Alignment for Progress: 
A National Strategy for Mental Health and Substance Use Disorders

Individuals with untreated MH/SUDs, but particularly untreated psychosis, are at very high risk of homelessness, incarceration, and early mortality.[1] Yet, too often, our system fails to help individuals get the help they need. Such help is especially important when the person’s illness results in agnosia, a symptom of their condition that impairs their ability to understand and perceive their own illness. Through a compassionate civil court process, states can help individuals with untreated serious mental illnesses (SMI) – particularly schizophrenia spectrum disorders and other conditions with psychosis – access clinically appropriate, community-based services.

This new approach is currently being implemented in California, which enacted the CARE Act in 2022. California’s CARE Court process allows family members, close friends, first responders, and MH/SUD providers to petition the CARE Court on behalf of an individual with untreated SMI and co-occurring SUDs.[2] The individual is provided legal counsel and is able to choose a voluntary supporter who can help the individual understand and communicate decisions. If the petition meets established criteria designed to protect the rights of individuals and ensure system accountability, the CARE Court can create a 12-month CARE plan (which can be extended to 24 months) to provide the individual with a broad range of services, including medications, recovery supports, and social services such as housing. Counties are mandated to provide these services. While medications can be ordered as part of a CARE plan, the administration of medications can never be forced.[3]

By moving upstream, California’s CARE Court is designed to prevent individuals with the most complex MH/SUD needs, who are frequently living on the streets, from much more restrictive conservatorships or incarceration.[2] Congress should support such efforts, while ensuring that states are protecting individuals’ legal and constitutional rights and building in accountability to prevent abuses.

Untreated psychiatric disorders in adolescents can lead to major lifelong problems for adults. It is particularly urgent for adolescents to receive treatment since about 14 percent of adolescents experience some type of mental health condition[1], and half of all mental illnesses begin by the age of fourteen.[2] However, medications to treat mental health and substance use disorders (MH/SUDs) have often not been approved for children and adolescents. For many health conditions, there can be a long lag between when the FDA approves a medication for adults to when (if ever) a medication is approved for children and adolescents.[3]

While it is critical to recognize differences between adults, children, and adolescents – and not to assume similarities – the fact that clinical trials are more expensive and burdensome for children and adolescents means that prescribers frequently prescribe FDA-approved medications “off-label” for youth.[3] A more rigorous approach is needed to help guide safe and effective treatments for adolescents, particularly those experiencing MH/SUD.

In early 2023, FDA staff presented to ISCTM (International Society of CNS Clinical Trials and Methodology) on potential opportunities to improve the availability of mental health medications for adolescents, particularly for schizophrenia, bipolar disorder, and major depressive disorder.[4] Large databases exist for all three diagnoses that contain thousands of adults and pediatrics. These databases could potentially be used to extrapolate the efficacy of medications for children and adolescents. There was “substantial evidence to support the full extrapolation of efficacy from adults to adolescents” where the disease is similar, the pharmacokinetics (medication levels in the blood/body) are similar, and the method of action and patient response are similar.[4]

The FDA should continue to explore avenues to increase the availability of key MH/SUD medications for adolescents when significant mental health conditions often first present. One option could be to allow a bioequivalence study and an open-label safety study to be done post-approval. Doing this could accelerate approvals to increase adolescents’ access to the best MH/SUD medications (which often have fewer side effects), encourage additional research, and leave in place incentives to study diseases in children and adolescents.

Childhood trauma, especially since the emergence of COVID-19, continues to have devastating effects on children and adults across the nation. Nearly half of children have been exposed to significant adverse childhood experiences (ACEs).[1] As children experience more ACEs, their risk for future mental health and substance use disorders (MH/SUDs) increases in adulthood. By preventing ACEs, the United States could reduce the adult incidence of depression by an estimated 44 percent (the highest of any health condition) and heavy drinking by 24 percent.[2] Despite the widespread occurrence of childhood trauma, only a very small fraction of the children who need care receive it because of socioeconomic barriers, including racism, poverty, and access to services.[3]

Congress should address this critical issue by passing comprehensive legislation like the RISE from Trauma Act. This bill would help to train frontline service providers and community members about trauma, toxic stress, and resilience, would require the Department of Justice (DOJ) to create a national center to disseminate best practices to law enforcement agencies to improve interactions, and establish grant programs improve prevent and reduce trauma across a variety of settings.[3][4]

The impact of environmental pollution and degradation, including the worsening effects of climate change, has a profound impact on communities’ mental and physical health. For example, numerous studies have shown that air pollution leads to higher levels of stress, depression, and even death for individuals with serious mental illness.[2] Recent research has shown that air pollution affects brain development and the mental health of children, with one large study finding that air pollution “is significantly associated with increased risk of psychiatric disorders.”[3] The authors of this study suggest that neuroinflammatory mechanisms may be to blame. A recent meta-analysis of more than 100 studies found that nearly three-quarters showed that mental health symptoms worsened after exposure to high levels of air pollution.[4] The study’s lead author remarked, “People who breathe polluted air experience changes within the brain regions that control emotions, and as a result, they may be more likely to develop anxiety and depression than those who breathe cleaner air.”[5] Yet another study found that exposure to air pollution was associated with an increase in psychiatric visits to emergency departments among children.[6]

Given the long history of higher levels of environmental pollution in and around Black and other communities of color,[7] including the siting of pollution sources such as highways and industry, it is essential that Congress take affirmative steps to eliminate the sources of pollution and the inequitable effects. The A. Donald McEachin Environmental Justice for All Act would be a major step in the right direction of addressing these injustices by providing resources, engaging with affected communities, fixing inequitable practices, and ensuring meaningful remedies.

