streets 
where they are is an opportunity to engage them in treatment 
services and get them on the path to recovery.

    That is where our efforts are focusing so heavily now, and 
I will say we are not feeling defeated, but it has been a major 
setback in the last couple of years with how dramatically 
things have shifted.

    Senator Braun. Well, thank you. I think without directly 
saying so by deduction, you can relate what is happening on the 
Southern border to what you are grappling with. Senator Markey 
and I have got two pieces of legislation about increasing 
provider and patient education.

    One is the Label Opioids Act and the other the Safe 
Prescribing of Controlled Substances Act. Through your work in 
addressing the opioid epidemic, can you speak to the importance 
of provider inpatient education and how these bills might 
impact that? Ms. Goldsby.

    Ms. Goldsby. Senator Braun, thank you. Sorry. I think the 
patient and provider education is key and we have a long way to 
go, especially with our provider education in all of our health 
care workforce.

    I think that has been a theme today that we have talked 
about folks not understanding addiction and mental health 
issues as disorders, addiction issues as chronic diseases, and 
the evidence based services, interventions, and treatment 
models that address these disorders successfully. And so we 
have come a long way.

    We have invested a lot in our response and in engaging the 
workforce as such. But I know that we have a long way to go, 
especially as we contemplate access and what that means for 
people who are approaching health care providers who don't or 
don't know how or don't address addiction appropriately.

    Senator Braun. Thank you. I would like you and the other 
members of the panel to take a look at these two bills. It 
would be a small step in at least trying to get more 
information out there and to weigh in on maybe endorsing both 
of these pieces of legislation. Thank you.

    The Chair. Thank you.

    Senator Kaine.

    Senator Kaine. Thank you, Chair. What an excellent panel of 
witnesses and my colleagues have asked very, very good 
questions. I want to first put a challenge on the table that I 
may be asking my colleagues to help us resolve. Two officers 
who were here defending the Capitol on January 6 died by 
suicide in the days right after that attack. Howard Lieberman 
good was a Capitol Police officer, Jeffrey Smith was a Metro 
Police officer.

    Two other Metro Police officers died by suicide a number of 
months later. I don't mention them because their families have 
not reached out and asked for help, and I don't want to presume 
their intentions. But the families of Officers Smith and 
Lieberman have reached out for help.

    Law enforcement officers, Federal, and State local are 
generally accorded a death benefit should they die in the line 
of duty. But law enforcement officers death benefits usually 
State that a death by suicide cannot be a death in the line of 
duty. That is a significant injustice that is directly tied to 
antiquated notions of suicide.

    It is often hard to determine whether a death is in the 
line of duty. If the law enforcement officer dies of cancer, 
usually the administrators of these plans have to go back and 
determine, well, was the officer exposed to a toxic substance 
in the line of duty, or is it related to something else? But to 
declare categorically that no death by suicide can ever be a 
line of duty death is a fundamental injustice, and both the 
Smith and Lieberman good families are now taking that up with 
the respective benefit plans under which they served.

    In the military, military suicides are not excluded as line 
of duty deaths. In fact, an overwhelming percentage of death by 
suicide of active duty military, they get investigated and the 
overwhelming percentage of these cases, they are determined to 
be a line of duty deaths. So this is a really important mental 
health issue for law enforcement. There is an unjust and 
antiquated view of suicide affecting these line of duty death 
determinations.

    There are two who served at this Capitol and died by 
suicide in the days right after the January 6 attack, and they 
have ongoing proceedings going before the relevant authorities. 
And so it may be slightly premature, but we may need to address 
this as a matter of law in the same way that we have allowed 
active duty military to have a suicide determined to be in the 
line of duty, law enforcement officers should not be shut off 
from them.

    I want to ask each of you about a passion of mine that has 
been shared by Members of the Committee and that is the mental 
health of our healers, keeping our healers healthy. Mental--
medical professionals prior to the pandemic had very 
dramatically escalating rates of suicide compared to the 
general population, and many medical professionals feel some 
significant stigma about seeking mental health counseling 
because of worrying about its effect on credentialing at 
hospitals or licensing at the State level or what colleagues 
might think.

    Committee colleagues have joined together with me in a 
bipartisan way to pass the Lorna Breen Act, which I introduced 
with others on this Committee, named to commemorate a very 
talented emergency room physician in New York, a Virginia 
native who died by suicide at the beginning of the real wave of 
pandemic in April 2020.

    But what can we do in the profession to help our healers 
feel more able to get the help they need?

    Mr. Prinstein. Sure. Thank you, Senator Kaine, for bringing 
that up and thank you for your work in this area. It is, in 
fact, very important. We are definitely seeing burnout. The 
mental health care providers are frontline workers too, of 
course. And we are seeing major burnout and concern among 
mental health care providers.

    In partnership with the CDC, the American Psychological 
Association has been providing some services for health care 
providers who are not only experiencing burnout and need 
psychological first aid training, but also are quite angry and 
are feeling really challenged by the amount of harassment that 
they are getting, the amount of victimization that they are 
being subjected to for treating folks due to COVID, for 
offering vaccines.

    A remarkable amount of frustration that they are 
experiencing for their patients that they can't get the 
opportunity to treat because they are overrun with folks who 
are experiencing COVID and are unvaccinated. There are a 
variety of things that can be done. As you ask providing 
concrete support, modeling self-care, psychological first aid 
training, as I mentioned.

    Excuse me, but I wanted to thank you for both of your 
points really raising this issue of stigma that is still 
pervading the way that we think about mental health issues 
versus physical health issues.

    I hope that this Committee can be very, very clear that 
that is sometimes also even reflected in the amount of funding 
that we provide to develop a workforce in mental health versus 
physical health care, and that just has to stop. Thank you.

    Senator Kaine. My time has expired.

    Thank you, Chair Murray.

    The Chair. Thank you.

    Senator Marshall.

    Senator Marshall. Thank you, Madam Chair. I want to lock in 
on prior authorization for a second. And my first question is 
for Dr. Durham. Prior authorization is the No. 1 administrative 
burden facing physicians today across all specialties. Prior 
authorization, the No. 1 administrative burden facing all 
physicians across all specialties.

    As a physician myself, I knew of the frustration of having 
to do this. Talk to a person who may be a non-specialist who 
wasn't from my area, so I couldn't imagine trying to do a prior 
off with you on a patient in the E.R., your years of 
experience, and as an obstetrician, I am trying to tell you who 
doesn't have--needed inpatient management.

    Couldn't imagine doing that. But this burnout is leading to 
early retirement. It ties up nurses. It is frustrating to 
nurses as well. It makes us all less productive. I guess my 
question--and you spoke about this earlier, prior 
authorization.

    My question is, do you ever feel that prior authorization 
is used to ration care or to delay the care of the patient 
needs?

    Dr. Durham. Thank you so much for your question, and as a 
fellow physician that you understand sort of what we are going 
through. I do think it delays care. Absolutely, especially in 
the emergency room context.

    We have literally two to 3 hours sometimes just to get 
someone a bed because we are waiting for the insurance to 
respond, to give the okay that yes, what you have presented to 
us meets the criteria for us to get a patient, an inpatient 
psychiatric bed.

    Without a doubt, it delays care. And when we are thinking 
about an emergency room, we have a lot of patients we need to 
see. I talked briefly in my testimony about we have been beyond 
capacity in our emergency rooms, and I think that that is not 
unique to BMC, but across the Nation during this crisis that 
people are going in for emergency services.

    Awaiting beds, awaiting placement just clogs the system, if 
you will.

    Senator Marshall. Thank you. My next question for Dr. 
Prinstein. We are going to stay on the same subject prior 
authorization. If there was a streamlined solution, would it be 
helpful to your specialty--streamlined meaning I would suppose 
that 10 diagnosis account for 80 or 90 percent of the issues 
that need to be prior off.

    We have Senate Bill 3018. It is bipartisan, bicameral as 
well. We have 17 sponsors, including 8 Democrats, 9 
Republicans, 450 national and State organizations are 
sponsoring this legislation, which would streamline the prior 
authorization. Would it be helpful for members in your 
specialty?

    Mr. Prinstein. Yes, I think it would, and thank you. 
Psychiatry represents, of course, a small percentage, just 10 
percent of the mental health workforce. The rest of us are 
psychologists, social workers, counselors, marriage and family 
therapists, and thinking of solutions that include all mental 
health providers is appreciated.

    Senator Marshall. Thank you. You bet. My next question for 
Ms. Goldsby. You work in the Department of Alcohol and Drug 
Abuse Services. Does prior authorization ever impact your 
patients, especially does it delay care or ration care?

    Ms. Goldsby. Senator Marshall, we do sometimes see prior 
authorizations delaying care, particularly for some patients 
who have insurance benefits when they are needing to be placed 
on medications.

    Senator Marshall. And a streamlined approach to those 
patients would be beneficial to your staff?

    Ms. Goldsby. Yes, absolutely. No barriers to treatment, 
yes.

    Senator Marshall. Okay, Dr. Lockman, kind of same issue, 
prior authorization in your world. I know you are doing 
research, more research based. Do you ever sit there and think 
about some of that where your research leads you to that, will 
patients have access to it? Are you worried about an insurance 
company deciding as opposed to evidence based medicine deciding 
what that patient should be receiving?

    Ms. Lockman. Absolutely. I concur. You know, every single 
hour that we spend navigating pre-authorization to get a 
patient the evidence based treatment that he or she needs is an 
hour that could be spent on something else.

    You are delivering the care that changes people's lives. It 
can be spent on also doing the training that you have mentioned 
is critical. So I think any way that we can cut down on the 
processes would be helpful so that we can just get people the 
treatment that they need.

    Senator Marshall. Okay, thank you so much. I will go to Ms. 
Rhyneer. Ms. Rhyneer, I am not going to ask you about prior 
authorization, so that is a good thing. I guess my question for 
you is, have you experienced some of the mandates, whether it 
is a mask mandate or vaccine mandate closing down school, how 
has that impacted the mental health of your students?

    Ms. Lockman. I think there has been some silver linings, 
and of course, I think COVID has exacerbated and introduced new 
issues. So during typical high school classes, a teacher is one 
of the first lines of defense. They can catch, you know, 
changes in a student's behavior, performance, or attitude. But 
during Zoom classes, I stared at a screen of gray squares. And 
so the teachers found fewer opportunities to ask, like, hey, 
are you Okay? How are things going at home? You seem a little 
off, is there anything you want to talk to or talk about? So 
that is kind of one bad thing.

    But a silver lining, on the other hand, is like, I think 
the conversation around mental health has become a little bit 
more comfortable. And so teachers have been like, if you need a 
self-care, take the day off, go take a walk, do your own thing. 
You know, let's take the Zoom class off for today, and that was 
something that was totally okay to do. So I think there is good 
and bad.

    I think I am willing to stay at home for the safety of our 
community. I also know that for some families, that makes it 
really hard. And for some families, it is not safe for the 
student to stay at home.

    School is kind of like the safety net or this security 
blanket to be away from that. And that makes it tough. I don't 
know if there is a way to say that it was all bad or all good.

    Senator Marshall. Thank you so much. I yield back.

    The Chair. Thank you.

    Senator Hassan.

    Senator Hassan. Thank you, Madam Chair, and I thank you and 
the Ranking Member for organizing and approving today's 
hearing. And to all of the witnesses, thank you so much for 
being here and for the work that you do. I want to start with a 
question to you, Dr. Prinstein. Young patients are being forced 
to wait in emergency rooms for up to a month, hoping an 
inpatient psychiatric bed will open up. And sometimes in my 
State, it is more than that.

    They have written to me recounting their experiences 
waiting in hospitals. They describe truly horrific experiences, 
such as being kept in isolation and going weeks without 
showers, let alone mental health care.

    The situation is so severe that New Hampshire used Federal 
funds to purchase a local hospital to take these children out 
of the emergency room. But we know there is more work that 
still needs to be done.

    Even with the purchase of this hospital and now additional 
beds, there are still long waits in our emergency rooms. What 
concrete steps can Congress take to effectively reduce youth 
wait times for urgent mental health care?

    Mr. Prinstein. Thank you so much for the question, Senator. 
I appreciate it. It is the case that once someone, especially a 
child, is experiencing imminent risk charges themselves and 
others, they do need to be in a hospital. They do need the 
constant surveillance. And we might think that adding more 
hospital beds is the answer. It certainly is an opportunity to 
make sure we have enough emergency services.

    But the problem truly has to be addressed by offering more 
outpatient providers that can make sure that kids never get to 
that level of crisis. We have the treatments, we have the 
science to show that it works. We just need more people to 
administer those treatments and keep kids from getting to that 
emergency stage.

    750 times more funding to make sure we have enough 
physicians in this country than what we are providing for our 
entire mental health care workforce. If we had that, if we 
treated the likelihood that one out of every five young women 
will experience a major depressive episode before the age of 
25, as we heard Ms. Rhyneer say, in Alaska, one out of every 
four young people are going to experience severe suicidality, 
think what we would do if that was a physical health disorder?

    We would be training people what to expect. We would be 
training parents and teachers to spot the warning signs. We 
would be making sure that everyone had access to treatment the 
minute that they started showing any symptoms of a physical 
health illness whatsoever.

    But it is happening for depression. And the reason why we 
are seeing all of this overrun in the hospitals is because we 
haven't provided the workforce to make sure that we can provide 
outpatient treatment before we reach that crisis stage.

    Senator Hassan. Well, thank you. And let me follow-up on 
the points you are making with Ms. Rhyneer and Dr. Durham. It 
is important that we acknowledge the stigma around mental 
health in schools. Ms. Rhyneer, you were just talking a little 
bit about things opening up a little bit and people talk more 
about it.

    I received a letter from a student from Candy in New 
Hampshire sharing her experience with what she considers is a 
real lack of awareness in her school. She wrote in part, 
schools and workplaces are not taking mental health seriously. 
We do not learn about mental health in school, nor the 
workplace.

    I have seen firsthand the way that these disorders can 
affect people. It is not seriously talked about, not taken 
seriously enough. It is powerful to hear students like this 
young woman talk openly about mental health, and we need to do 
more to support them. Points you all have been making.

    Dr. Durham and Ms. Rhyneer, how can we work with students 
to end the stigma around mental health? And I will start with 
Dr. Durham, and then we will go to Ms. Rhyneer.

    Dr. Durham. Thank you for that question. You know, when I 
think about the patients I see at BMC in particular, I talked 
about under-resourced communities, mostly low-income Black and 
Latinx folks that come and see us.

    There is a huge stigma and ethnic minority communities, and 
we need to start, like many of people have said here in schools 
at home, but also partnering with other community 
organizations, the church, other systems of care that people go 
to other than health care systems, that we can start opening 
that dialog and thinking more openly, sort of like Claire has 
done today, telling our stories.

    We have a lot of initiatives even within Boston Medical 
Center, of reaching out and partnering with our local churches. 
We have people in our Department that are doing some of that 
work to start breaking down barriers and stigma so people can 
come in for treatment.

    Senator Hassan. Well, thank you. Ms. Rhyneer.

    Ms. Rhyneer. Yes, I totally agree. I was going to say the 
same thing, we can support community and local organizations. 
Some of the ones that I was in was, I was introduced to Aiyana 
club, suicide prevention trainings, but also MHATS, Mental 
Health Advocacy Through Storytelling, and that encouraged me to 
tell my story.

    The program is youth led. It is youth founded. A group of 
incorporated school students working to decrease stigma and 
increase access to mental health resources through true 
personal short stories of mental health struggle and triumph. 
And we run a program, a 12 week program, twice a year, aiming 
to teach and guide conversations on mental health and 
storytelling, and then help participants develop their own 
stories on mental health.

    Then all of our participants share the story they have 
developed at a final live storytelling event, kind of in the 
style of a moc radio hour or anything else like that. So 
helping organizations in promoting them and encouraging them 
and funding them and things like that is really, really 
important.

    It was my own friends at this organization who taught 
curriculum and helped me tell my story, and it is because of 
those resources and that education that I opened up to my 
parents last year and the reason why I am here today.

    Senator Hassan. Well, thank you. And I realize I am out of 
time. I will follow-up, Ms. Goldsby, with the question to you 
about telehealth and medication assisted treatment. Thanks so 
much, Madam Chair.

    The Chair. Thank you.
    Senator Smith.

    Senator Smith. Thank you so much, Madam Chair. And I would 
like to start by asking unanimous consent to submit, for the 
record, a letter from AFSCME Council 5 and AFSCME Council 65 in 
Minnesota on the need for sustainable solutions and long term 
investments in the mental health care workforce.

    The Chair. So ordered.

    [The following information can be found on page 75 in 
Additional Material:]

    Senator Smith. Chair Murray and Senator Murkowski, I am so 
grateful for you holding this hearing and bringing together 
these experts and colleagues to dig into mental health and 
substance use disorder challenges. I mean, this is an epidemic, 
as we have heard today, that is traumatizing our country.

    Dr. Prinstein said it so well in his opening remarks, that 
this emergency is related to COVID, but it is the result of 
decades of systemic neglect and lack of attention and 
bifurcating mental and physical health to the detriment of our 
whole health.

    I can tell you, of course, I hear about this from 
Minnesotans every single day, educators and parents and 
students especially who are grappling with significant mental 
health conditions. And I want to share that this is personal 
for me for two reasons.

    The first is that my mentor, Paul Wellstone, who once held 
the seat that I have today, led on this issue with Senator, New 
Mexico Senator Pete Domenici. And through their leadership, 
Congress passed legislation to get parity for mental and 
physical health reimbursements in the insurance system.

    Now, as we have heard today, we are still climbing up that 
mountain to get compliance for mental health parity, and we 
won't stop until we do. But I want to just note their 
leadership, which was instrumental. And the second reason that 
this issue is personal to me is that I experienced depression 
when I was a young person, starting in college and then again 
when I was a young mom.

    I know a little bit about what it feels like to feel like 
there is something fundamentally wrong with you and there is 
nothing that can be done about it. There is no solution. And 
you know, I share my story because I want to--I am thinking 
about people who are currently suffering from mental health 
challenges and feel like they are all alone and nobody knows--
nobody knows, and that they can't talk about it because of the 
stigma.

    Ms. Rhyneer, I want to particularly thank you for your 
testimony and for sharing your story. Senator Murkowski knows 
that I actually also went to East Anchorage High School, so we 
have a little bit of Anchorage in common as well. But let me 
go, I am going to stay with you, Ms. Rhyneer. I want to just 
talk a little bit about mental health care in schools.

