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

Individuals with mental health and substance use disorders (MH/SUD) are overrepresented in the criminal legal system.[2] Often unable to access the care and treatment they need, these individuals tend to stay incarcerated longer.[3] To address gaps in MH/SUD resources, federal, state, and local groups have taken action. However, this has led to a patchwork response. Congress recognized this fragmentation and has called upon the federal government to coordinate its efforts. This could be accomplished with an interagency council or permanent working group.[1] The Federal Interagency Reentry Council, the U.S. Interagency Council on Homelessness,[1] and the SAMHSA Interagency Task Force on Military and Veterans Mental Health, which bring together federal agencies previously working separately, could serve as models to address behavioral health in the criminal legal system.[1][4][5]

The Health Resources and Services Administration (HRSA) projects a 20 percent decrease in the supply of adult psychiatrists by 2030.[2] At the same time, a three percent increase in demand is expected.[3] To encourage psychiatrists to practice in Health Professional Shortage Areas (HPSAs), Medicare’s HPSA Physician Bonus Program pays a 10 percent quarterly bonus to physicians, including psychiatrists, who provide Medicare-covered services in health shortage areas across the country.[4][5] However, with growing provider shortages, increased payments are needed to continue to incentivize psychiatrists to provide services to communities facing the highest need. In its 2022 Mental Health Workforce Enhancement Discussion Draft,[6] the Senate Finance Committee proposed such an increase.[1]

Immigrants, refugees, and asylum seekers face multiple stressors, such as family separation, poverty, housing insecurity, and unemployment.[4] In addition, about one in three experience depression, anxiety, or post-traumatic stress disorder (PTSD).[4] To address the mental health of those in the immigration system, CBP staff should be trained and MH/SUD experts made available.[1]. However, many immigrants and refugees fear seeking mental health support in fear of it impacting their immigration status.[2] Unfortunately, unaccompanied minors who are required to attend therapy have had their notes shared during court proceedings resulting in the denial of asylum.[5]

In a September 2020 letter, a number of organizations representing medical and mental health providers, including the American Academy of Pediatrics, American Psychiatric Association, American Medical Association, among others, cited the trauma incurred during immigration and immigration detention and their belief that the conditions in CBP custody to be inconsistent with evidence-based recommendations for children and women.

To protect the mental health of immigrants, refugees, and asylum seekers, CBP staff should have training, MH/SUD experts should be available, and it should be prohibited to share confidential information shared in therapy sessions.[1][2][3] Additionally, CBP officers face some of the highest suicide rates of any law enforcement. Between 2007 and 2022, 149 CBP employees died by suicide. The rate of suicide at CBP is almost 28% higher than at any other law enforcement agency. [6][7]

The Immigrants Mental Health Act includes provisions to address mental health challenges among immigrants as well as CBP agents and officers.[1] This includes assigning at least one qualified mental or expert on mental health and substance use disorders (MH/SUD) to each Border Patrol station, port of entry, checkpoint, forward operating base, secondary inspection area, and short-term custody facility. In addition, the act would restrict the sharing of mental health information for use in certain immigration proceedings.[1]

Despite effective MH/SUD treatments being available for a wide range of conditions, many Americans remain untreated or undertreated due to historically siloed MH/SUD and physical health systems.[2] Integrating MH/SUD and physical health services can increase access to MH/SUD care and improve patient outcomes.[2]

In 2017, the Centers for Medicare and Medicaid Services (CMS) began paying physicians and non-physician providers separately for supplying patients with Behavioral Health Integrated Services (BHI).[3] These services involve a closer partnership between primary care and MH/SUD providers providers, which has proven beneficial to patients and has evolved into the Collaborative Care Model (CoCM). This model has been demonstrated effective by more than 90 randomized-controlled trials and can help to more effectively utilize limited MH/SUD provider capacity.[4]

However, critical infrastructure is required to effectively implement BHI services.[4][5] Insufficient compensation for training and technical support has effectively contributed to continued payment silos between behavioral health and primary care.[5] Therefore, as proposed by the Senate Finance Committee in its November 2022 Mental Health Care Integration Discussion Draft, Congress should increase Medicare payment rates for BHI services.[1][6]

First responders are often the first on scene in an emergency, placing them at an increased risk for job-related trauma.[2][3] Thirty percent of first responders are likely to develop a mental health condition, such as depression or Post-Traumatic Stress Disorder (PTSD),[3] which is higher than the general population. Suicide attempts of fire and EMS professional is almost at seven percent, when the general population is at 0.5 percent.[3] With an increased risk for trauma, first responders need resources and support services.

On August 16, 2022, President Joe Biden signed into law the Public Safety Officer Support Act (PSOSA) of 2022, which officially acknowledged PTSD as a work-related injury.[4] While this is welcome progress, many employers, including law enforcement agencies and fire departments, are unable to hire full-time mental health professionals to treat first responders experiencing work-related PTSD or acute stress disorder.[1]

There are 10 ROTA-Rs, each located in one of the ten Health and Human Services Agency regions, whose purpose is to develop and disseminate training and technical assistance addressing opioid use in rural communities. ROTA-Rs identify model programs, and create and update materials related to prevention, treatment, recovery, and harm reduction activities for opioid and stimulant use. The centers have also expanded to include stimulant use disorders, which include methamphetamine use.[1] ROTA-Rs should be expanded to include other substance use and mental health disorders affecting rural communities, including alcohol use disorder, serious mental illnesses, and suicide prevention.