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

Mass shooters, on average, exhibit four to five observable and concerning behaviors before their attacks[2]. Firearms are used in half of suicide deaths, and a majority of gun deaths are suicides.[3] In states without ERPOs, individuals who notice warning signs have no legal way to intervene to remove firearms. ERPO laws create a legal process to prevent firearm deaths through intervention.[4]

ERPO laws in multiple states have been shown to be a promising tool for preventing firearm homicides and suicides. A case study in California found that ERPOs had been used to remove firearms from 21 individuals who had threatened to commit mass shootings and that none of these shootings had occurred at the time of the study.[5] Another study showed that ERPO laws saved a life for every 10 firearms removed in Indiana and a life for every 10-20 firearms removed in Connecticut.[6]

Currently, the U.S. public health surveillance system for mental health and substance use is severely lacking. The Substance Abuse and Mental Health Services Administration (SAMHSA), for example, runs the National Survey on Drug Use and Health, which provides estimates of substance use and mental health at the national, state, and substate levels.[1] Yet this data is delayed and is not broken down by local geographies that would allow officials to respond to local trends in near real time. Similarly, the CDC’s Provisional Drug Overdose Death Counts for a given month are released five months later and are not broken down by demographic groups or sub-state geographies, making meaningful responses extraordinarily difficult.[2]

In contrast, the U.S. has robust data available across many decades relating to the U.S. population, economy, and workforce. For example, the Department of Commerce houses the U.S. Census Bureau and the Bureau of Economic Analysis[3], while the Department of Labor houses the Bureau of Labor Statistics.[4] The failure to collect such robust data for mental health and substance use leaves our federal, state, and local government agencies, as well as other stakeholders, ill-positioned to properly address population needs and trends. By creating a world-class public health data system for mental health and substance use that collects a wide variety of mental health and substance use disorder data by demographic groups, Congress can ensure systems affecting mental health and substance use have foundational data needed to improve mental health and well-being across the country.

In 2020, 81 percent of 14- to 22-year-olds reported using social media “daily” or “almost constantly.”[1] During the pandemic, the time teenagers spent in front of screens for activities unrelated to school more than doubled, from 3.8 to 7.7 hours per day.[1] There is growing concern about the impact of social media and technology on youth mental health and wellbeing.[1]

In May 2023, the White House described steps it’s taking “to protect youth mental health, safety, and privacy online,” including the creation of a new “Task Force on Kids Online Health and Safety.”[2] Additionally, in September 2022, the Substance Abuse and Mental Health Service Administration (SAMHSA) awarded a $2 million grant to the American Academy of Pediatrics (AAP)[3][4] to establish a National Center of Excellence on Social Media and Youth Mental Health[5] to “serve as a centralized, trusted source for evidence-based education and technical assistance to support the mental health of children and adolescents as they navigate social media.”[5]

Congress has also recognized the need to address the issue, including language in the Consolidated Appropriations Act of 2023 that requires the U.S. Department of Health and Human Services to study the effects of smartphone and social media use on adolescents’ emotional, behavioral, and physical health and to research the health and developmental effects of media and technology more broadly on infants, children, and youth.[6][7] Congress should continue to support similar efforts through increased funding for research and consumer education.[1]

Numerous factors cause disparate outcomes for individuals in underrepresented or marginalized communities, including inaccessible mental health and substance use disorder (MH/SUD) services, cultural stigma around mental health care, discrimination, and lack of diversity in the MH/SUD workforce and in clinical research.[4][5][6][7] MH/SUD providers who are not culturally competent contribute to underdiagnosis or misdiagnosis of MH/SUDs in individuals from diverse populations.[8]  MH/SUD services that are culturally competent incorporate perspectives and decision-making from diverse groups[10][11] and provides care responsive to the beliefs, traditions, customs, practices, and needs of diverse individuals.[12][13]

While national standards for Culturally and Linguistically Appropriate Services (CLAS) in health and healthcare outline steps for health care organizations to reduce health disparities[14], additional culturally competent guidelines specific to mental health and substance use would be very valuable, especially given ongoing efforts to build an MH/SUD crisis response system centered around the 988 Suicide and Crisis Lifeline, which are essential to advancing efforts to decriminalize MH/SUDs. Such guidelines would advance efforts to increase culturally competent care such as requirements for Certified Community Behavioral Health Clinics (CCBHCs) to demonstrate cultural competence.[12] Unfortunately, 56 percent of White healthcare providers report having no cultural competency training to better serve their patients.[16] By developing culturally competent guidelines, SAMHSA could help  improve access to culturally competent MH/SUD care for underrepresented and marginalized communities.

The ADA protects individuals with disabilities, including mental health and substance use disorders (MH/SUDs), from discrimination.[3] Title II of the ADA applies to state and local government entities–including state licensing boards– and prohibits discrimination against individuals with disabilities in services, programs, and activities provided by those entities.[4] In a letter to the DOJ, Senators Wyden, Merkley, and Booker note an estimated two-thirds of state medical boards violate Title II of the ADA with personal, taxing, and unnecessarily broad questions about doctors’ MH/SUD history beyond what is necessary to fulfill the purpose of screening physicians for issues that may affect their ability to practice medicine[1][2][5][6][7][8][9][10] and may prevent physicians from seeking necessary mental health treatment.[1][2] Therefore, DOJ should issue guidance – and, if necessary, Congress should require the DOJ to do so – to protect healthcare professionals health privacy and hold state licensing boards accountable for ADA violations.

Annual screenings are critical components of prevention and early intervention of mental health and substance use disorders (MH/SUDs).[1] Early identification and treatment lead to better outcomes in overall health and may lessen long-term disability.[3] Key screenings include the Adverse Childhood Experiences (ACE) assessment and Screening, Brief Intervention, and Referral to Treatment (SBIRT). ACEs refer to traumatic events of abuse, neglect, or household challenges experienced by age 18.[4] Routine screenings provide an opportunity for the prevention, early detection, and intervention of the long-term effects of ACEs, may prevent and reduce the accumulation of ACEs, and improve the assessment and treatment for related health conditions.[5]

SBIRT delivers early intervention and treatment services through universal screenings that are comprehensive and integrated into primary care for persons at risk for or with substance use disorders.[6][7][8] Studies show that greater use of SBIRT is associated with larger decreases in substance use and that an essential factor in program sustainability is availability of funding.[8] While there are legal requirements to provide such screenings under certain health coverage (e.g. mandatory screenings as part of the Medicaid EPSDT benefit for children), health care providers should perform and health plans should reimburse for routine, evidence-based mental health screenings like those focused on ACEs and substance use disorders.[1]