    Last month, the University of Minnesota released some data, 
which said that 71 percent of principals in Minnesota are 
saying that more mental health resources for students would be 
the most important support that they could get. And I visited 
schools, and I have seen how this works and what a difference 
it can make.

    Ms. Rhyneer, could you talk to us about why in-school 
services are important, why they work for students, and kind of 
how you see they might get it the stigma challenges and other 
challenges that students have accessing the mental health care 
that they need.

    Ms. Rhyneer. Sure, yes. So school is a great place, just 
because it is a place where all students are going to be, and 
you can do a lot of different things in school. You can have 
the community, you can have the teaching, you can have peers, 
you can have a door to all working together and your parents 
too.

    Also, we have counselors and--or we want to have counselors 
and therapists in schools. But alsohaving the curriculum around 
is really important. You know, I have talked to numerous 
students who say they didn't realize how bad of the situation 
they were until years later. Like they never recognized their 
own systems. They never reached out for help.

    Having curriculum in schools is great to have people 
recognize their own symptoms and be like, oh, I think something 
is going on. I need to reach out to somebody. That person that 
they need to reach out to is, ONC 130, this room down the hall 
that they can walk down there and say, hey, I really need some 
help.

    That counselor can call the parent and be like, hey, I 
talked to your kid. Maybe you should talk to them. So it is a 
really great place to have all those services in one place.

    Senator Smith. It is such a great way of describing what 
difference it makes. And also, I would say how we can--you are 
really integrating physical and mental health because maybe you 
go in to see the school nurse about a stomachache and then the 
school nurse ask some questions and understands that what you 
really need there is some underlying issues you need to address 
around anxiety or depression, and it happens all in one place 
in the kind of integrated care that we have heard the experts 
and physicians on the panel talk about.

    Madam Chair, as you know--I am sure you know that I have 
several bills that I have been working on that would expand 
access to mental health care services in schools, and I am 
going to be very interested in pursuing these bills and this 
legislation as we go forward for exactly the reasons that I am 
Claire just described. Thank you so much.

    The Chair. Thank you.
    Senator Rosen.

    Senator Rosen. Thank you, Madam Chair. And thank you, 
Senator Murkowski, for holding this really important hearing 
today, and of course, for the witnesses, for being here. I want 
to build on what Senator Smith was talking about because it is 
important that we equip schools with the comprehensive mental 
health and suicide prevention resources we know are so critical 
because not just under Smith, but we have heard from everyone 
this morning schools, our students, we are just facing such a 
growing mental health crisis.

    In the American Academy of Pediatrics, they recently 
declared a national State of emergency in children's mental 
health. And in Nevada's Clark County School District, we 
tragically lost 20 students, 20 students to suicide since the 
onset of the pandemic in 2020. Those families will never be the 
same. And so we must do more to keep our students safe, to 
promote their mental health and their well-being.

    Which is why, as Senator Murkowski noted earlier, I am 
working with her on bipartisan legislation to help provide 
additional resources to support K-through-12 mental health. And 
currently the Substance Abuse Mental Health Services 
Administration, or SAMHSA for short, does not, does not have 
the authority to provide funding assistance directly to school 
districts to promote comprehensive health and suicide 
prevention services.

    Dr. Prinstein, given the current mental health crisis in 
our schools, would legislation authorizing SAMHSA to directly 
provide targeted and timely resources to K through 12 schools 
help prevent the mental health challenges before they occur, 
and of course, address suicide attempts and prevent a suicide 
from taking place?

    Mr. Prinstein. Yes, Senator Rosen. Thank you so much. 
Hurray, this is a great step and very, very important. The 
opportunity to make sure that schools themselves can use their 
local expertise and their knowledge of what their community 
needs is a fantastic idea.

    I will say, please do keep in mind that school staff are 
currently overwhelmed and usually turning to psychology and as 
well as other mental health care providers to teach them about 
the skills that are needed. Psychologists often do this just 
out of the goodness of their own heart. There is no 
reimbursement mechanism.

    This starts to become hopefully a far more widespread 
practice of schools instituting preventive programs throughout 
entire communities, please do think about ways that 
psychologists and other mental healthcare providers can be as 
helpful and dedicate as much time as possible to help teach the 
school staff what is needed, to use our evidence based 
assessments to screen for risk, and to use our evidence based 
interventions to reach and help as many people as possible.

    We have many prevention programs ready to deploy, and this 
is a very exciting opportunity that you are speaking of. Thank 
you.

    Senator Rosen. Well, you set me up perfectly for my next 
question, because all 17 counties in Nevada are designated as 
health professional shortage areas. And so that is why I am 
really proud of the work being done by University of Nevada 
Reno, the Master's level students, they are providing mental 
health counseling services to K through 12 students in nearby 
Churchill County and hopefully doing some of that other 
training when they are in the schools that you speak of.

    This partnership allows our UNR interns to gain real world 
experience in a supervised setting while also increasing the 
access and just the knowledge base for everyone in those 
schools, particularly right now in Churchill K-through-12 
students.

    Again, back to Prinstein, this is a model. We are using it 
in Nevada. How might this model or others that you see, not 
just in Nevada--how can we lead the way in helping to promote 
these kinds of partnerships that will address the burnout and 
critical shortages and get those benefits to the students and 
teachers as well counselors?

    Mr. Prinstein. I think it would be terrific if we had the 
workforce to be able to do that in all States. Imagine that 
there were school psychologists enough to deploy and consults 
with every school out there, not just one per school districts 
or one per county, sometimes with kids waiting for years before 
they are able to get an evaluation, meanwhile their parents 
watch them failing grades and experiencing difficulties, just 
waiting for that school psychologist to join in.

    There are sometimes only one mental health care provider 
for an entire county or for a 100 mile radius, which makes it 
very hard to consult with all the school districts that ask us 
to really play a role in just the way that you are describing.

    I think that this approach, coupled with a substantial 
increase in the workforce, could really be a wonderful model 
for us to try and change the way that we are thinking about 
mental health from a prevention approach as well as an 
intervention approach.

    Senator Rosen. Well, thank you. I appreciate that, and I 
look forward to working with all of you and my colleagues to 
promote workforce training in the mental health space. We 
really need it in so many areas. Thank you, Madam Chair.

    The Chair. Thank you. And we do have two votes called so 
that as all the Senators who have questions. Senator Murkowski, 
do you have any closing remarks?

    Senator Murkowski. Just very quickly, Madam Chair. And 
again, I agree this has been an excellent, excellent panel. You 
know, when we think about the issue of the issues of mental 
health and substance use disorders, so much of the response has 
to be when the individual is ready for it, it needs to be the 
intervention at that moment, and I was struck--I keep going 
back to reading Claire's testimony.

    Claire, you indicate, you said, while I worked at NAMI, the 
National Association of Mental Illness, I had to tell people 
they would be on a waitlist for 9 to 12 months before they 
would receive care from a caseworker, 3 months before the 
patient would be even contacted to confirm they could be 
accepted, another 6 months before they could talk to a 
caseworker and begin care.

    When we talk about the workforce issues, we cannot have a 
situation, an emergency, a crisis, and have an individual be 
told it will be 3 months before we know whether you can even 
receive care. So a lot of focus on the mental health issues.

    I will tell you, Dr. Prinstein, when you when you indicated 
that the United States is No. 1 in the world for suicide rates, 
we think that money can solve a lot of things, but apparently, 
we are not directing the resources to these very critical areas 
of mental health like we need to.

    Apparently, we haven't dedicated the resources for the 
workforce. Apparently, we haven't connected with the younger 
people and really all across the spectrum, we haven't addressed 
some of the racial issues that you have pointed out here. So we 
obviously have a great, great, great deal to do here.

    I think that today's witnesses have provided us great 
insight, but it is a reminder that we have so much to do. So 
thank you to all of our witnesses and look forward to working 
on these problems.

    The Chair. Senator Murkowski, thank you, and thank you for 
helping us put this together. Thank you to all of our 
witnesses. Senator Murkowski, you talked about workforce. That 
clearly is an issue. A number of other issues were addressed. 
But I think you actually identified one at the very beginning, 
which we don't talk about enough, and that is, how do we talk 
about suicide?

    I think there is, as you stated, among young people a 
willingness, a desire, understanding that this cannot be a 
taboo topic that in fact, we need to have an understanding of 
it. We need to have a discussion of it.

    But it is so hard for so many people to talk about it, as 
she said, because they fear that they are going to encourage 
somebody to do it. We all have a lot of learning to do, and we 
have a lot of learning within our schools and across our 
communities to deal with this issue.

    I look forward to working with you, Senator Murkowski, on 
that and all of our colleagues. That will end our hearing 
today. Again, I want to thank Senator Murkowski for joining me 
today. For all of our colleagues, for a very insightful 
discussion.

    I really want to thank all of our witnesses, Dr. Prinstein, 
Dr. Durham, Director Goldsby, Dr. Lockman, and Ms. Rhyneer for 
sharing your time and experience with us.

    For any Senators who wish to ask additional questions, 
questions, for the record will be due in 10 business days, 
February 15th at 5 p.m..

    This Committee will next meet February 8th for a hearing on 
employment opportunities and challenges for people with 
disabilities. Committee stands adjourned.

                          ADDITIONAL MATERIAL

                                 Council 5, AFSCME,
                                        Council 65, AFSCME,
                                                  January 31, 2022.
The Honorable Tina Smith
U.S. Senate Committee on Health, Education, Labor, and Pensions,
Washington, DC 20510.
    Dear Senator Smith,

    On behalf of the 43,000 working Minnesotans represented by AFSCME 
Council 5 and the 13,000 workers represented by AFSCME Council 65, we 
ask that this letter be part of the record of the February 1 hearing on 
Mental Health and Substance Use Disorders: Responding to the Growing 
Crisis. For too long behavioral health care has been an afterthought, 
leaving millions struggling to get the care they need for drug and 
opioid abuse, mental health, PTSD, and more. This hearing will help put 
this issue front and center.

    AFSCME members who are certified peer recovery specialists, nurses, 
social workers, counselors, support staff, and other behavioral health 
care workers help individuals in a range of settings. It's not just a 
job for them; it's a calling. Our members see the services they provide 
can offer hope, change the trajectory of a person's life, and help 
repair fractured families. These workers are on the frontlines 
witnessing how the job loss, isolation, death, and illness from COVID 
have traumatized families and increased the risk for depression, 
anxiety, substance use disorder, and even suicidal ideation. These 
workers are building the resilience of our communities and healing 
families, one person at a time. They are ready to help our fellow 
Minnesotans begin that road to recovery, find their way back from a 
relapse, and support recovery. They are unsung heroes who deserve our 
respect.

    As you consider developing legislation to improve our Nation's 
capacity to respond to the growing mental health and addiction crisis, 
we urge you to recognize that behavioral health staff are the 
foundation to any solution. Funds that are designed to increase the 
number of behavioral health care workers are important but not enough. 
Low pay, unsafe working conditions, and unacceptably high caseloads are 
factors that contribute to burnout and high staff turnover. Staff 
burnout and high staff turnover result in waiting lists for treatment, 
inconsistent care, wasted resources, and poor results. We need 
sustainable policies that ensure new funding is specifically targeted 
to rectify staff burnout and high turnover. This is how we can show our 
respect to this workforce and the clients they serve. We stand ready to 
work with you to remedy this dire situation.
            Sincerely,
                                              Julie Bleyhl,
                                                Executive Director,
                                                  AFSCME Council 5.
                                           Shannon Douvier,
                                                Executive Director,
                                                 AFSCME Council 65.

                         QUESTIONS AND ANSWERS

  Response by Mitch Prinstein to Questions of Senator Murphy, Senator 
       Kaine, Senator Smith, Senator Lujan, and Senator Murkowski

                             SENATOR MURPHY

    Question 1. How can we better prepare professionals in 
frequent contact with children and teens, such as teachers and 
pediatricians, to better deal with young people's unique 
behavioral health needs?

    Answer 1. We need to rethink the ways in which we approach 
mental health care for all populations, including our youth, by 
moving away from a focus primarily on crisis management and 
instead investing more in prevention. Therefore, we must meet 
kids where they are. This means their schools and communities. 
Evidence-based comprehensive behavioral health systems in 
schools provide a full complement of supports and services that 
establish multi-tier interventions and promote positive school 
environments.

    To help achieve this, teachers need increased training on 
embedding social and emotional learning in classroom 
curriculum. This would help build skills such as motivation and 
engagement, problem-solving, emotional intelligence, 
resiliency, agency, and relationship-building. To be 
successful, this must be done in partnership with parents, 
families, and caregivers.

    Finally, it is important to remember that mental health is 
health. Maintaining siloes between physical and behavioral 
health makes little sense, hurts overall health care outcomes, 
and perpetuates stigma around mental health. Most people, 
children included, receive their health care from their primary 
health provider. Adopting flexible models of integrating mental 
health care with primary care--which starts in the way we train 
providers--is key to increasing access to services for all 
populations, including children and adolescents.

    This also means increasing adoption of evidence-based 
models of integrated primary and behavioral healthcare. 
Children and teens routinely receive care in primary care 
settings, and identifying and addressing behavioral health 
issues could be made much easier if behavioral health 
specialists are embedded in those settings as part of the 
primary care team. Integrating psychologists into pediatric 
primary care practices through the Primary Care Behavioral 
Health (PCBH) model gives pediatricians a powerful ally in 
addressing the behavioral health needs of children, youth, and 
their families, and has a solid track record of success. 
Congress should support broader implementation of PCBH and 
other evidence-based integrated care models by providing 
stronger assistance and incentives for its adoption by primary 
care practices and behavioral health providers.

    Question 2. How might additional training for these 
professionals improve supports for young people?

    Answer 2. Additional training for these professionals can 
help bolster early detection and early interventions efforts, 
which are especially important for young people, as most mental 
health disorders begin between the ages of 14 and 24. Schools 
in particular are key to these efforts.

    Leveraging partnerships between community and school-based 
entities can provide training to teachers, administrators, and 
support personnel, as well as families, students, and community 
members to recognize signs of emotional and psychological 
concerns and provide best practices for the delivery of mental 
health care in schools. To help promote the mental health of 
all students, educator preparation and professional development 
programs should also include training on mental health 
literacy, social-emotional learning competencies, and reducing 
mental health stigma.

    Making training for integrated care service delivery 
broadly available to healthcare providers would help expand 
access to this treatment modality. Effective implementation of 
integrated primary and behavioral healthcare requires more than 
simply co-locating behavioral health and primary care 
providers. Research shows that training and technical 
assistance are frequently needed, since neither general medical 
providers nor behavioral health providers typically receive 
training in team-based care.

    Question 3. Knowing that we have significant health care 
disparities stratified by income, race, and geography (e.g. 
rural areas), how do we ensure health equity in addressing the 
behavioral health needs of children and teens?

    Answer 3. Despite the significant need for access to mental 
health services among young people, the mental health system 
remains largely geared toward adults. However, many of the same 
issues that plague the delivery of mental health care for 
adults, also arise in efforts to provide such services to 
children and adolescents: workforce shortages; a siloed 
healthcare system; and poor reimbursement rates for behavioral 
health services. These barriers disproportionately impact 
traditionally underserved and underrepresented populations.

    One of the ways in which we can begin to build a more 
equitable mental health care system is invest in programs that 
educate psychologists and diversify the field, such as the 
Graduate Psychology Education and Minority Fellowship programs. 
Student loan debt, which is carried in significantly larger 
numbers by psychologists of color, also impedes workforce 
diversity efforts. Pathways to student loan forgiveness, which 
also incentivize service in communities with lack of access to 
care, is critical. Once these professionals are in the field, 
we must also adequately reimburse them for the care they 
provide by fully enforcing Federal parity law.

    However, mental health does not exist in a vacuum and the 
psychological well-being of children is frequently tied to the 
overall health, safety, and stability of their surroundings, 
such as their communities, schools, and homes. COVID-19 has 
further strained individuals, families, and communities, with 
low-income and underrepresented minority populations being 
affected at even higher levels. Addressing the social 
determinants of health, including by investing in public 
education, affordable housing, and food security, is crucial to 
ensuring psychological health among all age populations, 
including children and adolescents.

                             SENATOR KAINE

    Even before the COVID-19 pandemic, children across America 
faced mental health challenges. In 2019, suicide served as the 
second leading cause of death among adolescents. Further, over 
the course of the pandemic, nearly two in three young people 
expressed that they were feeling down, depressed, or hopeless. 
As we work to address the youth mental health crisis, we cannot 
forget about our military families and youth that receive 
services through Tricare.

    Question 1. As we strengthen our investment in programs 
addressing youth mental health, how can we ensure that there is 
coordination and sharing among the agencies so that children 
and youth in military families, who rely on Tricare and often 
receive care in the military health systems, have access to the 
best practices and innovative solutions these programs provide?

    Answer 1. APA strongly encourages the Congress and the DoD 
to take steps toward addressing DoD IG's recommendations in 
their August 2020 report, including creating a system-wide 
staffing plan for MHS for the Behavioral Health System of Care 
and requiring TRICARE to adhere to the same standardized 
psychotherapy follow-up assessments currently in place in the 
Defense Health Agency (DHA). \1\ Implementing these, as well as 
OIG's other recommendations would be a step in the right 
direction toward guaranteeing access to quality mental health 
care for our service members and their families.
---------------------------------------------------------------------------
    \1\  Department of Defense Office of the Inspector General, 
Evaluation of Access to Mental Health Care in the Department of Defense 
(Aug. 10, 2020) https://media.defense.gov/2020/Aug/12/2002475605/-1/-1/
1/DODIG-2020-112--REDACTED.PDF
---------------------------------------------------------------------------
    Additionally, the current, unsustainably low reimbursement 
rate for mental health providers, including psychologists, 
through the TRICARE network is limiting the number of outside 
providers who would be able to serve our men and women in 
uniform. APA contacted DHA back in 2017 with our concerns \2\ 
but we are unaware of any action taken to rectify this issue. 
Additionally, the current pandemic has highlighted the 
disparity in reimbursement rates for telehealth compared to in-
person care. Studies have shown that telehealth interventions 
are just as successful as face-to-face interventions \3\, \4\, 
and during the pandemic and beyond, the telehealth 
reimbursement rate should be equal to the reimbursement rate 
for face-to-face visits. APA recommends adequately reimbursing 
psychologists in the TRICARE network and bringing parity to 
reimbursements for telehealth services. APA additionally 
recommends maintaining a strong in-house Military Health System 
by continuing to fund the Uniformed Services University and 
maintaining medical billets.
---------------------------------------------------------------------------
    \2\  Letter from APA Practice Organization to Adm. Bono, Defense 
Health Agency. https://www.apaservices.org/practice/advocacy/humana-
reimbursement-tricare.pdf
    \3\  Greenbaum, Z. (July 1, 2020). How well is telepsychology 
working? Monitor on Psychology, Vol. 51, Issue.5, 46. Retrieved from 
https://www.apa.org/monitor/2020/07/cover-telepsychology.
    \4\  Bashshur, R. L., Shannon, G.W., Bashshur, N., Yellowlees, P. 
M. (Feb. 1, 2016). The empirical evidence for telemedicine 
interventions in mental disorders. Telemed J E Health, Vol. 22 Issue 2, 
87-113. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC4744872/.
---------------------------------------------------------------------------

                             SENATOR SMITH

    Question 1. What are specific examples of initiatives that 
you have seen in your work that have done a good job of 
incorporating mental health into the broader response to COVID-
19? What should Congress learn from these successes?