More than half of all U.S. counties do not have a mental health or substance use disorder (MH/SUD) provider. While many MH/SUD services can be provided via telehealth, much more needs to be done to expand the MH/SUD workforce, including peer support specialists. These critical providers are formally trained and offer peer support, using their lived experience with a MH/SUD to promote recovery in other individuals. Peer support specialists are cost-effective and provide critical support that helps individuals build stronger support systems, engage with treatment, and manage both MH//SUD and physical health conditions. Increasing utilization of peer support specialists (including through telehealth) is a critical way to alleviate shortages of MH/SUD professionals, particularly in rural and other underserved areas. By helping individuals get the support and care they need, peer support specialists help prevent costly negative outcomes, including disability, hospitalization, incarceration, and even homelessness.[1] Indeed, research has shown that peer support services were associated with 2.9 fewer hospital admissions each year, and Medicaid programs saved an average of over $2,000 per month.[2]

Unfortunately, barriers remain in expanding the peer support specialist workforce. One critical barrier is insufficient standardization. For example, credentialing of peer support specialists is not standardized across states. The Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources & Services Administration (HRSA) should take steps to standardize credentialing. Additionally, the U.S. Bureau of Labor Statistics’ Standard Occupational Classification (SOC) system does not have a separate classification for peer support specialists.[3] Instead, peer support specialists are lumped in with “Social and Human Services Assistants.” The SOC system is how federal agencies classify workers in order to collect, calculate, and disseminate data. Congress should direct SAMHSA and HRSA to take steps to standardize credentialing of peer support specialists and the Office of Management and Budget to revise the SOC Manual to include a definition of peer support specialists.

Another barrier is that HRSA does not publish data on peer support specialists.[4] Such data is collected and published for psychiatrists, psychologists, and social workers – and includes information on the number of professionals and their location. Having data on peer support specialists would help identify gaps across the country, including where peer support specialists could fill gaps in available clinicians. HRSA collects much of this data through the Behavioral Health Workforce Education and Training (BWHET) program, but this data is not published. Congress should direct HRSA to add peer support specialists to its Workforce Bureau dashboard.

Finally, in 2022, the Senate Finance Committee’s Task Force on Workforce released draft legislation, which included a Medicaid workforce demonstration project modeled after a previous demonstration project.[5] Unfortunately, peer support specialists were not named within the draft. It is critical that any new workforce demonstration projects explicitly authorize peer support services so that these projects cover the range of provider types.

American moms are dying at the highest rate in the developed world, and the United States is the only country in the developed world with rising maternal mortality rates.[1] For every death, 70 more moms experience “near misses.”[2] Black moms are dying at three to four times the rate of their White counterparts,[3] while Native American moms are more than twice as likely to die from pregnancy-related causes.[4] Though maternal deaths have increased by 89 percent since 2018, [1] 80 percent of maternal deaths are preventable with appropriate care and treatment.[5]

The Black Maternal Health Momnibus Act includes 13 bills that would help decrease maternal deaths and reduce disparities.[6] Key provisions include:

• Funding community-based organizations to address social determinants of health that influence maternal health outcomes, like housing, transportation, and nutrition, and extending Women, Infants, and Children (WIC) eligibility in the postpartum period from 6 months to 24 months and in the breastfeeding period from 12 months to 24 months.
• Investing in digital tools to improve maternal health outcomes in underserved areas.
• Promoting payment models that incentivize maternity care and non-clinical support during and after pregnancy.
• Establishing and funding programs within hospitals to provide pregnant and postpartum patients the ability to report instances of racial, ethnic, or other types of bias.
• Funding local initiatives supporting people with mental health conditions or substance use disorders during or after pregnancy and funding programs to grow and diversify the maternal mental clinical and non-clinical healthcare workforce.
• Ending the practice of shackling pregnant people and targeting funds to federal, state, and local prisons and jails to establish programs for pregnant and postpartum women to access perinatal and postpartum healthcare.
• Requiring the Centers for Medicare and Medicaid Services (CMS) to consider models that improve the integration of telehealth services in maternal health care and establishing a new CMS Innovation Center demonstration project to promote equity and quality in maternal health outcomes for moms covered by Medicaid.
• Funding community-based programs, research, and health professional schooling that identify and address climate change-related maternal and infant health risks.