[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
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
48-898 PDF WASHINGTON : 2023
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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
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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.
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\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.
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\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
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Such universal programs also help address student behavioral
challenges by implementing positive, non-punitive, restorative measures
rather than retributive and exclusionary practices. \50\
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\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.
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\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.
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\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
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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
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\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.
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\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.
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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
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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.
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\5\ https://www.politico.com/news/2021/07/14/covid-pandemic-drug-
overdoses-499613
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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.
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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.
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\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.
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\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.
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\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
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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\
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\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
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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.
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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
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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\
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\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.
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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
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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\
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\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
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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.
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\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.
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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.
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\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.
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\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
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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.
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\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
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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.
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\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.
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\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.
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\1\ Press Release: https://www.bmc.org/news/press-releases/2020/
09/09/boston-medical-center-and-proof-alliance-collaborate-reduce-
prenatal
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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\
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\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
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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\
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\4\ Reference: https://www.thelancet--com/infographics/COVID-
0919--associated--caregiver--deaths
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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.
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\5\ Press Release: https://www.bmc.org/news/press-releases/2020/
09/09/boston-medical-center-and-proof-alliance-collaborate-reduce-
prenatal
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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.
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[Whereupon, at 12:08 p.m., the hearing was adjourned.]
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