    Answer 1. The COVID-19 pandemic caused a seismic 
reevaluation of how patients are assessed for and receive 
mental health treatment. Expanded access to new modalities of 
treatment such as telehealth have extended access to 
communities that have traditionally struggled to access 
treatment. Increasing implementation of evidence-based 
integrated pediatric primary and behavioral healthcare could 
also significantly increase access to care, improve treatment 
outcomes, promote healthy development, and aid in addressing 
social determinants of health. A substantial percentage of 
patients visiting primary care practices are experiencing 
behavioral health issues affecting their well-being, including 
both mental health and substance use disorders or difficulties, 
and behavioral factors associated with physical conditions or 
chronic disease management.

    More than a decade of research has documented the 
effectiveness of programs implementing the primary care 
behavioral health (PCBH) model, the collaborative care model 
(CoCM), and blended models of integrated care. One of the 
leading models of integrated care is the Primary Care 
Behavioral Health Model (PCBH), in which primary care 
providers, behavioral health consultants (BHCs), and care 
managers work as a team, sharing the same health record 
systems, administrative support staff, and waiting areas, and 
collaborate in monitoring and managing patient progress in 
order to improve the management of behavioral health problems 
and conditions.

    Generally, the BHC strives to see patients on the same day 
the primary care provider (PCP) requests help and works with 
the PCP to implement clinical pathways for treatment. An 
integrated care psychologist's day may include meeting with a 
parent of a child exhibiting behavioral difficulties or 
hyperactivity, seeing a new mother experiencing symptoms of 
depression, helping another patient manage chronic pain or 
diabetes, and working with another patient who has recently 
discontinued using his psychotropic medication. Both patients 
and providers have reported high levels of satisfaction with 
PCBH model services. From the patient's perspective, behavioral 
health services are seamlessly interwoven with medical care, 
mitigating the stigma often associated with behavioral health 
services.

    The PCBH model is particularly well-suited to use in 
pediatric care. Interventions and supports to promote 
children's physical, behavioral, and emotional health can 
positively influence the long-term trajectory of their health 
and well-being into adulthood. Almost all children are seen in 
primary care, and it is estimated that one in four pediatric 
primary care office visits involve behavioral or mental health 
problems. Psychologists can be especially helpful in pediatric 
care because assessing behavioral and emotional issues in 
children is generally more difficult than in adults, and 
pediatric education traditionally focuses on children's 
physical health. In addition to improving treatment in this 
area, early childhood behavioral health services can help 
mitigate the effect of adverse social determinants of health. 
Ideally, integrated pediatric primary care includes a whole-
family approach to services that encompasses screening and 
services for perinatal and maternal depression, domestic 
violence, and adverse childhood experiences.

    Adoption of PCBH and other integrated care models is often 
challenging for primary care providers, as they face barriers 
related to physical office space, the need for improved 
information technology systems, management procedures, clinical 
staffing and policies, health records and data tracking 
practices, and provider education and training. APA supports 
the provision of Federal financial and technical assistance to 
aid in the expansion of integrated care, whether provided 
through partnerships (including state agencies) or through 
direct aid to primary care providers. Initiatives and 
incentives to promote integrated care should support 
implementation of not just PCBH programs, but all evidence-
based models of integrated care. Because of differences in 
providers' patient populations and access to behavioral health 
providers, there is no ``one-size-fits-all'' approach to 
effective integrated primary care. APA urges Congress to 
continue giving primary care practices the flexibility to 
choose the model of integrated care that works best for their 
community.

    Question 2. What steps should Congress take to protect 
tele-mental health access, and what specific policies should be 
pursued for private federally regulated health plans, which 
fall under the jurisdiction of the HELP Committee?

    Answer 1. As you know, expanded access to mental health 
services via telehealth is proving to be a literal lifeline to 
the many Americans who are struggling during the pandemic. This 
expansion is especially beneficial to individuals in geographic 
areas and communities that have long lacked access to these 
services. We know, however, that the pandemic will have a 
mental health impact that will last far longer than the 
pandemic itself. We appreciate the Administration's efforts to 
preserve the current pandemic-era flexibilities on telehealth 
coverage--for example, its recognition of audio-only telehealth 
as a vital modality of treatment. However, we also feel that 
Congress can further support expanded access to telehealth in 
two primary ways: first, by removing unnecessary barriers to 
mental health treatment, such as the statutory requirement for 
periodic in-person visits. To that end, APA asks that the 
Committee take up and pass the bill you co-sponsored with 
Senator Cassidy to repeal this requirement, the Telemental 
Health Care Access Act (S. 2061). Second, to ensure that 
providers continue to offer telehealth services to the same 
extent going forward, Members of this Committee can pass 
legislation requiring private insurance plans to cover mental 
health services furnished via telehealth on the same terms and 
at the same reimbursement rates as their in-person 
counterparts. Specifically, we ask that the Committee introduce 
and adopt a Senate counterpart to the Telehealth Coverage and 
Payment Parity Act (H.R. 4480).

                             SENATOR LUJAN

    Question 1. The pandemic has exacerbated longstanding 
challenges patients and their loved ones have in seeking 
behavioral health services. This includes major workforce 
shortages, months-long waitlists for treatment, and entire 
regions of the country with no behavioral health providers. 
While these challenges are nation-wide, barriers to care are 
amplified in largely rural states such as New Mexico. One 
solution that shows promise is the rise of peer support 
workers--behavioral health providers who have been successful 
in their recovery and work in their communities to help others. 
It is critical that we support these workers and give them 
resources to combat the burnout and high turnover that prevents 
us from building an experienced and consistent workforce. What 
can we do to not only recruit new substance use disorder 
workforce employees, but also retain those we already have?

    Answer 1. APA shares your concern about provider burnout 
amidst increased demand for mental and behavioral health 
services. Indeed, the data shows that this phenomenon was 
clearly present long before the current pandemic. With added 
demand for services due to pandemic-related stressors, coupled 
with resurgent rates in abuse of opioids, stimulants, and other 
substances, we fear that, without prompt action, increased 
rates of provider burnout will impede providers' ability to 
provide quality evidence-based care.

    One essential step to developing and maintaining an 
adequate substance use disorder workforce is ensuring that they 
are adequately paid. Reimbursement rates for substance use 
disorder staff and programs is notoriously low. In 2017 the 
State of Virginia implemented the Addiction and Recovery 
Treatment Services (ARTS) benefit for Medicaid beneficiaries 
with substance use disorders, with a goal of substantially 
increasing access to care. The initiative included increased 
provider reimbursement rates for many existing services, and 
the addition of coverage for a new office-based opioid 
treatment model. Since ARTS was implemented, Virginia has seen 
substantial increases in the number of participating addiction 
treatment providers and facilities, including a quadrupling of 
the number of practitioners billing for addiction treatment 
services above 2016 levels. Treatment rates for opioid use 
disorders and other substance use disorders have more than 
doubled with initiation of ARTS.

    To increase the size and diversity of the behavioral health 
workforce, Congress can increase its support for key behavioral 
health workforce programs such as the Graduate Psychology 
Education (GPE) Program, the Minority Fellowship Program (MFP), 
and the Behavioral Health Workforce Education and Training 
(BHWET) Program. Additionally, to improve the pipeline of 
behavioral health providers, Congress can support efforts to 
allow psychology trainees--who receive 500-700 hours of direct 
patient experience through their training program--to bill for 
services they provide under the supervision of a licensed 
psychologist, similar to the flexibilities that medical school 
trainees currently enjoy. Finally, Congress can take steps to 
eliminate duplicative and unnecessary administrative burdens on 
independent practitioners; for example, while APA supported the 
policy goals of the No Surprises Act to provide a measure of 
cost transparency to patients, we are concerned that the way 
the Administration is implementing No Surprises Act imposes 
unnecessary burdens on behavioral health practitioners--such as 
the repetitive preparation ``good faith estimates'' of costs--
that do not further the Act's purposes.

    Question 2. We know that patients who are able to receive 
culturally sensitive behavioral health care and community 
centered care have improved outcomes. How can we better recruit 
and retain diverse behavioral health care providers who are 
able to provide high-quality care to their patients?

    Answer 2. In order to better recruit and retain diverse 
healthcare providers, it would be useful to provide increased 
funding to programs such as the Minority Fellowship Program 
that have a proven success record of providing support to a 
qualified, diverse population of mental health providers. The 
program provides mentorship and guidance for those interested 
in serving culturally diverse populations. It may be useful to 
also offer incentives to those entering the workforce in a 
diverse community. Incentives could include higher pay, 
educational opportunities, student loan forgiveness or 
repayment programs specific to those working directly with 
diverse populations.

    Question 3. In New Mexico, the COVID pandemic has 
overwhelmed an already strained behavioral health 
infrastructure. In some cases, patients experiencing substance 
use disorder or mental health crises wait months to be seen by 
a provider able to provide treatment. From your experience in 
the behavioral health space, can you speak to the importance of 
patients being able to access timely care?

    Answer 3. The importance of early intervention--both in 
response to a short-term crisis and over the long-term 
trajectory over a child's life--cannot be overstated. Even 
relatively small investments in children's mental health early 
in their lives can have clear positive long-term effects. Most 
common mental health disorders, including those with the 
greatest morbidity, have onset in childhood or adolescence. \5\ 
Childhood and adolescence provide critical periods for 
prevention, early detection, and intervention to promote 
lifetime well-being. Rather than activate resources only when a 
child experiences a crisis, which may inhibit the long-term 
effectiveness of treatment, our behavioral health system must 
focus resources earlier in a child's life and address the 
factors that led to the child experiencing a crisis in the 
first place.
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    \5\  Kessler, R.C. & Wang, P.S. (2008). The descriptive 
epidemiology of commonly occurring mental disorders in the United 
States. Annual Review of Public Health, 29, 115-129.
---------------------------------------------------------------------------

                           SENATOR MURKOWSKI

    Military Suicides: The Army in Alaska has experienced 
numerous suicides from 2016 to 2021, most of them occurred at 
the remote location of Ft. Wainwright. Army leadership has 
taken steps to improve quality of life, but suicides continue. 
Furthermore, aspects of military culture that value toughness 
and resiliency discourage help-seeking behavior. Studies have 
shown that some service members perceive a stigma attached to 
seeking mental health care, and express concerns that seeking 
care will harm their career opportunities.

    Question 1. What suggestions would you offer to military 
leadership to help combat this stigma and encourage military 
members to seek help when needed?

    Answer 1. Improve Access to Direct Care and Purchased Care 
Systems to Ensure Access to Mental Health Care for our 
Servicemembers and their Families. The mental health of our 
Servicemembers and their Families is a critical readiness 
issue. A 2020 DoD Inspector General (IG) report that found that 
DoD did not consistently meet outpatient mental health access 
to care standards for active-duty Servicemembers and their 
Families. \6\ APA has expressed serious concern multiple times 
in the past few years about network adequacy and cuts to 
reimbursement rates for psychologists. \7\, \8\ The IG report 
shows that the TRICARE network is inadequate to meet the mental 
health care needs of our Servicemembers and their Families. APA 
encourages you to improve access to care across both direct and 
purchased care systems to include holding TRICARE contractors 
accountable when they fail to meet the needs of Servicemembers 
and their Families.
---------------------------------------------------------------------------
    \6\  Department of Defense Office of the Inspector General. (2020). 
Evaluation of Access to Mental Health Care in the Department of 
Defense. Retrieved from https://media.defense.gov/2020/Aug/12/
2002475605/-1/-1/1/DODIG-2020-112--REDACTED.PDF
    \7\  APA Practice Organization. (2017) Letter to Admiral Bono, 
Defense Health Agency. Retrieved from https://www.apaservices.org/
practice/advocacy/humana-reimbursement-tricare.pdf
    \8\  American Psychological Association. (2020). Letter to 
Secretary Esper, Department of Defense. Retrieved from https://
www.apa.org/news/press/releases/2020/10/letter-mental-health-access-
tricare.pdf
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    Maintain efforts to improve DoD's culture and climate. APA 
applauds previous efforts to end sexual harassment and assault, 
root out extremism, and make the DoD a safe place to work for 
all Servicemembers, regardless of gender, sexual orientation, 
gender identity, race, ethnicity, or religion. These quick-
reaction efforts from the Task Forces to Stand Down must be 
accompanied by long-term policy changes. Members of the 
military must be able to rely on and trust their fellow 
Servicemembers. Any actions that undermine that trust, such as 
fearing sexual assault, racism, retaliation, or extremism, must 
be addressed directly at all levels of command. This is a 
critical readiness issue for the DoD, and we urge Congress to 
ensure DoD continues these efforts.

    Continue to Focus on Suicide Prevention and Lethal Means 
Safety. As you know, the DoD has been focused on suicide 
prevention among Servicemembers for several years. Data from 
previous annual suicide reports and ongoing surveillance 
indicate that this continued emphasis is greatly needed. \9\, 
\10\ DoD's Annual Suicide Report for Calendar Year 2019 found 
that the primary method of suicide was by firearm for 
Servicemembers and their Families, with rates ranging from 59.6 
percent to 78.7 percent across military populations. Lethal 
means safety is critical to reducing suicide rates among these 
populations.
---------------------------------------------------------------------------
    \9\  Department of Defense, Under Secretary of Defense for 
Personnel and Readiness. (2020). Annual Suicide Report: Calendar Year 
2019. Retrieved from https://www.dspo.mil/Portals/113/Documents/CY2019 
percent20Suicide percent20Report/DoD percent20Calendar percent20Year 
percent20CY percent202019 percent20Annual percent20Suicide 
percent20Report.pdf'ver--YOA4IZVcVA9mzwtsfdO5Ew percent3d
    \10\  Department of Defense, Defense Suicide Prevention Office. 
(2020). Department of Defense (DoD) Quarterly Suicide Report (QSR) 3d 
Quarter, CY2020. Retrieved from https://www.dspo.mil/Portals/113/TAB 
percent20A--20201112--OFR--Rpt--Q3 percent20CY percent202020 
percent20QSR--final--1.pdf
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    Increase Continuity for Separating Servicemembers as they 
Transition out of Service. Studies have shown that 
transitioning out of the military to civilian life increases 
risk for suicide, especially in certain populations. \11\ The 
DoD's in Transition program, the Transition Assistance Program, 
and Yellow Ribbon Reintegration Program must be fully funded 
and continuously improved to meet the needs of Servicemembers 
across active and reserve components. It is also critical that 
Servicemembers are aware of, and have access to, Department of 
Veterans Affairs (VA) services. We encourage the DoD to devote 
more resources to data-sharing with VA and other agencies to 
ensure a smooth transition to civilian life.
---------------------------------------------------------------------------
    \11\  Ravindran C, Morley SW, Stephens BM, Stanley IH, Reger MA. 
Association of Suicide Risk With Transition to Civilian Life Among US 
Military Service Members. JAMA Netw Open. 2020;3(9):e2016261. 
doi:10.1001/jamanetworkopen.2020.16261
---------------------------------------------------------------------------
    Support Basic and Applied Research. The basic and applied 
behavioral science research conducted by civilian and uniformed 
psychologists in the DoD is essential to modernize military 
personnel and talent management systems and to improve 
readiness, capacity, performance, and effectiveness at the 
individual, team, unit, and organizational levels. Basic and 
applied research is also needed to understand and address the 
stigma associated with mental health care and ways to ensure 
fairness toward and the full integration of women and minority 
groups. Moreover, psychologists should be involved in data 
analytics and artificial intelligence research to address how 
human cognitive biases have unintentionally been incorporated 
into various algorithms. Continued investment in the Minerva 
Research Initiative and social science research is essential to 
these efforts and must remain fully funded to strengthen the US 
national security apparatus. Finally, increased support for 
Minority Serving Institutions is critical in order to maintain 
a competitive advantage.

    Question 2. What steps would you suggest for leadership to 
take in order to improve suicide prevention efforts in remote 
and isolated locations, like Interior Alaska?

    Answer 2. Research is needed to better understand the 
contributors to regional differences in suicide mortality 
across the United States. Rural areas are highly diverse with 
respect to their landscapes, demographic composition, and 
socioeconomic conditions. Studies are needed to identify risk 
and protective factors for mental health outcomes within 
different types of rural communities and across the rural-urban 
continuum.

    For rural populations, firearms and poisoning are the most 
common means of suicide, and those populations are at higher 
risk for suicide via firearms and pesticide ingestion because 
of greater familiarity and accessibility. Classification as a 
military veteran also confers risk; for example, in a study of 
over five million veterans in the United States, rural veterans 
were at 20 percent greater risk for suicide than urban 
veterans. \12\ Research reviewing the effectiveness of lethal 
means safety interventions has shown that restricting access to 
handguns, pesticides or other lethal means for patients with 
suicidal ideation or training clinicians to recommend lethal 
means restriction can reduce rates of suicide by these means. 
\13\
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    \12\  McCarthy, J. F., Blow, F. C., Ignacio, R. V., Ilgen, M. A., 
Austin, K. L., & Valenstein, M. (2012). Suicide among patients in the 
Veterans Affairs health system: rural-urban differences in rates, 
risks, and methods. American journal of public health, 102 Suppl 
1(Suppl 1), S111--S117. https://doi.org/10.2105/AJPH.2011.300463
    \13\  Stewart, E.G. (2018). Mental Health in Rural America: A Field 
Guide (1st ed.). Routledge. https://doi--org.ezproxy.lib.vt.edu/
10.4324/9781315189857
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    Particularly striking are the suicide rates among 
adolescents and young adults in these communities. Suicide 
rates in 2014 for American Indian/Alaskan Native individuals 
between the age of 15 to 24 years old was 39.7 per 100,000, 
compared with the overall U.S. rate of 9.9 per 100,000. This 
rate is more than 3 and a half times the suicide rate for males 
of all races in the age group. The suicide rate for AI/AN 
females in the same age group was lower than males at 20.2 per 
100,000. However, this rate was still nearly six times the rate 
for females of all races. \14\
---------------------------------------------------------------------------
    \14\  U.S. Department of Health and Human Services, Substance Abuse 
and Mental Health Services Administration, (2017). Suicide Clusters 
within American Indian and Alaska Native Communities: A review of the 
literature and recommendations. HHS Publication No. SMA17-5050. 
Rockville, MD. Retrieved from: https://store.samhsa.gov/sites/default/
files/d7/priv/sma17-5050.pdf
---------------------------------------------------------------------------
    As part of the coordinating role, the NIMH Office of Rural 
Mental Health Research should collaborate with other 
departments that are building networks to reach high risk rural 
populations, including veterans, farmer, ranchers and the 
agricultural community. The Department of Veterans' Affairs, 
the Department of Agriculture, the Substance Abuse and Mental 
Health Services Administration, Health Resources and Services 
Administration, Indian Health Service and others. Farmers, 
agricultural and migrant workers face unique stressors. The CDC 
results on deaths by suicide per capita (by occupation) reveal 
that these stressors can have tragic effects. Farmers, 
agricultural workers and their families likely would benefit 
from stress assistance programs tailored to the specific needs 
of this population. including such elements as a stress hotline 
and prescription drug abuse education for farmers, ranchers and 
agricultural workers.

    To achieve health equity for rural and frontier 
populations, APA recommends taking a population health approach 
that also recognizes the cultural and geographic diversity of 
rural and frontier populations, including African Americans, 
Native American/American Indian, Latinx, Hispanic, veterans, 
women, farmers, LGBTQ populations, ranchers, migrants, 
individuals with disabilities and those living in resource-
limited areas with declining population density. While the 
prevalence of mental health disorders is similar to populations 
in urban settings, rural and frontier communities face unique 
barriers to care that have been classified broadly in terms of 
accessibility, availability, acceptability, affordability and 
stigma, and a robust research agenda should seek to address 
each of these barriers. \15\
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    \15\  Juntunen, C.L., & Quincer, M.A. (2017). Underserved rural 
communities: Challenges and opportunities for improved practice. In. 
J.M. Casas, L.A. Suzuki, C.M. Alexander & M.A. Jackson (Eds) Handbook 
of Multicultural Counseling (4th edition) (pp. 447-456). Thousand Oaks, 
CA: Sage Publications.
---------------------------------------------------------------------------
    Access to psychologists in rural and frontier communities 
is of particular concern to APA, which has documented these 
workforce shortages. Of the 734 U.S. counties that were 
entirely rural, the vast majority (93.6 percent) had no records 
of licensed psychologists, about 2.4 percent had one to four 
licensed psychologists, and 4.0 percent had five or more 
licensed psychologists. \16\ Research is needed on specific 
effective and innovative recruitment strategies for rural 
mental health providers, including a focus on cultural 
competence in rural populations.
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    \16\  American Psychological Association. (2016). County-Level 
Analysis of U.S. Licensed Psychologists and Health Indicators. https://
www.apa.org/workforce/publications/15-county-analysis
---------------------------------------------------------------------------
    The expansion of integrated care and telemental health 
holds promise for improving access to mental and behavioral 
health care and improving outcomes, but more research is needed 
to determine the essential components of integrated health care 
teams and ensure that workforce shortages do not undermine the 
ability to implement evidence-based interventions in these 
communities. Research is also needed to increase the 
availability of evidence-based behavioral health assessment, 
evaluation, prevention, and treatment within medical practices 
(in addition to primary care) in rural settings, including 
barriers to access.

    Historically, research takes an urban-centered approach 
that has not focused on the unique needs of rural and frontier 
populations when developing or conducting research and 
implementing interventions. APA supports the greater 
recognition of the need to develop research programs that 
recognize the tremendous diversity of, and within, rural and 
frontier communities. To achieve health equity, community-based 
participatory research should include community engagement 
strategies that take into consideration these diverse cultures 
to increase the participation of rural communities in research 
and diversify the research workforce. As much of the research 
on rural health disparities examines disparities between rural 
and urban communities, additional research could focus on 
disparities within rural communities. Growing diversity 
increases the difficulty of fully understanding the 
psychological characteristics and needs of rural citizens. 
Culturally competent providers must also recognize the culture 
inherent in the geographic and social locations of rural 
citizens and be open to both the challenges and opportunities 
to supporting rural psychological health and well-being. \17\
---------------------------------------------------------------------------
    \17\  Juntunen, C.L., & Quincer, M.A. (2017). Underserved rural 
communities: Challenges and opportunities for improved practice. In. 
J.M. Casas, L.A. Suzuki, C.M. Alexander & M.A. Jackson (Eds) Handbook 
of Multicultural Counseling (4th edition) (pp. 447-456). Thousand Oaks, 
CA: Sage Publications.
---------------------------------------------------------------------------
    In addition to the complexity of rurality itself, it is 
important to note that other vulnerable populations, including 
elders and people living in poverty, are over-represented in 
rural communities. Rural areas also include culturally diverse 
populations, although this is not consistently recognized. 
Racial and ethnic minorities in rural areas may live in even 
more isolated communities (such as American Indian reservation 
and tribal lands) and often are overlooked in diversity 
conversations, but that is also changing as rural demographics 
reflect more ethnic and racial diversity. \18\ Some tribes do 
not recognize traditional diagnoses like major depressive 
disorder. American Indians and Alaska Natives have a much 
higher reported rate of distress (13 percent) in comparison to 
the general population (9 percent). \19\
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    \18\  Lichter, D.T. (2012). Immigration and the new racial 
diversity in rural America. Rural Sociology, 77, 3-35. doi: 10. 0.1111/
j.1549-0831.2012.00070.
    \19\  Stewart, E.G. (2018). Mental Health in Rural America: A Field 
Guide (1st ed.). Routledge. https://doi--org.ezproxy.lib.vt.edu/
10.4324/9781315189857
---------------------------------------------------------------------------
    Refugees and undocumented immigrants are a group which face 
a number of mental health issues such as PTSD and attachment 
issues (relevant to family separation both at the border and in 
general). When traveling to the United States, they face a 
number of traumatic events like abuse or torture, leading to 
social adjustment issues. These are very unique problems, which 
need to be treated with culturally competent care. There are 
also language and cultural barriers which need to be taken into 
account. Similar to Native Americans and Alaskan Natives, this 
group have different cultural understandings of what we would 
consider a diagnosis. \20\
---------------------------------------------------------------------------
    \20\  Stewart, E.G. (2018). Mental Health in Rural America: A Field 
Guide (1st ed.). Routledge. https://doi-org.ezproxy.lib.vt.edu/10.4324/
9781315189857
---------------------------------------------------------------------------
    Considering that much of the research on empirically 
supported treatments is conducted with urban populations, 
little is generalizable to rural residents' who often face 
unique challenges that may act as barriers to care, treatment 
engagement and retention, and treatment outcomes. Research is 
needed to more explicitly identify clinical and professional 
methods and strategies that engage and retain rural patients in 
behavioral health treatment.

    To counter disparities in mental health care there has been 
a growing momentum to introduce technologies to deliver mental 
health care remotely. Tele-mental health enables effective care 
management, expands access to services, and promotes the 
integration of primary and mental healthcare services. The 
Veterans Affairs Health Administration has been a leading 
health care system in delivering these types of services with 
great success. \21\ More recently, due to the global pandemic, 
telemental health expansion across other health care systems 
has also shown great promise in offering adequate and timely 
mental health care. \22\ These technologies have been found 
acceptable to older adult communities. \23\
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    \21\  Caver, K. A., Shearer, E. M., Burks, D. J., Perry, K., De 
Paul, N. F., McGinn, M. M., & Felker, B. L. (2020). Telemental health 
training in the veterans administration puget sound health care system. 
Journal of clinical psychology, 76(6), 1108-1124.
    \22\  Patel, S. Y., Huskamp, H. A., Busch, A. B., & Mehrotra, A. 
(2020). Telemental Health and US Rural--Urban Differences in Specialty 
Mental Health Use, 2010--2017. American Journal of Public Health, 
110(9), 1308-1314.
    \23\  Choi, N. G., Caamano, J., Vences, K., Marti, C. N., & Kunik, 
M. E. (2020). Acceptability and effects of tele-delivered behavioral 
activation for depression in low-income homebound older adults: in 
their own words. Aging & Mental Health, 1-8.
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    Despite the advantages of telehealth for care services, 
several barriers exist. For example, critical issues remain 
with coverage and reimbursement, licensure, broadband access 
and adequacy, privacy and policy barriers. There are also 
concerns related to shortages in the community-based geriatric 
healthcare workforce shortage in delivering care and using 
these technologies.

    Research on the effectiveness of different modalities of 
telehealth care delivery in rural communities is needed. While 
video-based telehealth and telepsychiatry services provide 
clinicians the opportunity to observe important, non-verbal 
cues that may have clinical relevance, many rural and frontier 
residents lack adequate broadband infrastructure to support the 
delivery of video-based services (Graves et al., 2020; FCC, 
2020). \24\, \25\, \26\ Prioritizing the effectiveness of other 
telehealth delivery models to increase access to behavioral 
health care is warranted given this geographic digital divide.
---------------------------------------------------------------------------
    \24\  Lindsay JA, Hogan JB, Ecker AH, Day SC, Chen P, Helm A. The 
Importance of Video Visits in the Time of COVID-19. J Rural Health. 
2021 Jan;37(1):242-245. doi: 10.1111/jrh.12480. Epub 2020 Jun 30. PMID: 
32506751; PMCID: PMC7300637.
    \25\  Graves JM, Mackelprang JL, Amiri S, Abshire DA. Barriers to 
Telemedicine Implementation in Southwest Tribal Communities During 
COVID-19. J Rural Health. 2021 Jan;37(1):239-241--doi: 10.1111/
jrh.12479. Epub 2020 Jun 30. PMID: 32506685; PMCID: PMC7300815.
    \26\  Federal Communications Commission. (2021). Bridging the 
Digital Divide for All Americans. https://www.fcc.gov/about--fcc/fcc--
initiatives/bridging-digital-divide-all--americans.
---------------------------------------------------------------------------
    Research addressing the impact of audio-only telehealth 
services on mental health treatment access in rural and remote 
regions is needed. The pandemic has demonstrated significant 
access related opportunities through audio-only services that 
have uniquely met rural patients' needs. Rural individuals are 
more likely to face internet service and technology-based 
barriers to telehealth services. Audio-only services that rely 
on phone access is typically more reliable and available in 
rural areas when compared to internet-based video telehealth 
services. APA recommends that NIMH invest in research to test 
multiple tele-mental health delivery systems (e.g., telephone, 
versus videoconference, or hybrid formats) to address optimal 
care in rural settings, including for older adults.

    Increasing access to evidence-based integrated primary and 
behavioral healthcare could also aid in preventing suicide in 
rural areas, especially in conjunction with telehealth. In the 
primary care behavioral health (PCBH) model of integrated care, 
psychologists and other behavioral health providers work 
together with primary care providers in delivering team-based 
care. Congress should support broader implementation of PCBH 
and other evidence-based integrated care models by providing 
stronger assistance and incentives for its adoption by primary 
care practices and behavioral health providers. Integrated care 
is already in use by both the Veterans Health Administration 
and the Department of Defense to improve the identification and 
treatment of mental health and substance use disorders for 
their patients.

    Schools are important settings for accessing mental health 
professionals, yet rural students are less likely to have 
access to school-based mental health services. \27\ School-
based mental health service is an ever-evolving and growing 
service that effectively meets the needs of rural and 
underserved children and adolescents. There are a number of 
successful school-based programs that have been established and 
tested by psychologists but relatively few have been 
specifically implemented or tested in rural schools. In many 
rural areas, the school bus is the most reliable form of 
transportation, making school-based settings the optimal 
setting to access children and families in need. This service 
presents diverse opportunities for screening, prevention, and 
treatment of some of our most at-risk rural individuals and 
families. APA recommends behavioral health services in schools 
to address rural-urban disparities in access to mental health 
care. Expanding research partnerships with schools and school-
based health centers could demonstrate effectiveness in school-
based interventions for children and adolescent mental health.
---------------------------------------------------------------------------
    \27\  Shelton AJ, Owens EW. Mental Health Services in the United 
States Public High Schools. J Sch Health. 2021 Jan;91(1):70-76. doi: 
10.1111/josh.12976. Epub 2020 Nov 8. PMID: 33161576.
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    Question 3. On what aspects of military suicide prevention 
should future congressionally funded research efforts focus?

    Answer 3. One of the biggest issues in the military 
community specifically is the ongoing stigma surrounding mental 
health and lack of access to resources that Veterans and active 
Servicemembers feel comfortable accessing. There is still a lot 
of concern out there that if a Servicemember seeks mental 
health treatment their career will be derailed, or they will 
lose security clearance. Research into the current state of 
this stigma is necessary to develop adequate solutions. 
Additionally, APA supports the Guarding Mental Health Act that 
helps to reduce this stigma specifically for U.S. Coast Guard 
Members.

    APA also supports the use of high-quality, evidence based 
mental health care for the treatment of mental health 
conditions Veterans are experiencing. When considering non-
traditional and innovative approaches in caring for Veterans, 
they should be done in conjunction with evidence-based care. 
This is exemplified by the VA's Whole Health approach to care, 
which focuses on centering the Veteran and caring for them in a 
more holistic manner. In focusing on traditional and innovative 
approaches to care, the COVER (Creating Options for Veterans' 
Expedited Recovery) Commission report includes information 
about what types of therapies may be useful in caring for 
Veterans experiencing mental health issues. \28\ Critically, 
the VA must ensure that therapies that do not have evidence are 
not funded. This funding could be better used for other 
therapies that have more research showing their efficacy, such 
as yoga, acupuncture, mindfulness and chiropractic care.
---------------------------------------------------------------------------
    \28\  Creating Options for Veterans' Expedited Recovery. United 
States Department of Veterans Affairs. 2020 Jan. https://www.va.gov/
COVER/docs/COVER-Commission-Final-Report-2020-01-24.pdf
---------------------------------------------------------------------------
    Suicide prevention and lethal means counseling tailored to 
veterans should be further encouraged, which would require 
education and training for VA providers and community care 
providers on lethal means safety and suicide prevention and 
would direct VA to create a veteran-specific lethal means 
counseling and suicide prevention session. Nearly 70 percent of 
suicide deaths were due to firearms, compared to less than 50 
percent in the general population. \29\ Additionally, APA 
recognizes the need for workforce development. Scholarship 
programs for psychologists who agree to work at Vet Centers 
after graduating are vital to ensuring the VA has the workforce 
necessary to support current demands.
---------------------------------------------------------------------------
    \29\  22019 National Veteran Suicide Prevention Annual Report. 
https://www.mentalhealth.va.gov/docs/data--sheets/2019/2019--National--
Veteran--Suicide--Prevention--Annual--Report--508.pdf
---------------------------------------------------------------------------
    We support the Access to Suicide Prevention Coordinators 
Act, which requires VA medical centers to have at least one 
suicide prevention coordinator on staff and calls for a study 
on the feasibility of reorganizing suicide prevention 
coordinators to report to the Office of Mental Health and 
Suicide Prevention. Suicide Prevention Coordinators are vital 
to VA's efforts to reduce veteran suicide and ensuring 
appropriate staffing and prioritization of these positions 
within VA is a crucial step toward lowering rates of veteran 
suicides.

    Congress must also increase Continuity for Separating 
Servicemembers as they Transition out of Service. Studies have 
shown that transitioning out of the military to civilian life 
increases risk for suicide, especially in certain populations. 
\30\ DoD's inTransition program is an excellent resource for 
servicemembers as they are separating from the service and 
throughout their career. It is critical that inTransition, the 
Transition Assistance Program, and the Yellow Ribbon 
Reintegration Program are fully funded to meet the needs of 
active duty servicemembers as well as the National Guard and 
Reserve. It is also critical that transitioning servicemembers 
know about and have access to Department of Veterans Affairs 
(VA) services.
---------------------------------------------------------------------------
    \30\  Ravindran C, Morley SW, Stephens BM, Stanley IH, Reger MA. 
Association of Suicide Risk With Transition to Civilian Life Among US 
Military Service Members. JAMA Netw Open. 2020;3(9):e2016261. 
doi:10.1001/jamanetworkopen.2020.16261
---------------------------------------------------------------------------
    DoD and VA-specific services and research must be 
complemented by suicide prevention programs directed at the 
broader population, but also available to current and former 
Servicemembers. Removing barriers to the provision of 
telehealth services in Medicare, Medicaid and commercial 
insurers, including allowing audio-only telehealth services, 
reimbursement parity, the ability providers to practice across 
state lines are important steps to increase access. Community 
mental and behavioral health infrastructures also need to be 
kept from collapse to ensure providers have resources to 
maintain operations and meet increasing needs of treatment. 
This includes Medicaid funded community mental and behavioral 
health centers, other nonprofit community mental health 
organizations and providers of mental health and addiction 
services.

    Provider Burnout: Throughout the pandemic, I have been 
concerned about our health care workforce. Now, with a 
workforce shortage across the country, acute shortages in 
workers as infected staff isolate, and mounting burnout as we 
enter year three of this pandemic, I am more concerned than 
ever about the future of our health workforce.

    Question 1. Specifically in the mental health care sector, 
what steps can we take to help support the mental health needs 
of health providers, and expand and improve retention in an 
already-depleted workforce?

    Answer 1. APA shares your concern about provider burnout 
amidst increased demand for mental and behavioral health 
services. Indeed, the data shows that this phenomenon was 
clearly present long before the current pandemic. With added 
demand for services due to pandemic-related stressors, coupled 
with resurgent rates in abuse of opioids, stimulants, and other 
substances, we fear that, without prompt action, increased 
rates of provider burnout will impede providers' ability to 
provide quality evidence-based care. To increase the size and 
diversity of the behavioral health workforce, Congress can 
increase its support for key behavioral health workforce 
programs such as the Graduate Psychology Education (GPE) 
Program, the Minority Fellowship Program (MFP), and the 
Behavioral Health Workforce Education and Training (BHWET) 
Program. Additionally, to improve the pipeline of behavioral 
health providers, Congress can support efforts to allow 
psychology trainees--who receive 500-700 hours of direct 
patient experience through their training program--to bill for 
services they provide under the supervision of a licensed 
psychologist, similar to the flexibilities that medical school 
trainees currently enjoy. Finally, Congress can take steps to 
eliminate duplicative and unnecessary administrative burdens on 
independent practitioners; for example, while APA supported the 
policy goals of the No Surprises Act to provide a measure of 
cost transparency to patients, we are concerned that the way 
the Administration is implementing No Surprises Act imposes 
unnecessary burdens on behavioral health practitioners--such as 
the repetitive preparation ``good faith estimates'' of costs--
that do not further the Act's purposes.

    Suicide Prevention and Screening: A study from 2016 
estimated that 11 percent of ED patients present with suicide 
ideation. However, only 3 percent of patients were being 
identified by screening. In addition, upwards of 70 percent of 
patients who leave the ED after a suicide attempt never attend 
their first outpatient appointment.

    Question 1. I have sponsored a bill, S. 467, that provides 
direct assistance to hospital emergency departments so they can 
enhance their ability to screen for high-risk suicidal patients 
and improves the treatment they receive while in emergency 
rooms. Do you believe that hospital emergency departments can 
play important role in identifying and treating suicidal 
patients who otherwise would never be screened for possible 
suicide?

    Answer 1. As you noted Senator, emergency rooms do provide 
crisis mental health care in almost every jurisdiction in the 
country and are often ill-equipped to manage that task. More 
than 500,000 people present to emergency departments each year 
with deliberate self-harm or suicidal ideation--both major risk 
factors for suicide. Up to 80 percent of suicide decedents 
visit healthcare settings in the year before death, and about a 
fifth of decedents are seen in healthcare within the week of 
death, making the delivery of effective interventions a top 
priority. Legislation such as yours can help improve training, 
staffing and procedures so that emergency rooms may better 
manage their mental health patients in crisis, improving the 
quality and consistency of the care those patients receive. 
It's critically important to ensure emergency departments have 
policies of consistent universal screening for suicide risk and 
resources to ensure their patients can receive follow-up care. 
Additional funding for research is also important, to 
understand how services can be targeted to the needs to 
different populations. Despite advances in treatments over the 
past several decades, and effective psychosocial interventions 
that reduce repeat suicide attempts, there remain few evidence-
based interventions that have been tested for their rapid-onset 
benefits for reducing suicide risk.

    Role of Social Media and Isolation: As Dr. Murthy 
highlighted last month, youth mental health and substance 
misuse has been on the rise even before the pandemic, meaning 
pre-global pandemic we were failing to address the factors that 
lead to mental health crisis and substance misuse in youth. 
Anecdotally we know that increased screen time and exposure to 
social media is having an impact on youth.

    Question 2.. What efforts are underway to research this 
impact and better understand the implications and 
recommendations for care?

    Answer 2. There has never been a more important time to 
examine the impact of social media on children. Psychological 
scientists, in particular, are increasingly warning that the 
use of digital media platforms can exploit biological 
vulnerabilities among. \31\, \32\ It has long been established 
that adolescence is associated with neurological changes that 
promote cravings for social attention, feedback, and status. 
Research demonstrates that digital media satisfies these 
cravings at a neural level, activating the same neural regions 
as drugs. \33\, \34\, \35\ We know that there are ways to 
beneficially use social media platforms, especially for those 
individuals seeking to buffer the impacts of negative life 
events, decrease feelings of isolation, gain a sense of 
purpose, and experience feelings of acceptance or being 
understood. \36\ And early evidence of technology-based mental 
health interventions also show promise at treating a range of 
problems. \37\, \38\, \39\ But users of social media platforms 
remain uninformed and biologically susceptible to negative 
outcomes.
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    \31\  Crone, E.A., & Konijn, E.A. (2018). Media use and brain 
development during adolescence. Nature Communications, 9, 1--10. 
https://doi.org/10.1038/s41467-018-03126-x
    \32\  Wilmer, H. H., & Chein, J. M. (2016). Mobile technology 
habits: Patterns of association among device usage, intertemporal 
preference, impulse control, and reward sensitivity. Psychonomic 
Bulletin and Review, 23(5), 1607--1614. https://doi.org/10.3758/s13423-
016-1011-z
    \33\  De-Sola Gutierrez, J., Rodriguez De Fonseca, F., & Rubio, G. 
(2016). Cell-phone addiction: A review. Frontiers in Psychiatry, 7. 
https://doi.org/10.3389/fpsyt.2016.00175
    \34\  Griffiths, M. D., Kuss, D. J., & Demetrovics, Z. (2014). 
Social networking addiction: An overview of preliminary findings. 
Behavioral Addictions: Criteria, Evidence, and Treatment, 119-141. 
https://doi.org/10.1016/B978-0-12-407724-9.00006-9
    \35\  Kirby, B., Dapore, A., Ash, C., Malley, K., & West, R. 
(2020). Smartphone pathology, agency and reward processing. Lecture 
Notes in Information Systems and Organisation, 321-329. https://
doi.org/10.1007/978-3-030-60073-0--37
    \36\  Daine, K., Hawton, K., Singaravelu, V., Stewart, A., Simkin, 
S., & Montgomery, P. (2013). The Power of the Web: A systematic review 
of studies of the influence of the Internet on self-harm and suicide in 
young people. PLoS ONE, 8(10), e77555. https://doi.org/10.1371/
journal.pone.0077555
    \37\  Galla, B. M., Choukas--Bradley, S., Fiore, H. M., & Esposito, 
M. V. (2021). Values--alignment messaging boosts adolescents' 
motivation to control social media use. Child Development, 92(5), 1717-
1734. https://doi.org/10.1111/cdev.13553
    \38\  Myers, K. M., Valentine, J. M., Melzer, S. M. (2007, Nov). 
Feasibility, acceptability, and sustainability of telepsychiatry for 
children and adolescents. Psychiatric Services, 58(11), 1493-1496. 
https://doi.org/10.1176/ps.2007.58.11.1493
    \39\  Nelson, E. L., Cain, S., & Sharp, S. (2017, Jan). 
Considerations for conducting telemental health with children and 
adolescents. Child Adolescent Psychiatric Clinics of North America, 
26(1), 77-91. https://doi.org/10.1016/j.chc.2016.07.008
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    Another area of concern among scientists is the heightened 
potential for peer influence facilitated by digital media 
platforms. This is exacerbated by the proliferation of 
misinformation and disinformation campaigns that gain traction 
specifically due to the accessibility of digital media. 
Psychological science demonstrates that digital media creates 
the illusion that expressed opinions represent many others' 
beliefs and not just the thinking of an isolated user. \40\, 
\41\, \42\, \43\, \44\ Participation on digital media platforms 
changes how we think about what others think. Science 
demonstrates that this has created a powerful link between 
young people's Instagram exposure and their offline risk-taking 
behavior, such as excessive alcohol use. \45\, \46\ \47\, \48\
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    \40\  Chen, J., Liang, Y., Mai, C., Zhong, X., & Qu, C. (2016). 
General deficit in inhibitory control of excessive smartphone users: 
Evidence from an event-related potential study. Frontiers in 
Psychology, 7, 511. https://doi.org/10.3389/fpsyg.2016.00511
    \41\  Dong, G., Zhou, H., & Zhao, X. (2011). Male Internet addicts 
show impaired executive control ability: Evidence from a color-word 
Stroop task. Neuroscience Letters, 499(2), 114--118. https://doi.org/
10.1016/j.neulet.2011.05.047
    \42\  Gao, L., Zhang, J., Xie, H., Nie, Y., Zhao, Q., & Zhou, Z. 
(2020). Effect of the mobile phone related-background on inhibitory 
control of problematic mobile phone use: An event-related potentials 
study. Addictive Behaviors, 108, 106363. https://doi.org/10.1016/
j.addbeh.2020.106363
    \43\  Gao, Q., Jia, G., Zhao, J., & Zhang, D. (2019). Inhibitory 
control in excessive social networking users: Evidence from an ERP-
based Go-Nogo task. Frontiers in Psychology, 10, 1810. https://doi.org/
10.3389/fpsyg.2019.01810
    \44\  Nesi, J.L., & Prinstein, M.J. (2015). Using social media for 
social comparison and feedback seeking: Gender and popularity moderate 
associations with depressive symptoms. Journal of Abnormal Child 
Psychology, 43(8), 1427--1438.
    \45\  Cabrera-Nguyen, E. P., Cavazos-Rehg, P., Krauss, M., Bierut, 
J., & Moreno, M. A. (2016). Young adults' exposure to alcohol-and 
marijuana-related content on Twitter. Journal of Studies on Alcohol and 
Drugs, 77(2), 349--353. https://doi.org/10.15288/jsad.2016.77.349
    \46\  Curtis, B. L., Lookatch, S. J., Ramo, D. E., McKay, J. R., 
Feinn, R. S., & Kranzler, H.R. (2018). Meta-analysis of the association 
of alcohol-related social media use with alcohol consumption and 
alcohol-related problems in adolescents and young adults. Alcoholism: 
Clinical and Experimental Research, 42(6), 978--986. https://doi.org/
10.1111/acer.13642
    \47\  Pegg, K. J., O'Donnell, A. W., Lala, G., & Barber, B. L. 
(2018). The role of online social identity in the relationship between 
alcohol-related content on social networking sites and adolescent 
alcohol use. Cyberpsychology, Behavior, and Social Networking, 21(1), 
50--55. https://doi.org/10.1089/cyber.2016.0665
    \48\  Moreno, M. A., Chassiakos, Y. R., Cross, C., Hill, D., 
Ameenuddin, N., Radesky, J., Hutchinson, J., Boyd, R., Mendelson, R., 
Smith, J., Swanson, W. S., & Media, C. C. (2016). Media use in school-
aged children and adolescents. Pediatrics, 138(5). https://doi.org/
10.1542/peds.2016-2592
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    Increased peer victimization and harassment, as well as 
more severe discrimination directed toward racial, ethnic, 
gender, and sexual minorities, represent another serious area 
of concern. Scientific findings have revealed more frequent and 
offensive forms of harassment directed toward youths online as 
compared with offline. \49\, \50\ Brain scans of adults and 
youths reveal that these forms of harassment activate the same 
regions of the brain that respond to physical pain and trigger 
a cascade of reactions that replicate physical assault and 
create physical and mental health damage. \51\
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    \49\  Tynes, B. M., Giang, M. T., Williams, D. R., & Thompson, G. 
N. (2008). Online racial discrimination and psychological adjustment 
among adolescents. Journal of Adolescent Health, 43(6), 565-569. 
https://doi.org/10.1016/j--jadohealth.2008.08.021
    \50\  Cannon, D. S., Tiffany, S. T., Coon, H., Scholand, M. B., 
McMahon, W. M., & Leppert, M. F. (2007). The PHQ-9 as a brief 
assessment of lifetime major depression. Psychological Assessment, 
19(2), 247-251. https://doi.org/10.1037/1040-3590.19.2.247
    \51\  Epps-Darling, A., Bouyer, R. T., & Cramer, H. (2020, 
October). Artist gender representation in music streaming. In 
Proceedings of the 21st International Society for Music Information 
Retrieval Conference (Montreal, Canada) (ISMIR 2020). ISMIR (pp. 248-
254).
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    Finally, the lack of transparency into the inner workings, 
policies and measured impacts of these platforms must be 
addressed. The impact of social media algorithms on the user 
experience is woefully understudied due in large part to the 
lack of visibility by researchers into the data and how 
algorithms work. \52\ Social media companies employing 
algorithms to display content to users should provide 
explanations on how these technologies work and how they might 
drive or reward certain types of posts or behavior. Data from 
algorithms, along with internal research should also be made 
public to allow researchers and policymakers to achieve a 
greater understanding of the impacts of social media on users, 
particularly children. Federal agencies should prioritize 
research into the impacts of social media and providing private 
researchers with grants and other support to ensure findings 
relating to these platforms are made broadly available.
---------------------------------------------------------------------------
    \52\  Bravo, D. Y., Jefferies, J., Epps, A., & Hill, N. E. (2019). 
When things go viral: Youth's discrimination exposure in the world of 
social media. In Handbook of Children and Prejudice (pp. 269-287). 
Springer, Cham. https://doi.org/10.1007/978-3-030-12228-7--15
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    For a more comprehensive summary of the currently available 
research in this area, I am attaching a summary of a 
forthcoming research handbook I co-edited. The Handbook of 
Adolescent Digital Media Use and Mental Health is scheduled for 
release by Cambridge University Press in 2022.

    Question 3. What methods should we focus on to prevent the 
onset of substance misuse and mental health disorders in 
America's youth?

    Early detection and early intervention are critical to 
preventing the onset of mental health and substance misuse 
disorder among children and adolescents, however a focus on 
prevention rather than crisis management continues to be rare. 
As most young people spend a majority of their time in school, 
school-based mental health care is an essential tool for 
prevention purposes. Such services can build resiliency and 
mental health literacy among youth, to both address needs and 
destigmatize mental health. Leveraging partnerships between 
community and school-based entities can provide training to 
teachers, administrators, and support personnel, as well as 
families, students, and community members to recognize signs of 
emotional and psychological concerns and provide best practices 
for the delivery of mental health care in schools.

    Furthermore, increased adoption of evidence-based models of 
integrating primary and behavioral health care is another way 
to help increase prevention, early detection, and early 
intervention, while also reducing stigma around mental health, 
which prevents many ethnic and racial minority populations, 
including Black, Hispanic, Asian/Pacific Islander, and Tribal, 
from seeking needed care.
                                ------                                


Response by Michelle P. Durham to Questions of Senator Murphy, Senator 
   Kaine, Senator Smith, Senator Lujan, Senator Collins, and Senator 
                               Murkowski

                             SENATOR MURPHY

    Question 1. How can we better prepare professionals in 
frequent contact with children and teens, such as teachers and 
pediatricians, to better deal with young people's unique 
behavioral health needs?

    Answer 1. As the Director of Clinical Training at TEAM UP 
for Children, a pediatric integrated model in federally 
qualified health centers (FQHCs) in Massachusetts, I see 
firsthand the impact that targeted staff training and supports 
can have on quality of care and child health. The TEAM UP for 
Children model, co-developed by Boston Medical Center (BMC) and 
partner FQHCs, is based on the National Academy of Medicine's 
Promotion Framework and focuses on promotion, prevention, early 
identification of emerging behavioral health issues, and swift 
access to behavioral health services that are delivered by a 
multi-disciplinary team. TEAM UP for Children enables pediatric 
primary care providers to better manage common behavioral 
health diagnoses in the primary care setting through clinical 
training, quality improvement support, and a team-based model 
that includes embedded behavioral health clinicians and 
community health workers. This type of model could be scaled up 
to serve additional clinical sites and adapted to suit other 
settings, such as schools, to increase the ability for 
frontline staff to identify and address children's behavioral 
health needs, while also making mental health services 
available in the places where children are.

    Question 2. How might additional training for these 
professionals improve supports for young people?

    Answer 2. The goal of this type of approach is really about 
prevention. In other words, reaching young people before they 
are in crisis. Bolstering mental health resources and supports 
in the places where children are--in schools and other 
community settings--allows for children to be able to access 
help at the time that they need it. Oftentimes this requires 
intervening before there is an actual behavioral health 
diagnosis, which conventional health insurance plans typically 
don't permit. In July 2021, Massachusetts' combined Medicaid 
and Children's Health Insurance Program (CHIP) or 
``MassHealth'' added a new integrated behavioral health code to 
allow mental health clinicians to receive reimbursement for 
seeing a pediatric patient up to six times without needing a 
mental health diagnosis https://www.mass.gov/doc/physician-
bulletin--103--integrated--behavioral--health--service--code--
description--and--billing--requirements--download. This type of 
flexibility shows great promise and could serve as a prevention 
model other states could emulate.

    Question 3. Knowing that we have significant health care 
disparities stratified by income, race, and geography (e.g. 
rural areas), how do we ensure health equity in addressing the 
behavioral health needs of children and teens?

    Answer 3. The TEAM UP for Children model is designed to 
disrupt health care disparities. By strengthening the ability 
of FQHCs to recognize emerging child behavioral health issues 
and intervene early with appropriate treatment, TEAM UP for 
Children aims to improve life outcomes for tens of thousands of 
low-income children across Massachusetts. Ensuring that mild 
and moderate cases of common mental disorders (depression, 
anxiety, ADHD, etc.) can be managed in the pediatric primary 
care setting, and at FQHCs in particular, which 
disproportionately serve as the site of care for low-income 
children and children of color, opens up access to mental 
health care to a population that historically has high needs 
but faces the highest barriers to care. Investing in community 
health workers (CHWs), which play a central role in the TEAM UP 
for Children model, would also serve to advance health equity. 
CHWs serve as a bridge to the community as they are often 
members of the community and are trained to work with families 
to address basic needs, provide mental health education, and 
offer school support in culturally and linguistically 
appropriate ways.

                             SENATOR KAINE

    Even before the pandemic, underserved, rural, and minority 
communities faced too many barriers in accessing health care, 
and mental health services are not exempt. This has only been 
exacerbated by nationwide physician shortages. And, while the 
number of mental health providers of color has grown in recent 
years, they still only account for 17 percent of the workforce 
according to the American Psychological Association. It is 
clear that we need more mental health professionals. We know 
that mental health services are delivered by a wide array of 
professionals, and that primary care providers are often at the 
forefront of mental health care.

    One way we can address this issue is by diversifying and 
expanding our physician pipeline, as medical students of color 
and those from rural areas are more likely to practice in the 
communities they are from. This Congress, I reintroduced 
important legislation, the Expanding Medical School Education 
Act, to help us get one step closer to ensuring communities 
have access to the medical professionals they need. This bill 
supports the creation or expansion of medical schools in 
medically underserved communities and at minority-serving 
institutions, including Historically Black Colleges and 
Universities.

    Question 1. Could you speak to the importance of having 
cultural and linguistic diversity among mental health 
providers?

    Answer 1. Senator Kaine, thank you for your question and 
for supporting this important bill. Increasing ethnic, cultural 
and linguistic diversity in the mental health workforce is 
critical to engaging diverse communities in treatment. There is 
great stigma around mental illness and seeking treatment. It is 
well known that those that do make the first step to treatment, 
do not feel heard or understood during clinical encounters. At 
times their symptoms are dismissed, overlooked, or 
misdiagnosed. We know that racism and discrimination create an 
unequal system of care for diverse populations. By increasing 
the diversity in the physician workforce, people can engage in 
treatment with folks who look like them, share the same faith, 
understand the language, and understand the person's culture to 
better inform care.

                             SENATOR SMITH

    Question 1. What steps should we be taking at the Federal 
level to address the immediate shortage of pediatric mental 
health beds?

    Answer 1. A regional approach to expand the full continuum 
of care services, not just crisis services, including an 
emphasis on prevention and moving upstream to address health-
related social needs, behavioral health integration in primary 
care settings, and other means of enabling individuals to 
access outpatient mental health services when they need it, 
could lead to reduced reliance on emergency services and 
inpatient mental health services for children and adults. 
Timely response is key and can potentially avoid requiring 
emergency or inpatient-level care.

    Massachusetts has several models for investing in 
prevention that are ripe for replication:

         LThe Boston Emergency Services Team (BEST)--
        led by Boston Medical Center--provides a comprehensive 
        and highly integrated system of crisis evaluation, 
        intervention, and treatment services to residents of 
        the Boston-area, including mental health urgent care 
        centers, mobile crisis intervention for youth, 
        community crisis stabilization program for adults, and 
        a jail diversion program.

         LChildren's Behavioral Health Initiative 
        (CBHI), which initially focused on youth covered by 
        MassHealth (Medicaid/CHIP) and has since expanded to 
        include commercial health insurance, provides coverage 
        for an enhanced continuum of home-and community-based 
        behavioral health services and requires primary care 
        providers to screen for behavioral health conditions as 
        a routine part of care.

    Question 2. What are specific examples of initiatives that 
you have seen in your work that have done a good job of 
incorporating mental health into the broader response to COVID-
19? What should Congress learn from these successes?

    Answer 2. Telehealth profoundly expanded access to mental 
health services during the COVID-19 pandemic. Telehealth 
enabled BMC to maintain and exceed our pre-pandemic volume of 
mental health services, with over 90 percent of our outpatient 
psychiatric visits conducted via telehealth at peak. In 
addition, show rates to telehealth visits (video and audio-only 
combined), which to-date hover around 75-85 percent, have 
exceeded show rates to in-person behavioral health visits pre-
COVID-19 by roughly 10 percentage points, suggesting that 
telehealth has significantly reduced barriers and enhanced 
timely access to care for our patients.

    Even as in-person volume has steadily returned at BMC, 
audio-only services continue to account for a significantly 
greater percentage of our ambulatory visit volume compared to 
video. BMC data demonstrate that a higher proportion of White 
and English-speaking patients scheduled and completed 
ambulatory visits via video compared to non-White (particularly 
Black and Latinx) and non-English-speaking patients. This trend 
of differential utilization of video care by race/ethnicity and 
language has been shown to be consistent across diverse medical 
systems.

    We urge Congress to pass the ``Telemental Health Care 
Access Act of 2021'' to remove the requirement for Medicare 
beneficiaries to have an in-person visit for mental health 
services in order to access telehealth for mental health 
services, and instead allow providers to rely on clinical 
discretion and patient preference to determine the appropriate 
treatment modality (audio, video, or in-person).

    Question 3. What steps should Congress take to protect 
tele-mental health access, and what specific policies should be 
pursued for private federally regulated health plans, which 
fall under the jurisdiction of the HELP Committee?

    Answer 3. In 2021, the BMC integrated behavioral health 
program launched a pilot telehealth hub for behavioral health 
counseling visits to take place in community in partnership 
with a local church. By providing access to video capable 
technology, high-speed, reliable internet, and a private space 
in a convenient, trusted location, the pilot seeks to reduce 
barriers for people to utilize telehealth. The Federal 
Government could play a role in helping accelerate the 
development of community telehealth hubs by providing grants to 
health systems, hospitals, federally qualified health centers, 
schools, and community-based organizations to purchase 
equipment, retrofit space, hire staff, and receive or provide 
technical assistance.

    Question 4. Do existing systems of care recognize a 
developmental disorder such as fetal alcohol spectrum disorders 
(FASD), or do you believe that a lack of identification could 
be a significant gap in treating these individuals for their 
mental health disorders? What are the barriers in integrating 
FASD-informed identification and care into existing systems?

    Answer 4. In September 2020, BMC was awarded a 3-year, $2.9 
million Health Resources and Services Association (HRSA) grant 
to fund the SAFEST Choice Learning Collaborative, a program 
aimed at reducing the incidence of prenatal alcohol exposure 
and improving outcomes in children with suspected or diagnosed 
fetal alcohol spectrum disorders (FASD). The program--which is 
a joint effort between BMC, Boston University Schools of 
Medicine and Public Health, and Minnesota-based Proof 
Alliance--uses the Extension for Community Healthcare Outcomes 
(ECHO) virtual education platform to provide primary care 
providers at community health centers in New England and the 
Upper Midwest with training and support from experts about FASD 
and how to screen for and counsel women about the risks of 
alcohol use during pregnancy, as well as train pediatric 
providers on identifying and caring for children and 
adolescents with suspected or diagnosed FASD. \1\ More 
information on the program is available on our website: https:/
/www.bmc.org/addiction/training-education/safest-choice.
---------------------------------------------------------------------------
    \1\  Press Release: https://www.bmc.org/news/press-releases/2020/
09/09/boston-medical-center-and-proof-alliance-collaborate-reduce-
prenatal
---------------------------------------------------------------------------

                             SENATOR LUJAN

    Question 1. Health care worker burnout is devastating given 
the great debt of gratitude we owe them. That is why I was 
pleased to support the American Rescue Plan that dedicated $103 
million to reduce burnout and promote mental health and 
wellness of health care workers, which over $1 million went to 
the University of New Mexico Hospital to support the frontline 
workers who are sacrificing so much while caring for others. 
How can burnout be prevented or reduced among existing 
behavioral health providers?

    Answer 1. I prefer the term ``moral injury or moral 
distress'' to ``burnout'' as I believe it better describes the 
reality facing our Nation's frontline healthcare workers. Both 
terms point to system failures whereas burnout places the onus 
on individuals, e.g. the clinicians with symptoms of exhaustion 
and low productivity. Systems have responded to calls to 
address healthcare worker burnout with ``resilience training'' 
yoga or other individually centered interventions without 
changing the system. This kind of misaligned approach is 
problematic and unlikely to yield the intended results. Moral 
injury is more than just being overworked--it's the inability 
for providers to be able to do their jobs, confronting systemic 
issues that don't change, frequent barriers, and lack of 
supports.

    ``Moral injury describes the challenge of simultaneously 
knowing what care patients need but being unable to provide it 
due to constraints that are beyond our control.'' \2\, \3\
---------------------------------------------------------------------------
    \2\  Dean W, Talbot S, Dean A (2019). Reframing Clinician Distress: 
Moral Injury Not Burnout. Federal practitioner: for the health care 
professionals of the VA, DoD, and PHS, 36(9), 400--402.
    \3\  Epstein EG, Whitehead PB, Prompahakul C, Thacker LR & Hamric 
AB (2019). Enhancing Understanding of Moral Distress: The Measure of 
Moral Distress for Health Care Professionals, AJOB Empirical Bioethics, 
10:2, 113-124, DOI: 10.1080/23294515.2019.1586008

---------------------------------------------------------------------------
    Potential solutions to address moral injury include:

         Ldecreasing administrative burden such as 
        prior authorizations;

         Lincreasing the amount of time clinicians 
        spend with patients especially those that have co-
        occuring illness and/or need additional support due to 
        housing, financial, and/or food needs;

         Lparity in payment for physical and mental 
        health treatments.

                            SENATOR COLLINS

    I have heard firsthand from parents and caregivers in Maine 
who are gravely concerned about a greater incidence of speech 
development delays in children. Compounding their concerns is 
the fact that increased absences and continued daycare and 
preschool closures are still widespread across the country. 
Parents and teachers have anecdotally raised concerns that this 
may be related to mask use. Actually seeing people talk is 
foundational to phonetic development for all children, and 
especially those with disabilities or learning disorders.

    Harvard's Center on the Developing Child explains that, 
``As early experiences shape the architecture of the developing 
brain, they also lay the foundations of sound mental health. 
Disruptions to this developmental process can impair a child's 
capacities for learning and relating to others--with lifelong 
implications.''

    Question 1. Dr. Durham, are children with speech delays at 
a greater risk of developing mental health problems compared to 
other children? If so, what are clinicians doing now to prepare 
for the pandemic's secondary mental health consequences on 
children?

    Answer 1. Children of all ages have the potential to be 
impacted by the pandemic. Many of the families we serve at BMC 
have had to work outside of the home throughout the pandemic to 
continue providing for their families. This meant families 
living in multigenerational homes often were exposed to the 
virus. We have seen recent data indicating many children have 
lost parents and/or caregivers due to COVID-19 (linked below). 
Grief from death of loves ones, loss of school connections, 
loss of activities once enjoyed and/or the inability to stay 
fully connected to friends and family will impact many across 
all ages. The Federal Government could ensure that mental 
health services in schools and in communities are well equipped 
to support children and their families. In schools, in 
particular, supports should be in place not only for children, 
but for staff as well. It is imperative the adults caring for 
children at schools have the supports they need to continue to 
be mentally prepared to also be a source of support for 
children in schools. \4\
---------------------------------------------------------------------------
    \4\  Reference: https://www.thelancet--com/infographics/COVID-
0919--associated--caregiver--deaths
---------------------------------------------------------------------------

                           SENATOR MURKOWSKI

    Mental Health Workforce: I am deeply concerned by the 
worsening, widespread shortage of mental health professionals, 
which has only been exacerbated by the COVID-19 pandemic. Over 
half of Alaska's population, three hundred and eighty thousand 
Alaskans, live in a designated Mental Health Professional 
shortage area. Workforce shortages create another serious 
barrier to accessing mental health care services, especially 
for those living in rural communities, like many Alaskans. Last 
May, I joined Senator Smith in introducing the Mental Health 
Professionals Workforce Shortage Loan Repayment Act. This bill 
establishes a student loan repayment program for mental health 
professionals who work in these shortage areas. My hope is that 
this legislation will help expand the mental health workforce 
and incentivize professionals to provide much-needed mental 
health care to those living in rural communities and other 
underserved areas.

    Question 1. What other steps do you recommend taking to 
address mental health workforce shortages, specifically with 
regard to the shortages facing Americans in underserved and 
rural areas?

    Answer 1. Congress should consider expanding the list of 
eligible sites that qualify for the National Health Service 
Corps (NHSC) loan repayment program as a means to entice more 
clinicians to enter the mental health field. A promising 
example of this is the Health Resources and Services 
Administration (HRSA) Substance Use Disorder Treatment and 
Recovery Loan Repayment Program (STAR-LRP)--authorized by the 
SUPPORT for Patients and Communities Act of 2018--which allows 
certain clinical roles providing substance use disorder 
treatment to receive up to $250,000 in loan repayment after 6 
years. BMC recently became a STAR-LRP approved facility and 
expects this will be a significant asset to our recruitment 
efforts. Conversely, BMC, despite being an urban safety-net 
hospital that provides a continuum of mental health services to 
historically marginalized communities, does not qualify as a 
NHSC-approved site, meaning our mental health providers are not 
eligible to receive loan repayment.

    Beyond the shortage of providers, the mental health 
workforce is not representative or reflective of the U.S. 
population--for instance, only 2 percent of Psychiatrists 
identify as Black. In addition to expanding the NHSC loan 
repayment program for the mental health workforce to include 
urban safety-net providers, efforts should be directed toward 
providing greater investment in a racially and ethnically 
diverse mental health workforce, such as proposed in the 
``Pursuing Equity in Mental Health Act'' (S. 1795).

    Question 2. What can and should be done to grow the 
employee pipeline in this field?

    Answer 2. In order to grow the mental health employee 
pipeline, we must understand that the issue at its root is a 
pipeline issue that requires holistic solutions. Just as we say 
in medicine, that a person's zip code is more influential than 
their genetic code in determining life trajectory and long-term 
health, where a person lives, the color of their skin, and 
language they speak is highly determinative of the quality of 
education and resources available, the level of exposure to the 
mental health field, and stigma associated with mental illness.

    Substance Use: During COVID, we have seen a sharp rise in 
substance misuse specifically alcohol, the most widely used and 
misused substance. Unfortunately, a landmark NIH study in 2018 
established that 1 in 20 school-aged children are affected by 
fetal alcohol spectrum disorders--FASD. Because of its 
significance and its status as an overlooked disability that 
includes debilitating stigma, I introduced S. 2238, the FASD 
Respect Act. My legislation establishes common standards of 
care and increases the capacity to manage FASD in medical and 
mental health settings.

    Question 3. Do you believe pediatricians, psychiatrists, 
and other professionals need to be better informed about FASD--
is knowledge of FASD sufficient in your department? If more 
education and training is needed, how can that be achieved? How 
can stigma be lessened for individuals living with scorned 
behavioral health conditions, like FASD?

    Answer 3. In September 2020, BMC was awarded a 3-year, $2.9 
million Health Resources and Services Association (HRSA) grant 
to fund the SAFEST Choice Learning Collaborative, a program 
aimed at reducing the incidence of prenatal alcohol exposure 
and improving outcomes in children with suspected or diagnosed 
fetal alcohol spectrum disorders (FASD). The program--which is 
a joint effort between BMC, Boston University Schools of 
Medicine and Public Health, and Minnesota-based Proof 
Alliance--uses the Extension for Community Healthcare Outcomes 
(ECHO) virtual education platform to provide primary care 
providers at community health centers in New England and the 
Upper Midwest with training and support from experts about FASD 
and how to screen for and counsel women about the risks of 
alcohol use during pregnancy, as well as train pediatric 
providers on identifying and caring for children and 
adolescents with suspected or diagnosed FASD. \5\ More 
information on the program is available on our website: https:/
/www.bmc.org/addiction/training-education/safest-choice.
---------------------------------------------------------------------------
    \5\  Press Release: https://www.bmc.org/news/press-releases/2020/
09/09/boston-medical-center-and-proof-alliance-collaborate-reduce-
prenatal
---------------------------------------------------------------------------
    Suicide Screening in the Emergency Department: A recent CDC 
report on emergency department visits for people age 12-25 
found an over 50 percent increase visits for suspected suicide 
attempts during early 2021. This not only underscores the 
devastating mental health impact of the pandemic on our youth, 
but highlights yet another way that COVID-19 has strained our 
hospitals and medical staff.

    I introduced a bill, the Effective Suicide Screening and 
Assessment in the Emergency Department Act, to improve the 
screening and treatment of patients in hospital emergency 
departments who are at high risk for suicide. It will make sure 
that we can better identify our most vulnerable mental health 
patients so they do not slip through the cracks when they are 
treated in hospitals, and make sure hospitals have the 
resources they need to provide these critical services.

    Question 4. Can you talk about the need for improved 
suicide screening protocols in the Nation's emergency rooms 
and, second, do you support efforts to bolster the resources 
available to emergency rooms so they can enhance their 
screening for high-risk suicide patients?

    Answer 4. Boston Medical Center has a Psychiatric Emergency 
Department and is the lead agency for the Boston Emergency 
Services Team (BEST), which provides a comprehensive and highly 
integrated system of crisis evaluation, intervention, and 
treatment services. However, I'm fully aware that this is not 
typical of emergency departments everywhere. While I support 
screening for high-risk suicide patients in emergency 
departments, it's absolutely essential that a positive screen 
result in an appropriate response with access to appropriate 
resources for follow-up.
                                ------                                


Response by Sara Goldsby to Questions of Senator Murphy, Senator Smith, 
   Senate Lujan, Senator Murkowski, Senator Braun, and Senator Scott

                             SENATOR MURPHY

    Question 1. How can we better prepare professionals in 
frequent contact with children and teens, such as teachers and 
pediatricians, to better deal with young people's unique 
behavioral health needs?

    Answer 1. More education and training can always be done 
for all professionals to understand that all behaviors have 
meaning.

    Schools are well positioned to provide mental health and 
substance use programming and services to youth. In particular, 
school-based student assistance programs can be effective in 
providing substance use prevention, mental health promotion, 
early intervention, referral to treatment and guided support 
programming and services. As described by the Substance Abuse 
and Mental health Services Administration (SAMHSA), student 
assistance programs ``integrate trained personnel into schools 
to support and enhance the work of school faculty, as well as 
provide direct intervention services to students (Student 
Assistance: A Guide for School Administrators, SAMHSA, 2019).

    For health care professionals, more must be done to 
integrate training related to mental health and youth into 
medical education curricula. This includes screening, early 
identification and referral processes. In addition, more must 
be done to recruit and train more people interested in serving 
youth and young adults. Our nation faces a severe workforce 
shortage--including a shortage of those serving children and 
teens.

    We can also support professionals to be healthy models of 
emotion and behavior regulation, which implicitly reinforces 
positive feedback loops, helps children and teens connect with 
emotions, regulate behaviors, and improve decision-making.

    Professionals could also be supported to increase overall 
comfort addressing difficult conversations with children and 
parents and caregivers.

    Question 2. How might additional training for these 
professionals improve supports for young people?

    Answer 2. Additional training for professionals and 
increasing pediatric time with young people stands to improve 
treatment outcomes. As an example, trauma, depression and ADHD 
present in similar ways. When professionals can get at a 
distinct and accurate diagnosis young people have improved 
outcomes.

    When professionals feel more confident in their 
capabilities and practices with unique and difficult behavioral 
needs young people will be better helped earlier.

    Question 3. Knowing that we have significant health care 
disparities stratified by income, race, and geography (e.g. 
rural areas), how do we ensure health equity in addressing the 
behavioral health needs of children and teens?

    Answer 3. Focusing more resources, programs, and services 
on the populations experiencing worse outcomes and less access 
due to income, race, and location will help ensure better 
health equity. Moreover, the most significant long-term impact 
on disparities will occur when the resources, programs, and 
services are aimed at improving the social determinants well-
being overall. Finally, we know the therapeutic relationships 
for youth and young adults are incredibly important. More work 
can be done to recruit and train people of color to work in the 
mental health and substance use fields.

                             SENATOR SMITH

    Question 1. What are specific examples of initiatives that 
you have seen in your work that have done a good job of 
incorporating mental health into the broader response to COVID-
19? What should Congress learn from these successes?

    Answer 1. Rapid implementation of telehealth during COVID-
19 isolation measures to deliver mental health and substance 
use services was an instant solution to many who had challenges 
with access due to transportation and childcare before the 
pandemic. Implementing the policy and finance mechanisms that 
enabled telehealth was done quickly out of necessity. And we 
are still evidencing the successes of patient engagement and 
retention to services having eliminated those long-standing 
barriers. We can learn that a universal and coordinated 
response for a probable solution or promising practice can 
advance our goals overall even without urgent circumstances.

    Additionally, phone and text availability to mental health 
and addictions counselors that were implemented during COVID-19 
continue to be a utilized connection to care. As the 988-crisis 
line is implemented nation-wide we hope to see continued 
success and development of a service array that meets the needs 
of all callers.

                             SENATOR LUJAN

    Question 1. Access to MAT improves patient survival, but 
some estimate that only 10 percent of those with opioid use 
disorder can access MAT. I applaud the Department of Health and 
Human Services under Secretary Becerra's leadership for working 
to remove barriers that were keeping qualified practitioners 
from treating opioid use disorder with MAT. As someone working 
to combat substance use disorder at the state level, what 
policy recommendations would you make to ensure that there's a 
broad provider network that's adequately trained in medically 
assisted treatment?

    Answer 1. We are very grateful for the recent policy 
changes that have given more practitioners greater flexibility 
to provide MAT. In South Carolina, we have thousands of 
qualified prescribers who have taken the training allowing them 
to do office-based buprenorphine treatment. Despite their 
training and DATA 2000 Waiver approval, most of the 
practitioners are still not actively treating patients with 
addiction. Through our years of work with the healthcare 
community and providers across our state, we believe that 
earlier experiential practice and training in MAT services will 
break down the biases that some professionals hold toward 
people with addiction. Additionally, practical and supported 
experience earlier in training helps providers feel more 
confidence in the service delivery.

    Question 2. In addition to increasing the workforce, what 
other barriers are keeping those with substance use disorder 
from accessing MAT?

    Answer 2. There are still strong philosophies among care 
providers, decisionmakers, and the public that medications for 
opioid use disorder are simply a substitution for the 
substances people use illicitly. Many people believe that the 
only successful recovery is recovery without medications of any 
kind. This lack of understanding of the science and uniformed 
narrative drives a bias against evidence-based services, 
hindering the implementation of the medical services, and 
deterring people from them.

    Question 3. What additional barriers to treatment impact 
communities of color?

    Answer 3. The stigma of substance use disorders and their 
treatments, the costs of treatment, and stigmatizing attitudes 
of healthcare workers can all be unique barriers to communities 
of color. Early intervention programs, prevention services, and 
education about evidence-based treatment that is developed by 
local community leaders in trusted community organizations 
helps ensure cultural and language preferences are addressed. 
This can lead to improving earlier access to treatment and 
recovery support. In South Carolina, we work with our faith-
based organizations to do this kind of work. Additionally, 
punitive responses to substance use have disproportionately 
impacted communities of color. There are higher arrest rates 
for drug-related offenses for black individuals than white 
individuals. However, criminal justice systems can evolve to 
become a point of entry to treatment with diversion and 
deflection programs that adhere to standards, and support 
evidence-based treatment.

    Question 4. The first year of the COVID-19 pandemic saw the 
highest number of overdose deaths on record. Now that Pandora's 
Box has been opened and opioids are readily available in every 
corner of our country, we must use every tool at our disposal 
to save lives. As with MAT, there is growing evidence that harm 
reduction programs prevent death and connect those experiencing 
substance use disorder with the resources they need to move 
toward recovery. Dr. Goldsby, what more can the Federal 
Government do to support states hoping to expand harm reduction 
resources?

    Answer 4. In December 2021, SAMHSA released a grant funding 
opportunity for harm reduction programming that was included in 
the American Rescue Plan Act (ARPA). While only 25 awards are 
anticipated for the 3-year projects, hundreds of people across 
the states and territories attended the SAMHSA-supported 
webinars for the prospective applicants. At least six entities 
from South Carolina alone applied for the funds to begin and 
expand their harm reduction programs. DAODAS assisted many of 
the applicants in their planning conversations with local 
municipal leaders and community stakeholders. The result of the 
conversations that stemmed from the funding opportunity is a 
better understanding of harm reduction activities, and more 
acceptance of harm reduction as prevention and intervention 
strategy on the continuum of care. More support for the 
education of the evidence-based approach, and the 
implementation of the programs and services will help the harm 
reduction expand to undoubtedly save more lives.

                           SENATOR MURKOWSKI

    SUD Treatment and Recovery: While treatment receives the 
bulk of attention and investment from Congress, and prevention 
has dedicated funding via the Substance Abuse Prevention and 
Treatment Block Grant (SABG), there are no comparable dedicated 
funding streams for recovery support services. Once consumers 
receive treatment, they require a variety of services to help 
them get their lives on track. These can include housing, job 
training, the benefits of fellowship, and the services of peer 
professionals. SUD prevention, treatment, and recovery is a 
continuum of care and services.

    Question 1. Congress has proposed a 10-percent set aside in 
the SABG so that states may invest in recovery. How do you 
believe this money would best be spent?

    Answer 1. As the Single State Authority (SSA) managing the 
SAPT Block Grant in South Carolina, we have used existing 
funds, including SAPT Block Grant funds, to support a number of 
initiatives along the recovery continuum. For example, we 
support the development of collegiate recovery programs at our 
colleges and universities, and the development and growth of 
several independent recovery community organizations (RCOs) 
around the state.

    From 2018 to 2021 we supported the training and 
certification of 344 Peer Support Specialists. Many of these 
peers are now employed by are treatment services providers and 
recovery community organizations. Because Medicaid and private 
insurance coverage of the peer services is so little, we also 
support the salaries for most of these positions. Additionally, 
DAODAS has had a long-time partnership with Oxford House Inc. 
to ensure recovery housing is available across the state. A 10-
percent set aside in the SABG, with a corresponding increase in 
this program, would enable us to build on, expand, and sustain 
these kinds of programs and services.

    Question 2. Ms. Goldsby, are you seeing increased usage of 
alcohol and other harmful substances among pregnant and 
parenting women due to COVID-19 and other factors? If so, how 
is your department responding, and what measures have proven 
effective in educating the public, training primary care 
professionals, and increasing access to therapeutic recovery 
services for women?

    Answer 2. In South Carolina we began to worry about 
pregnant and parenting women specifically in March 2020. As 
soon as isolation measures due to COVID-19 were put in place we 
began seeing social media messages reinforcing increased 
alcohol use and medication misuse for women who were working 
from home and managing childcare and homeschooling 
simultaneously. In May 2020, our agency began pushing messages 
on social media platforms to counter the messages and reinforce 
healthier coping behaviors and less consumption.

    Knowing that some women were drinking more, earlier in the 
day, and possibly using other substances leads us to believe 
that many who otherwise would never have had a substance use 
disorder might have developed one during the last 2 years.

    We continue to work with the South Carolina Birth Outcomes 
Initiative with many partners to include health systems and 
women's services providers as we advocate for screening brief 
intervention and referrals to treatment for pregnant and 
parenting women at medical visits, which is not consistently 
done currently.

    With the December COVID-19 Supplement and the March COVID-
19 Supplement to the SAPT Block Grant, we developed and are 
supporting a statewide call line, and telehealth services as a 
supplement to our Plan of Safe Care effort follow-up for 
pregnant and postpartum women identified with substance use 
issues. It is modeled after the Massachusetts Child Psychiatry 
Access Program for Moms that promotes maternal/infant/child 
health for 1 year after delivery. Our program will train and 
educate healthcare providers in South Carolina on substance use 
disorders and mental disorders for pregnant and postpartum 
women. It will provide real-time psychiatric consultation via 
telehealth, and access to a care coordinator who will provide 
resources and referrals to women during the 12 months 
postpartum. This will be transformative for our families and 
our providers and our state. It is wholly supported by short-
term COVID-19 relief funds. We will be looking at ways to 
sustain this programming to stay on track with non-punitive 
interventions and care for families that could otherwise have 
social service intervention.

    In South Carolina, we support four Family Care Centers 
which are residential programs for pregnant and postpartum 
women specifically designed to deliver family centered services 
where women receive clinical substance use treatment while 
living with their baby or young children and receiving 
therapeutic services to healing as a family unit. The SAPT 
Block Grant and Medicaid reimbursement helps supports these 
Centers.

    Finally, we appreciate the funds provided in the Pregnant 
and Postpartum Women's (PPW) Residential Services Grant Program 
within SAMHSA's Center for Substance Abuse Treatment (CSAT). 
This program allocates grants to programs that support family 
centered services in residential settings. In 2016, the 
Comprehensive Addiction and Recovery Act (CARA) re-authorized 
the PPW Residential Services Grant Program, and authorized a 
pilot program to enhance flexibility in the use of funds to 
provide family centered substance use services to pregnant and 
postpartum women in non-residential service settings. We 
sincerely appreciate both the residential program and the pilot 
initiative. We hope Congress will continue to support these 
initiatives.

    Question 3. What is your state doing to improve recovery 
support services, and what lessons can the Federal Government 
take from your efforts? We are interested in hearing about your 
progress in both urban and rural areas, and amongst all 
demographics.

    Answer 3. With State Opioid Response funds, we have funded 
recovery community organizations (RCOs) across the state. While 
only a couple of RCOs have been established longer than 5 
years, we aim to meet the needs of their growth to address 
urban needs while also meeting the needs of RCOs that are 
emerging, (or have been established fewer than 5 years) and 
those RCOs that are new and just establishing themselves as 
service delivery organizations.

    Our funds and technical assistance support implementation 
and continuation of recovery-based initiatives and programs for 
persons and families affected by substance use disorders in an 
effort to reduce the consequences of opioid and stimulant 
misuse in our state. Our approved strategies that RCOs 
implement, and allowable use of the funds guide organizations 
to engage with specific populations and encourage service 
delivery and outreach to rural areas or locations that bring 
access to the people in need of services. Examples of this 
include providing mutual aid groups outside of the 
organization's walls and immediate geographic area, and 
providing Certified Peer Support Specialist services in 
specific locations such as detention centers, hospitals, and to 
faith-based groups.

    In our field we say you should `meet the person where they 
are' literally and figuratively. As administrators, we do this 
with recovery community organizations with the aim of being 
supportive and collaborative for the best possible outcomes.

    We are also currently working with the National Alliance of 
Recovery Residences (NARR) to support independent recovery 
residences as they work toward national standards and 
certification. The South Carolina legislature is considering a 
bill that would require recovery residences to be certified and 
adhering to national standards in order to received state funds 
or referrals. This stands to improve our awareness of the many 
recovery residences around our state, and ensure adherence to 
ethical practices and conditions for residents.

                             SENATOR BRAUN

    CDC recently published a report finding that two drugs--
para-fluorofentanyl and metonitazene--are being seen more often 
by medical examiners looking into overdose deaths. They often 
are taken with--or mixed with--illicit fentanyl, the drug 
mainly responsible for the more than 100,000 U.S. overdose 
deaths in the last year. A news report in the Indiana Gazette 
last Friday stated that U.S. overdose deaths have been rising 
for more than two decades, but they accelerated in the past 2 
years--jumping more than 20 percent in the latest year alone, 
according to the most recently available CDC data, through June 
2021.

    Yet, even as the crisis escalates, the Substance Abuse and 
Mental Health Services Administration (SAMHSA) found that in 
2020, only 11.2 percent (nearly 300,000) of people aged 12 or 
older with a past year opioid use disorder received medication 
treatment, which reduces the risk for overdose. This data 
demonstrates a shocking gap between the need for service and 
access and availability.

    Question 1. As a cosponsor of the Mainstreaming Addiction 
Treatment Act, I'd like to hear from you how we can further 
increase access to life-saving medication. What other policies 
are needed to ensure those suffering from opioid use disorder 
can get the treatment they need?

    Answer 1. The recent policy changes that have given more 
practitioners greater flexibility to practice medication-
assisted treatment have helped. Still in South Carolina, we 
have thousands of prescribers who can treat addiction, but they 
do not. Many healthcare professionals still do not screen 
patients for substance use disorders. This obstructs access to 
care when most people may only ever encounter an opportunity 
for intervention and treatment with a primary care or hospital 
experience.

    There is still a need for primary care and hospital service 
practice transformation to include screening, brief 
interventions, and referral to specialty addiction treatment 
(SBIRT), as well as the practice of medical treatment for 
substance use disorders in those settings. This could develop 
with strong technical assistance, supported practice 
implementation, and perhaps even with financial incentives. 
Until our healthcare providers understand and realize the 
reward and benefit to addressing addiction like they do other 
chronic diseases, bias and stigma will remain inside of 
healthcare. Training and practical application stands to change 
hearts and minds to create access. Still, without local 
policymakers' understanding of evidence-based treatment, 
feasibility of more integrated care remains varied. An example 
of this is local regulation that prohibiting Opioid Treatment 
Programs or other specialty addiction treatment services to be 
integrated into other healthcare settings or commercially zoned 
to convenient and safe geographic locations.

                             SENATOR SCOTT

    SUDs and Treatment Access: Sadly, we are all too familiar 
with the ongoing addiction crisis in this country, which has 
been exacerbated by the pandemic. South Carolina, like many 
other states, is experiencing high rates of alcohol abuse, 
opioid abuse, stimulant abuse, and broad polysubstance use. 
During the pandemic, we saw dangerous substance abuse behavior 
promoted on social media platforms. For instance, memes, 
hashtags, and other references normalized day drinking to 
address the effects of lockdowns, unemployment, and other 
pandemic-fueled stressors. Sadly, what may have started as a 
casual way to pass the time, changed consumption habits, and 
spiraled Americans into addiction.

    Question 1. Director Goldsby--Can you discuss the work 
being done to address these issues in South Carolina, 
specifically how you're utilizing Federal support to combat not 
just opioid abuse, but also alcohol and stimulant abuse?

    Answer 1. In May 2020 as we began to see social media 
normalizing drinking to cope with the stressors of the 
pandemic. We launched our own social media effort creating 
memes to counter the messages and show support for healthier 
relationships with alcohol. The messages carried links to the 
Alcohol Use Disorder Identification Test, quick self-test on 
our website to help determine risk of alcohol problems.

    In June 2020, with the support of a $1.9 million SAMHSA 
grant award for COVID-19 Crisis Response, we partnered with the 
South Carolina Department of Mental Health to launch the SC 
Hopes Mental Health and Addictions Support Line, offering 24/7 
telephonic connection to mental health and addictions 
counselors, and certified peer support specialists. The 
addictions counselors and peer specialists we engaged to rotate 
on the call line are all primarily serve in our public system 
supported by the SAPT Block Grant. Strong TV, social media, and 
billboard marketing around the state, and the inclusion of 
Spanish and hearing impaired services has driven use of the 
line to more than 5,640 calls since June 1st, 2020.

    Question 2. Following up here, Director Goldsby--Can you 
describe some of the difficulties you have encountered in the 
limitation on what certain programs can be used to treat and 
whether or not additional flexibility would be helpful to give 
you additional tools and resources to better combat the broader 
epidemic?

    Answer 2. We were able to use the State Opioid Response 
(SOR) funds that we had on hand in March 2020 to immediately, 
almost proactively respond when we knew isolation was going to 
occur and impact people with substance use issues. While we 
support a robust public education and prevention campaign about 
the dangers of and the resources for opioid and stimulant use 
issues, we were limited in what we could leverage for messaging 
on problematic alcohol, and problematic substance use more 
broadly, and had to rely on a limited amount of state funds we 
had on hand for those efforts.

    We have used SOR funds to purchase transportation vouchers 
for patients to get to and from treatment. This has been 
helpful short term especially in rural counties when patients 
would otherwise not access care.

    The SOR dollars limit resources to patients who have opioid 
and stimulant use disorders. As we roll out programs and 
services like the transportation vouchers, these Federal 
spending limitations generate the appearance that to our 
addiction service providers or our programs favor certain 
people with certain types of addiction issues. We have relied 
on a limited amount of state funds we have on hand for 
transportation vouchers to support people with other substance 
use diagnoses.

    Furthermore, the substance specific funding requires the 
service providers and the state administration to track dollars 
to specific diagnoses which adds heavy administrative burden 
all around that could be alleviated if funds were intended for 
any substance use disorder diagnosis.

    Until the December 2020 and March 2021 COVID relief 
supplements came to South Carolina, none of the Federal funds 
we had on hand allowed the purchase of important technology 
such as phones, laptops, and broadband to support the 
transition to telehealth services. Luckily, we had a limited 
amount of state funds on hand to support those needs in early 
2020 when the transition occurred.

    Rural Access to Opioid Treatment: On January 3, 2022, HHS 
Secretary Becerra renewed the public health emergency for 
opioids. The opioid epidemic doesn't discriminate and has 
touched every community in America. Throughout rural America, 
including most of South Carolina, access to evidence-based 
treatment for substance use disorders has always been a 
challenge. In 2018, the U.S. Department of Health and Human 
Services' Office of Inspector General released a report that 
showed 40 percent of all counties in the country didn't have a 
single medical practitioner able to prescribe buprenorphine, 1 
of only 3 FDA-approved medications for treating opioid use 
disorder. This includes almost a quarter of my own state and 
disproportionately impacts rural counties across the country.

    Question 3. Director Goldsby--Your department has worked 
with the National Institute on Drug Abuse and the South 
Carolina Department of Health and Human Services to improve 
access to treatment for opioid use disorder in rural emergency 
rooms across our state. What has worked well in bringing 
treatment for opioid use disorder to rural residents of our 
state and what can Congress and the Federal Government do to 
help?

    Answer 3. The SUPPORT Act gave practitioners greater 
flexibility to practice medication-assisted treatment (MAT) 
extending the privilege of prescribing buprenorphine in office-
based settings to other qualifying practitioners like nurses 
and Physician Assistants. In addition, Federal policy allowing 
certain practitioners to treat up to 100 patients is a change 
that helped. Still in South Carolina, we have thousands of 
prescribers who can treat addiction, but do not. This dynamic 
is creating an access barrier in rural areas. There is still a 
need for primary care and hospital service practice 
transformation to include screening and medical treatment of 
substance use disorders. This could be developed with strong 
technical assistance, supported practical change 
implementation, and perhaps even with financial incentives. 
Until our healthcare providers understand and realize the 
reward and benefit to addressing addiction like they do other 
chronic diseases, bias and stigma will remain inside of 
healthcare. Training and practical application stands to change 
hearts and minds to create access.
                                ------                                


Response by Jennifer D. Lockman to Questions of Senator Murphy, Senator 
              Smith, Senator Murkowski, and Senator Scott

                             SENATOR MURPHY

    Question 1. How can we better prepare professionals in 
frequent contact with children and teens, such as teachers and 
pediatricians, to better deal with young people's unique 
behavioral health needs?

    Question 2. How might additional training for these 
professionals improve supports for young people?

    Answer 1. Pediatricians should all be taught in universal 
screening practices utilizing universal screeners such as the 
Pediatric Screening Checklist and suicide-specific screeners 
such as the Columbia Suicide Severity Rating Scale

    Answer 2. Pediatricians and Teachers could benefit from 
effective, tailored trainings in brief engagement and 
intervention strategies:

         LPediatricians who utilize motivational 
        interviewing, a brief (10-15 minute) intervention 
        focused on increasing client engagement in their goals, 
        can increase engagement in mental health care for 
        clients (Desai, 2019; Reinauer et al., 2021)

         LFor pediatricians who identify a patient that 
        is at risk of harm to themselves or others; safety 
        planning and lethal means counseling are a necessary 
        step to engage in with clients prior to discharge to 
        increase probability the client's crisis is allayed 
        prior to entry in mental health care (Schwartzman et 
        al, 2021; Sisler et al., 2020). Those clients--who are 
        screened, have developed a safety plan/blocked access 
        to lethal means, and have a referral to follow-up 
        care--have a significantly higher chance of getting to 
        their appointment with tools to help them through 
        crises that may present prior to engagement in 
        specialty behavioral health care.

         LEffective tailored trainings include those 
        that have a simulation based learning or immersive 
        trainings. These types of trainings are intrinsic to 
        other high stakes environments (i.e., pilots, surgeons, 
        etc.); however, despite strong evidence suggesting high 
        efficacy of simulation-trainings--there is little 
        uptake in behavioral health settings of these types of 
        trainings. Given the high risk nature of suicide and 
        the need for consistent practice--simulation based 
        training may increase mastery and decrease length of 
        booster trainings (Matterson et al, 2018; Carter et al, 
        2018). In addition, simulation trainings are effective 
        at increasing confidence and preparedness in talking to 
        students about mental health (Green et al., 2020). 
        Therefore, increasing the effectiveness of 
        interventions while increasing systemic feasibility of 
        training. Funding that includes time for institutions 
        to offset revenue as well as pay pediatricians, 
        teachers, and other relevant staff to participate in 
        simulated training experiences is needed.

         LThis is an area where our Research Institute can 
        offer significant subject matter expertise. As such, 
        should you or any of your staff have any specific 
        questions about simulation training for suicide 
        intervention/prevention--please do not hesitate to 
        reach out to our team.

    Both teachers and pediatricians should have support from 
their superiors to devote the time and space necessary for 
mental health--this requires cultural and institutional shifts 
to ensure time and resources are allocated.

         LThere should be support (either physically or 
        tele-located) for students screened/identified as being 
        at risk for suicide. Pediatricians and teachers could 
        be trained in identification tools and brief 
        motivational enhancement strategies--as mentioned 
        above--then refer to more highly trained specialists 
        and school-based liaisons.

         LSpecialists and school-based liaisons trained 
        in crisis assessment/triage/intervention could then 
        take on the key roles of suicide risk assessment and 
        triage. Individualized education plans (IEPs) for those 
        students identified at higher risk should include 
        weekly treatment team meetings between counselors/
        teachers/families/pediatricians/specialists/liaisons. 
        Using this model, pediatricians and teachers could have 
        a key, but minimal role, which would allow for them to 
        focus on the primary jobs that they have been trained 
        to do.

         LUltimately, expanded and consistent funding 
        or reimbursement/coverage for school-based and 
        emergency-room based mental health liaisons, as well 
        funding for the necessary training in crisis 
        strategies, would greatly improve continuity of care 
        between identification of students at risk and 
        engagement with these students.

    Quicker and prolonged engagement in treatment. Research 
suggests that children that engage in care as fast as possible 
after identified and those that receive more consistent care 
get better faster than those who have lag times between 
identification and treatment (see samhsa.gov at https://
ncsacw.samhsa.gov/files/rpg-ta-brief-referral-engagement.pdf).

    Finally, we can have all the best evidence and training in 
the world, but without the workforce--our response to the 
current (and projected growing) need will be woefully 
insufficient. Above all other policy measures, we urge that 
Congress prioritize policy solutions to address the mental 
health staff shortages.

    To this end, we strongly urge that Congress consider both 
short-term emergency and long term policy solutions to address 
the current gap in the workforce. Following we outline one 
short term measure Congress can immediately take as well as 
longer term policy solutions to address the behavioral health 
workforce crisis in America.

    With regard to short-term solutions to the behavioral 
health workforce crisis, we urge Senate HELP and Finance to 
consider short/medium-term, emergency measures to ensure 
providers have tools to better recruit and retain their 
workforce. According to Centerstone's own internal exit 
interview data, staff leaving cite salary as the No. 1 reason 
they are leaving. As such we suggest the introduction of the 
following new, emergency grant program:

         LIntroduce an Emergency Workforce Funding Bill

         LCreate a new grant program, that community/
        safety net provides could apply to request funding to 
        support retention bonuses, wage increases, and more to 
        incentive workforce recruitment and retention for front 
        line staff

         LEligible Provide Types

         LPsychiatrists

         LPhysicians with a buprenorphine waiver

         LPsychologists

         LNurse practitioners with a buprenorphine 
        waiver

         LPhysician assistants with a buprenorphine 
        waiver

         LClinical social workers

         LLicensed mental health counselors

         LLicensed marriage & family therapists

         LCase managers

         LPeer support specialists

    Use of Funds. The eligible entities described below are 
permitted to use the funds toward:

         LRetention bonuses

         LHazard pay

         LOvertime

         LShift deferential pay (wage increases)

         LOther additional compensation and employee 
        benefits deemed by the Secretary as necessary to retain 
        clinical staff

    In terms of long term solutions to address the behavioral 
health workforce crisis, we suggest the following legislative 
vehicles which we believe get at longer term, systemic barriers 
that restrict workforce and access to evidence-based behavioral 
health services:

         LPass the Excellence in Mental Health and 
        Addiction Treatment Act of 2021 (S. 2069).

         LWe see this legislation as the single most 
        critical piece of legislation that Congress can pass to 
        increase training for evidence-based practices, elevate 
        the quality/standard of care in community mental health 
        settings, and address long standing workforce barriers 
        through the Prospective Payment System (PPS) payment 
        methodology that allows providers to offer more 
        competitive wages to their frontline staff. 
        Furthermore, Certified Community Behavioral Health 
        Clinics (CCBHCs) are required to serve patients 
        regardless of payer type and offer a wide area of 
        required services, including mobile crisis and crisis 
        stabilization.

         LFull implementation of this model can take a 
        couple years; thus, we recommend that Congress take 
        shorter term measures--as noted above. That being said, 
        in the long term--this legislation is probably the most 
        critical piece of behavioral health legislation 
        Congress can pass in 2022 to transform the community 
        mental health system.

         LPass the Behavioral Health Services Crisis 
        Expansion Act (S. 1902).

         LCoverage is a key component toward ensuring 
        that services are sustainable and available to 
        consumers in a time of crisis. Ensuring that both 
        public and private payers cover crisis services can 
        drastically increase availability and access for 
        consumers when they need it most.

         LEnsure that any telehealth extensions include 
        a delay of the in-person requirement on telemental 
        health services, as outlined in The Telemental Health 
        Care Access Act (S. 2061).

         LThis in-person requirement of telemental 
        health services--if implemented--will further encumber 
        already overworked providers to arbitrarily delineate 
        between their patients on ``who gets what type of 
        service'' based on diagnosis, rather than clinical 
        presentation and best practice. This approach is 
        counter to the gold standard of providing the ``right 
        care at the right time'' to improve patient and 
        population health outcomes. Passage of S. 2061 would 
        address this barrier.

    Finally we urge passage of the Mental Health Access 
Improvement Act of 2021 (S. 828).

         LThis legislation would add other master's 
        level therapists (i.e., Marriage & Family Therapists, 
        etc.) to eligible providers under Medicare (which is 
        currently restricted to only Licensed Clinical Social 
        Workers). Passage of this legislation would allow our 
        behavioral health workforce to work with the full scope 
        of their training and education.

    In conclusion, in order to better prepare professionals in 
frequent contact with children and teens, we need mental health 
professionals to refer them to. Employees are leaving the 
mental health workforce at a rapid pace due to low wages and 
high stress. To address the behavioral health workforce 
crisis--that is particularly elevated in community, not-for-
profit mental health settings--we need Congress to pass 
legislation that ensures providers have the tools they need to 
not only recruit and retain staff, but to elevate the quality 
of care--while increasing access.

    Question 3. Knowing that we have significant health care 
disparities stratified by income, race, and geography (e.g. 
rural areas), how do we ensure health equity in addressing the 
behavioral health needs of children and teens?

    Telehealth

    Answer 3. We know that telehealth has increased access to 
care for clients that otherwise have difficulty with 
transportation or scheduling. In fact, we also know that 
treatment for depressive symptoms using telehealth services is 
equivalent to face-to-face services in reduction of depressive 
symptoms based on evaluation data from our CCBHC during the 
COVID-19 pandemic (unpublished data, 2022).

    988 and Crisis Services

         LAs we look toward addressing health 
        disparities in addressing the behavioral health needs 
        of children and teens--there is tremendous opportunity 
        to ensure the Nation's new 988 three-digit dialing code 
        for the National Suicide Prevention Lifeline (set to 
        launch July 16, 2022) and corresponding services 
        through the crisis continuum are culturally competent 
        and meets the needs of vulnerable, marginalized 
        populations. Specifically:

         LCrisis teams, ideally, should reflect the 
        diversity of the communities served and ensure 
        community response and stabilization services meets the 
        needs of everyone in the community; and

         LCongress can urge SAMHSA to develop child-
        focused crisis engagement guidelines to emphasize both 
        evidence-based strategies specific to child and 
        adolescent populations as well as provide further 
        guidelines toward ensuring services address long-
        standing health disparities.

                             SENATOR SMITH

    Question 1. What are specific examples of initiatives that 
you have seen in your work that have done a good job of 
incorporating mental health into the broader response to COVID-
19? What should Congress learn from these successes?

                          Telehealth expansion

    Answer 1. We know that telehealth flexibilities availed 
through the COVID-19 Public Health Emergency has increased 
access to care for clients that otherwise have difficulty with 
transportation or scheduling. In fact, we also know that 
treatment for depressive symptoms using telehealth services is 
equivalent to face-to-face services in reduction of depressive 
symptoms based on evaluation data from our Certified Community 
Behavioral Health Clinic (CCBHC) during the COVID-19 pandemic 
(unpublished data, 2022). Additionally, initial findings 
indicated that a cohort of clients receiving telehealth 
medication assisted treatment (MAT) experienced a 9 percent 
reduction in average days using any substance, a 29 percent 
reduction in average days depressed or anxious, and a 9 percent 
increase in treatment satisfaction at 6 months relative to 
face-to-face clients (Hanauer, M., Moore, J. T., & Lockman, J, 
2020).

         LTo that end we thank you and Senator Cassidy 
        for your leadership on Telemental Health Care Access 
        Act--S. 2061. The Telemental Health Care Access Act 
        would provide continuity in behavioral health care 
        access by removing the statutory requirement that 
        Medicare beneficiaries be seen in person within 6 
        months of being treated for a mental health service via 
        telehealth. We strongly urge that this provision be 
        included with any extension of telehealth 
        flexibilities--as is currently being considered for the 
        fiscal year 2022 omnibus spending bill.

                         Increasing engagement

    Utilizing funding from our SAMHSA Emergency Response for 
Suicide Prevention grants, we were able to form a team of 
clinicians to deploy suicide prevention strategies in novel 
ways that increase engagement and decrease resources. In 
Indiana, our staff utilized a weekly suicide screen/safety plan 
review approach with bachelor's level unlicensed staff. Those 
staff would then refer onto master's level counselors for 
further assessment if the client screened positive for 
increasing suicide risk. In addition, these clients could be 
seen biweekly for suicide-specific treatment, which allowed for 
decreased resourcing (as opposed to weekly visits for 
screening/safety plan review with a bachelor's-level staff 
person).

         LTo ensure on-going engagement for those in a 
        mental health crisis, we strongly urge that Congress 
        consider passage of the Behavioral Health Services 
        Crisis Expansion Act (S. 1902) as a crucial component 
        to financing the crisis care continuum via ensuring 
        coverage as well as the Excellence in Mental Health and 
        Addiction Treatment Act of 2021 (S. 2069) which 
        advances the CCBHC model--a model in which care 
        coordination, access, and crisis services are required 
        components of the care delivery model.

                           SENATOR MURKOWSKI

    Suicide Screening in the Emergency Department: A recent CDC 
report on emergency department visits for people age 12-25 
found an over 50 percent increase visits for suspected suicide 
attempts during early 2021. This not only underscores the 
devastating mental health impact of the pandemic on our youth, 
but highlights yet another way that COVID-19 has strained our 
hospitals and medical staff.

    I introduced a bill, the Effective Suicide Screening and 
Assessment in the Emergency Department Act, to improve the 
screening and treatment of patients in hospital emergency 
departments who are at high risk for suicide. It will make sure 
that we can better identify our most vulnerable mental health 
patients so they do not slip through the cracks when they are 
treated in hospitals, and make sure hospitals have the 
resources they need to provide these critical services.

    Question 1. Can you talk about the need for improved 
suicide screening protocols in the Nation's emergency rooms 
and, second, do you support efforts to bolster the resources 
available to emergency rooms so they can enhance their 
screening for high-risk suicide patients?

                           Suicide Screening

    Answer 1. It is admirable and vital to increase suicide 
screening protocols to better catch high risk patients. To do 
so comprehensively, two specific actions are required.

    First, funding is needed to study and administer adaptive 
screening measures (see King et al., 2021) that have been found 
to be best at predicting future suicide attempts and to study 
upstream screening measures (such as measures of interpersonal 
drivers of suicide) to better understand why people are driven 
to suicide and treat these drivers upstream so fewer people are 
thinking about suicide. Both of these types of measures would 
be exceptional in an emergency department screening.

    Second, to match the increased need for suicide screening 
and supports in emergency rooms we need to answer the following 
question: what happens to those individuals after the emergency 
room? How do we improve continuity of care post-screening? If a 
person is coming into the emergency room for suicidal thoughts 
or a suicide attempt, they are in a vulnerable space and needed 
to be treated with respect, transparency, honesty, and be given 
the hope that things will change. We support resources 
dedicated to screening and assessment in hospitals with a 
caveat; that these changes also support triage and engagement 
practices with follow-up care. Post hospitalization is the most 
critical risk period for suicide known to researchers, with 
rates of suicide 100x higher than the global suicide rate in 
the 3 months following hospital discharge (Chung et al., 2017). 
Screenings and assessments are only good for hospital emergency 
rooms if they can quickly triage and transport patients. 
Screenings and assessments in hospital emergency rooms are only 
good for the behavioral health of our clients if they are 
respected and cared for enough to be connected with immediate 
follow-up care. Therefore, funding for resources not only for 
screening and assessment practices but also triage, 
transportation, and engagement with intensive outpatient or 
outpatient mental health treatment is necessary. Continuity of 
care to the crisis continuum is key for comprehensive suicide 
prevention

    To that end, we applaud and thank your and Senator King's 
leadership in advancing the Effective Suicide Screening and 
Assessment in the Emergency Department Act of 2021 (S. 467). We 
support the passage of this bill, and appreciate that the 
legislative text specifically emphasizes ``enhancing the 
coordination of care for such individuals after discharge'' as 
well as the provision which requires grantees ``to establish 
and implement policies and procedures with respect to care 
coordination, integrated care models, or referral to evidence-
based treatment to be used upon the discharge from the 
emergency department of patients who are at risk of suicide.'' 
Thank you for your leadership for this highly vulnerable 
population.

                             SENATOR SCOTT

    Question 1. According to the U.S. Department of Health and 
Human Services, 20 percent of children and adolescents 
experience some type of mental health issue during their school 
years and a 2019 report by the Substance Abuse and Mental 
Health Services Administration stated that ``Among the 3.8 
million adolescents ages 12-17 who reported a major depressive 
episode in the past year, nearly 60 percent did not receive any 
treatment.'' Can you speak to the role of telehealth in 
expanding access to mental and behavioral health services for 
children in school-based settings and opportunities for public-
private partnerships?

    Answer 1. Telehealth allows the opportunity for more 
children in school-based settings to connect with 
psychiatrists, nurse practitioners, psychologists, and more who 
cannot be physically integrated into the school setting due to 
lack of resourcing. Centerstone does not have any public-
private partnerships in school-based settings, but we have 
partnered in adult crisis diversion settings with private 
funders (e.g., Cook Medical Group in Indiana) to match funds 
raised by Centerstone and their partners in the Bloomington, 
Indiana community.

    With regard to our public-private partnership in Indiana, 
the Stride Center fulfills a community-wide need for people 
experiencing substance use or mental health crisis who need a 
connection to care and a place to go rather than 
hospitalization or imprisonment (this is often referred to as 
crisis receiving or stabilization). Many times the options for 
an individual in a moment of crisis are hospitalization or 
jail, both of which are more costly and do not treat presenting 
symptoms or diagnosis. The goal of the Stride Center is to 
deescalate the situation and connect the guest with appropriate 
treatment resources (i.e., the right care at the right time). 
To date, the average amount of time for law enforcement to 
complete a drop off at the Stride Center is under 5 minutes; 
whereas processing for jail or the emergency department is 2 
hours--saving both time and money through allowing law 
enforcement to spend their time addressing criminal activity 
and individuals in need of mental health or addiction treatment 
care--to receive the care they need. From our experience, 
public-private partnerships can add immense value to community-
based services and the associated outcomes.
                                ------                                

    [Whereupon, at 12:08 p.m., the hearing was adjourned.]

                                   [all]